COVID-19 vaccine-related immunological adverse event presented as reversible autoimmune disease with rheumatological feature and pulmonary infiltrates

Rheumatological manifestation with acute febrile respiratory illness known to occur after coronavirus disease 2019 (COVID-19) pneumonia and presenting as long COVID disease, its occurrence with COVID vaccination is not very well associated or described in the literature. In this case report, a 45-year-old female presented with constitutional symptoms, persistent fever, and lung parenchymal infiltrates, without mycobacterial microscopic or genome documentation, received empirical antituberculosis (TB) treatment with the progression of disease with little clinical or radiological response. Bronchoscopy workup was inconclusive and tropical screen for bacterial, fungal, TB, and malignancy was negative. Vasculitis workup was inconclusive and rheumatological workup documented highly raised antinuclear antibodies titers. We have started her on steroid and hydroxychloroquine and clinical response documented with near-complete resolution of shadows in 12 weeks. Rheumatological syndrome which is a rare vaccine-related adverse event, reversible and easily treatable with routinely available medicines and importantly it is having excellent prognosis. Minimal systemic adverse events are known to occur with all viral vector vaccines, but its occurrence is rare and it should not impact on routine vaccinations as vaccination is a key step in this pandemic to protect humankind

The Role of initial and follow-up C-reactive protein titer in COVID-19 pneumonia: A single-center study of 1000 cases in a tertiary care setting in India

Introduction: Robust data of C-reactive protein (CRP) are available in bacterial infection, and it can be utilized in this coronavirus disease 2019 (COVID-2019) pneumonia pandemic for initial assessment before planning of treatment in indoor setting compared to other inflammatory markers and computerized tomography (CT) severity. Methods: A prospective, observational, 12-week-follow-up study, included 1000 COVID-19 cases confirmed with real-time reverse transcription-polymerase chain reaction; all cases were assessed with lung involvement documented and categorized on high-resolution computerized tomography (HRCT) thorax, oxygen saturation, and inflammatory marker as CRP at entry point and follow-up. Age, gender, comorbidity, use of bilevel positive airway pressure/noninvasive ventilation (BiPAP/NIV), and outcome as with or without lung fibrosis as per CT severity were key observations. Statistical analysis is performed using Chi-square test. Results: The HRCT severity score at entry point has significant correlation with CRP titer [P < 0.00001]. CRP titer has significant association with duration of illness (P < 0.00001). Comorbidities has significant association with CRP titer (P < 0.00001). CRP titer has significant association with oxygen saturation at entry point (P < 0.00001). BiPAP/NIV requirement during hospitalization has significant association with CRP titer (P < 0.00001). Timing of BiPAP/NIV requirement has significant association with CRP titer (P < 0.00001). Follow-up CRP titer during hospitalization compared to entry point normal and abnormal CRP has significant association in post-COVID lung fibrosis (P < 0.00001). Conclusions: CRP has documented a very crucial role in COVID-19 pneumonia in predicting severity of illness, progression of illness, and sequential CRP titers that will help assessing response to treatment during hospitalization and analyzing post-COVID lung fibrosis

Unexplained fever, weight loss, and worsened dyspnea with pulmonary hypertension as the presenting symptoms of mixed connective tissue disease with interstitial lung disease: A case report with review of literature

Pulmonary manifestations of mixed connective tissue disease (MCTD) include as bronchiolitis, bronchiectasis, and interstitial lung disease with or without pulmonary hypertension. Tuberculosis (TB) is the most common diagnosis in India in the presence of constitutional symptoms such as cough, fever, and weight loss with lung parenchymal abnormality, irrespective of microscopic or nucleic acid amplification test abnormalities due to high tuberculosis prevalent tropical setting. In this case report, a 35 year old female presented with constitutional symptoms and lung parenchymal nodules, interstitial involvement with lung fibrosis and pulmonary hypertension. Mediastinal window documented necrotic mediastinal lymph nodes, without negative mycobacterial microscopic (smear examination) or genome documentation (Gene Xpert MTB/RIF). She had received empirical anti tuberculosis treatment for three months without clinical or radiological response, resulted in progression of disease with clinical and radiological worsening and referred to our unit for further workup. Bronchoscopy guided evaluation for tropical screen including bacterial, fungal and tuberculosis with malignancy was inconclusive. Vasculitis and CTD workup documented antinuclear antibody (ANA) test strongly positive with very highly raised titres, with positive antigen as U1 small nuclear ribonucleoprotein particle, SSA/RO, single strand DNA, and Scl 70. Treatment initiated with systemic steroids, tadalafil, mycophenolate and diuretics, and satisfactory clinical response documented as near complete resolution of pulmonary parenchymal abnormalities in 24 weeks and pulmonary hypertension in 12 weeks. Pulmonary manifestations of MCTD are common, underestimated in the presence of constitutional symptoms, and early pickup of entity in course of illness will have good outcome with excellent prognosis

Bronchial wash Gene Xpert MTB/RIF in lower lung field tuberculosis: Sensitive, superior, and rapid in comparison with conventional diagnostic techniques

AbstractBackgroundLower lung field tuberculosis (LLF TB) is an atypical presentation of tuberculosis (TB). LLF TB is common, and a proportionate number of non-resolving pneumonia cases are diagnosed to have pulmonary TB.Materials and MethodsThe prospective observational study was conducted during June 2013 to December 2015 in the Department of Pulmonary Medicine, MIMSR Medical College, Latur, India; the objective of the study is clinical, microbiological, and radiological presentation of LLF TB and the comparison of yield of conventional diagnostic techniques and bronchoscopy-guided modalities in LLF TB. Additional important objective of the study is to find LLF TB in patients with nonresolving pneumonia (NRP). A total of 2,600 patients with pulmonary TB were included in the study after inclusion and exclusion criteria. Ethical clearance was taken from the ethical committee of the institutional review board. Consent was taken from the patients before inclusion in the study. Statistical analysis was done using chi-square test.ResultsIn the present study, 300 (11.53%) cases of LLF TB of total 2600 pulmonary tuberculosis were included, females constitutes 66.66% (200/300) with mean age of 58.4 ± 11.8 years and males constitutes 33.34% (100/300) with mean age of 56.8 ± 10.6 years. Constitutional symptoms were observed as cough in 93% cases, fever in 83% cases, shortness of breath in 72% cases, anorexia in 91% cases, and weight loss in 84% cases. Radiological assessment of study cases documented the involvement of right lower zone in 84% cases and left lower zone in only 16% cases. In the studied LLF TB cases, 57 cases (20.66%) were diagnosed by routine sputum microscopic examination for acid fast bacilli (AFB) and 80 cases (28%) were diagnosed by induced sputum microscopic examination for AFB. In the study of 170 LLF TB cases, head-to-head comparison between conventional diagnostic techniques (sputum microscopy and Induced sputum microscopy for AFB) made diagnosis in 60 cases, while bronchoscopy-guided sampling techniques (BAL for AFB and BAL for Gene Xpert MTB/RIF) made diagnosis in 155 cases (91.17%) (P&lt; 0.00001). Comorbid conditions such as human immunodeficiency virus (HIV) coinfection in 36 cases (12.00%), Diabetes mellitus in 64 cases (21.33%), and chronic kidney disease (CKD) in 22 cases (7.33%) were observed. Comorbidities were observed in 41.67% of the studied cases and found very significant assessment to have successful treatment outcome (P&lt; 0.00001). In the study of 300 LLF TB cases, 60 cases were having NRP pattern. In LLF TB cases with NRP pattern, bronchoscopy-guided bronchial wash microscopy for AFB made diagnosis in 18 cases (42%), while bronchoscopy-guided BAL for Gene Xpert MTB/RIF made diagnosis in 58 cases (96.66%) (P&lt; 0.00001).ConclusionLLF TB is usually underdiagnosed because of diverse clinical and radiological presentation, less diagnostic yield of conventional diagnostic modalities, and these modalities used routinely and universally. Bronchoscopy-guided diagnostic techniques are superior, sensitive, and reliable to confirm LLF TB. Gene Xpert MTB/RIF in bronchial wash samples is found to be best diagnostic modality in evaluating LLF TB and should be used routinely to have successful treatment outcome. A proportionate number of NRP cases are having LLF TB and a high index of suspicion is a must while evaluating these cases.</jats:sec

Isolated pulmonary hypertension without interstitial lung disease with progressive dyspnea in young female needs connective tissue diseases workup: A case report with review of the literature

Obstructive airway disease is the leading cause of breathlessness in young patients and in the absence of atopy or chest radiograph abnormalities such as nontubular heart and enlarged pulmonary artery mandates more workup. Pulmonary manifestations of mixed connective tissue disease (MCTD) range from bronchiolitis and bronchiectasis to interstitial lung disease and pulmonary hypertension. In this case report, a 25 year old female, presented with progressive dyspnoea and received treatment in line of obstructive airway disease with inhaled bronchodilators with inhaled corticosteroids with clinical worsening and no treatment response even after 24 months with good compliance. Radiological workup documented cardiomegaly with enlarged pulmonary artery in chest X-ray, multidetector computed tomography (MDCT) thorax documented grossly enlarged pulmonary arteries with dilated right heart chambers, and echocardiography documented severe pulmonary hypertension with dilated right atrium and right ventricle. Vasculitis and connective tissue diseases (CTD) workup was documented as strongly positive antinuclear antibody (ANA) with very highly raised titers, with other parameters in ANA blot documented positive antigens such as U1-small nuclear ribonucleoprotein particle, SSA/RO, single-strand DNA, and Scl-70. We have started on tadalafil, ambrisentan, and diuretics, and documented clinical response with increased work performance with improved quality of life with stabilization of pulmonary artery pressures on echocardiography at 12 weeks of treatment. We recommend young female genders with progressive dyspnea with nontubular heart on chest radiograph with or without enlarged pulmonary artery needs prompt workup such as high-resolution computed tomography/MDCT thorax, echocardiography, and ANA blot for early pickup of underlying CTD/MCTD to have successful treatment outcome

Reversible rheumatological syndrome with acute febrile respiratory illness secondary to COVID vaccination

Rheumatological manifestation with acute febrile respiratory illness known to occur after coronavirus disease 2019 (COVID-19) pneumonia and presenting as long COVID disease, its occurrence with COVID vaccination is not very well associated or described in the literature. In this case report, a 45-year-old female, presented with constitutional symptoms, persistent fever, and lung parenchymal infiltrates, without mycobacterial microscopic or genome documentation, received empirical anti-tuberculosis treatment with the progression of disease with little clinical or radiological response. Bronchoscopy workup was inconclusive and tropical screen for bacterial, fungal, Tuberculosis, and malignancy were negative. Vasculitis workup was inconclusive and rheumatological workup documented highly raised ANA titers. We have started her on steroid and hydroxychloroquine and clinical response documented with near-complete resolution of shadows in 12 weeks. Rheumatological syndrome which is a rare vaccine-related adverse event, reversible, and easily treatable with routinely available medicines and importantly, it is having excellent prognosis. Minimal systemic adverse events are known to occur with all viral vector vaccines, but its occurrence is rare and it should not impact on routine vaccinations; as vaccination is a key step in this pandemic to protect humankind

Serial interleukin-6 titer monitoring in COVID-19 pneumonia: Valuable inflammatory marker in the assessment of severity, predicting ventilatory support requirement, and final radiological outcome – Prospective observational study in tertiary care setting in India

Introduction: Coronavirus disease 2019 (COVID-19) pneumonia is heterogeneous disease with variable effect on lung parenchyma, airways, and vasculature, leading to long-term effects on lung functions. Materials and Methods: Multicentric, prospective, observational, and interventional study included 1000 COVID-19 cases confirmed with reverse transcription-polymerase chain reaction. All cases were assessed with lung involvement documented and categorized on high-resolution computed tomography (CT) of the thorax, oxygen saturation, inflammatory marker as interleukin-6 (IL-6) at entry point and follow-up. Age, gender, comorbidity, and use bilevel positive airway pressure/noninvasive ventilation (BIPAP/NIV) and outcome as with or without lung fibrosis as per CT severity were key observations. Statistical analysis is performed using Chi-square test. Results: Age ( 50 years) and gender (male versus female) has significant association with IL-6 (P < 0.00001) and (P < 0.010], respectively. CT severity score at entry point has significant correlation with IL-6 level (P < 0.00001) IL-6 level has significant association with duration of illness (P < 0.00001). Comorbidity as diabetes mellitus, hypertension, chronic obstructive pulmonary disease, ischemic heart disease, and obesity has significant IL-6 level (P < 0.00001). IL-6 level has significant association with oxygen saturation (P < 0.00001). BIPAP/NIV requirement during course hospitalization has significant association with IL-6 level (P < 0.00001). Timing of BIPAP/NIV requirement during hospitalization has significant association with IL-6 level (P < 0.00001) Serial IL-6 titer during hospitalization as compared to entry point normal and abnormal IL-6 has significant association in post-COVID lung fibrosis (P < 0.00001). Conclusions: IL-6 is easily available, and universally acceptable inflammatory marker, documented crucial role in COVID-19 pneumonia in predicting the severity of illness, progression of illness including “cytokine storm” and assessing response to treatment during hospitalization

Dengue-COVID-19 overlap: A single-center prospective observational study in a tertiary care setting in India

Background: Dengue-COVID-19 overlap is a mixture of both diseases sharing few similarities in pulmonary and extrapulmonary involvement. Although dengue fever is more commonly reported in tropical settings, very little literature is available regarding dengue-COVID-19 overlap in Indian context. Due to high prevalence of both diseases later being pandemic disease, and overlapping laboratory and clinical parameters, we have conducted a study to observe dengue-COVID-19 overlap in Indian settings in tertiary care hospitals. Methods: This prospective, observational study included 600 COVID-19 cases with dengue nonstructural protein 1 or dengue immunoglobulin (Ig) M positive, with lung involvement documented and categorized on high-resolution computerized tomography (CT) thorax at entry point. All cases were subjected to dengue IgG antibody titers and dengue IgM/IgG antibody titer analysis after 12 weeks of discharge from the hospital. Results: Dengue-COVID-19 overlap was documented in 16.33% (98/600) of cases. CT severity has documented a significant correlation with dengue-COVID-19 overlap cases (P < 0.00001). Hematological evaluation, white blood cell count, and platelet count were having a significant association with dengue-COVID-19 overlap (P < 0.0076 and P < 0.00001, respectively). Clinical parameters as hypoxia have a significant association with dengue-COVID-19 overlap (P < 0.00001). Inflammatory markers such as interleukin-6, C-reactive protein, and lactate dehydrogenase have a significant association in dengue-COVID-19 overlap (P < 0.00001), respectively. In study of 600 cases of “dengue COVID 19 overlap”, post COVID lung fibrosis was documented in 92/600 cases. Serological assessment between dengue IgM/IgG antibody and COVID antibody titers has a significant association with post covid lung fibrosis (P < 0.00001). Conclusions: Dengue-COVID-19 overlap is clinical syndrome with overlapping clinical and laboratory workup of both the illnesses. High index of suspicion is must in all COVID cases in tropical settings where dengue is endemic, and all cases with leucopenia and thrombocytopenia with fever should be screened for dengue serology. False-positive dengue serology or dengue antigen cross-reactivity is known to occur in underlying COVID-19 illness, and have impact on clinical outcome as it will result in delay in COVID appropriate treatment initiation and many cases require intensive care unit treatment due to progressed COVID pneumonia