April 2022 Medical Image of the Month: COVID Pericarditis

Figure 1. A: Pericardial enhancement on thoracic CT (red arrows). B: Thoracic CT in lung windows showing mosaic attenuation (black arrows) and bilateral pleural effusions (red arrows).

Figure 2. A: Static image of parasternal short axis on transthoracic echocardiogram showing moderate, generalized pericardial effusion with right ventricular diastolic collapse (red arrow). B. Static image of parasternal long axis on transthoracic echocardiogram again showing a moderate, generalized pericardial effusion (red arrow). Lower panel: video of echocardiogram in parasternal long axis view.

A 76-year-old patient presented with fatigue and shortness of breath after missing one session of dialysis. Past medical history included end stage renal disease on hemodialysis and atrial fibrillation on anticoagulation. Initial labs showed that she was COVID positive with mild elevation in troponin and a BNP 1200. While an inpatient, she had received a few sessions of dialysis and treatment for COVID (including dexamethasone and remdesivir). Initial echo showed an ejection fraction of 60-65% with a small generalized pericardial effusion, a thickened pericardium with calcification. A few days after admission patient was suddenly noted to be hypotensive with systolic blood pressure in the 70s and altered mental status. Repeated labs showed a D-Dimer of 17,232, leukocytosis, lactic acidosis, troponin 0.556 ng/ml and arterial blood gas with metabolic acidosis. With a worsening clinical picture, repeat imaging was obtained. CT angiography of the chest was negative for pulmonary embolism; however, it showed a large pericardial effusion with reduced size of the right ventricle more so than left, concerning for cardiac tamponade (Figure 1A). CT chest also showed moderate-to-large pleural effusions with scattered mosaic attenuation of the lung parenchyma (Figure 1B). Repeat transthoracic echocardiogram had a moderate generalized pericardial effusion with right ventricular diastolic collapse concerning for pericardial tamponade (Figure 2). Her airway was secured with endotracheal intubation and vasopressors added for hemodynamic support. Pericardiocentesis was indicated however, patient’s INR was severely elevated in the setting of anticoagulation use. Efforts were made to lower INR with FFP; however, patient had a PEA arrest the following day and expired.

COVID-19 has been classically known for its detrimental lung damage; however, it has shown to cause extrapulmonary effects as well. Cardiac injury is one phenomenon that has been seen with the fulminant inflammatory state that COVID is known to cause. With a few cases reported for COVID pericarditis, it is a possible culprit when all other causes have been ruled out. Pericardial involvement can be seen in about 20% of COVID 19 cases, with effusion found in about 5% of patients (1). Concomitant myocarditis can also be found in up to 17% of patients. Having isolated cardiac involvement with COVID is rare, with most cases presenting mainly as lung involvement in addition to other organs affected as well. Clinically, patients with pericarditis typically experience chest pain and in the setting of COVID infection, an increase in inflammatory markers. Characteristic findings of pericarditis include friction rub on auscultation, diffuse ST elevations on EKG and a potential progression to pericardial effusion on echo. When a pericardial effusion becomes large enough, it can progress to cardiac tamponade (2). Having a high clinical suspicion for tamponade is crucial in a patient who has developed respiratory distress and hypotension in the setting of recent viral pericarditis. It is a clinical diagnosis and requires rapid treatment with pericardiocentesis to prevent cardiac arrest.

Sarah Youkhana, MD¹ and Maged Tanios, MD²

St. Mary Medical Center, Long Beach, CA USA

¹Internal Medicine Resident, PGY-3

²Medical Director, Critical Care Services

References

1. Diaz-Arocutipa C, Saucedo-Chinchay J, Imazio M. Pericarditis in patients with COVID-19: a systematic review. J Cardiovasc Med (Hagerstown). 2021 Sep 1;22(9):693-700. [CrossRef] [PubMed]
2. Imazio M, Gaita F, LeWinter M. Evaluation and Treatment of Pericarditis: A Systematic Review. JAMA. 2015 Oct 13;314(14):1498-506. [CrossRef] [PubMed]

Cite as: Youkhana S, Tanios M. April 2022 Medical Image of the Month: COVID Pericarditis. Southwest J Pulm Crit Care Sleep 2022;24(4):62-3. doi: https://doi.org/10.13175/swjpccs006-22 PDF

Medical Image of the Month: Diffuse White Matter Microhemorrhages Secondary to SARS-CoV-2 (COVID-19) Infection

Figure 1.  An axial, maximal intensity projection (MIP), susceptibility weighted image (SWI) of the brain demonstrates numerous, punctate foci of susceptibility artifact in the genu (red arrow) and splenium of the corpus callosum (blue arrows). Other foci of susceptibility artifact are seen in the juxtacortical white matter (green arrows). These foci are consistent with microhemorrhages.

Clinical Scenario: A 59-year-old woman with hypothyroidism presented to the emergency room with progressive shortness of breath for 2 weeks.  Upon arrival, she was markedly hypoxic necessitating use of a non-rebreather to maintain her oxygen saturations above 88%. A chest radiograph demonstrated extensive, bilateral airspace disease. She was diagnosed with SARS-CoV-2 (COVID-19) pneumonia and started on the appropriate therapies. Approximately 48 hours into her hospitalization, she required intubation with mechanical ventilation due to her progressive hypoxemic respiratory failure.  She was intubated for approximately 5 weeks with a gradual improvement in her respiratory status, but not to the point where she was a candidate for a tracheostomy.  Despite being off sedation for an extended period, she remained unresponsive.  A CT of the head without contrast did not demonstrate any significant abnormalities.  An MRI of the brain was subsequently performed and demonstrated diffuse juxtacortical and callosal white matter microhemorrhages (Figure 1). Given her persistent encephalopathy and marked respiratory failure, her family elected to pursue comfort measures.

Discussion: In a recent retrospective analysis of brain MRI findings in patients with severe COVID-19 infections, 24% of the patients had extensive and isolated white matter microhemorrhages. White matter microhemorrhages with a predominant distribution in the juxtacortical white matter and corpus callosum are nonspecific and thought to be related to hypoxia.  Alternatively, small vessel vasculitis possibility related to a SARS-CoV-2 infection may result in this pattern of microhemorrhagic disease.  Diffuse axonal injury (DAI) is another etiology for microhemorrhagic disease distributed in the juxtacortical white matter and corpus callosum. However, DAI is secondary to a deceleration-type injury in the setting of trauma which is not present in most patients presenting with a SARS-CoV-2 infection. The prognosis of this condition remains to be determined.

Kelly Wickstrom, DO¹, Nicholas Blackstone MD², Afshin Sam MD¹, Tammer El-Aini MD¹

¹Banner University Medical Center – Tucson Campus, Department of Pulmonary and Critical Care, Tucson, AZ USA

²Banner University Medical Center – South Campus, Department of Internal Medicine, Tucson, AZ USA

References

1. Kremer S, Lersy F, de Sèze J, et al. Brain MRI Findings in Severe COVID-19: A Retrospective Observational Study. Radiology 2020: 297: E242-E251. [CrossRef] [PubMed]
2. Radmanesh A, Derman A, Lui Y et al. COVID-19-associated Diffuse Leukoencephalopathy and Microhemorrhages. Radiology. 2020 Oct;297(1):E223-E227. [CrossRef] [PubMed]

Cite as: Wickstrom K, Blackstone N, Sam A, El-Aini T. Medical Image of the Month: Diffuse White Matter Microhemorrhages Secondary to SARS-CoV-2 (COVID-19) Infection. Southwest J Pulm Crit Care. 2021;22(2):56-7. doi: https://doi.org/10.13175/swjpcc001-21 PDF

Medical Image of the Month: Viral Pneumonias

Figure 1. Pulmonary viral infection spectrum on thoracic CT scan in lung windows: A= Coronavirus NL63; B= Adenovirus; C= Influenza AH1 2009; D= COVID-19; E= Coronavirus HKU1; F= Influenza AH1 2009.

Numerous viruses, including the corona, influenza and adenoviruses can cause lower respiratory tract infection in adults (1). Viral pneumonia in adults can be classified into two clinical groups: so-called atypical pneumonia in otherwise healthy hosts and viral pneumonia in immunocompromised hosts. Until the COVID-19 pandemic, influenza virus types A and B caused most cases of viral pneumonia in immunocompetent adults. Immunocompromised hosts are susceptible to pneumonias caused by a wide variety of viruses including cytomegalovirus, herpesviruses, measles virus, and adenovirus. The CT imaging findings consist mainly of patchy or diffuse ground-glass opacity, with or without consolidation, and reticular areas of increased opacity, are variable and overlapping. The imaging findings in COVID-19 pneumonia are generally not distinctive compared to other viral pneumonias, including other coronaviruses such as SARS and MERS (2). A recent study systematically reviewed the longitudinal changes of CT findings in COVID-19 pneumonia. The results suggested that the lung abnormalities increase quickly after the onset of symptoms, peak around 6-11 days, and are followed by persistence of the findings.

Bacterial pneumonias may also take multiple forms and are sometimes difficult to radiographically separate from viral pneumonia (3). However, the presence of ground-glass opacities alone is unusual for a bacterial pulmonary infection. Rather, bacterial infections commonly present as areas of consolidation with air bronchogram formation, centrilobular nodules (often with branching configurations) and airway thickening.

Michael B. Gotway MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

References

1. Kim EA, Lee KS, Primack SL, et al. Viral pneumonias in adults: radiologic and pathologic findings. Radiographics. 2002 Oct;22 Spec No:S137-49. [CrossRef] [PubMed]
2. Wang Y, Dong C, Hu Y, Li C, Ren Q, Zhang X, Shi H, Zhou M. Temporal Changes of CT Findings in 90 Patients with COVID-19 Pneumonia: A Longitudinal Study. Radiology. 2020 Mar 19:200843. [CrossRef] [PubMed]
3. Panse PM, Jokerst CE, Gotway MB. May 2020 Imaging Case of the Month: Still Another Emerging Cause for Infiltrative Lung Abnormalities. Southwest J Pulm Crit Care. 2020. May 1. (in press). [CrossRef]

Cite as: Gotway MB. Medical image of the month: viral pnuemonias. Southwest J Pulm Crit Care. 2022;20(5):163-4. doi:  https://doi.org/10.13175/swjpcc028-20 PDF 

May 2020 Imaging Case of the Month: Still Another Emerging Cause for Infiltrative Lung Abnormalities

Prasad M. Panse MD

Clinton E. Jokerst MD

Michael B. Gotway MD

Department of Radiology

Mayo Clinic, Arizona

Scottsdale, Arizona 85054

Clinical History: A 46-year-old man with a history of well-controlled asthma presented to the Emergency Room with complaints of worsening non-productive cough for 4-5 days followed by fever to 104°F over the previous 3 days. The patient also complained of some chills and loose stools. The patient denied rhinorrhea, sore throat, congestion, and nausea or vomiting. The patient also denied illicit drug use, and drinks alcohol only occasionally and denied smoking.

The patient’s physical examination showed a pulse rate of 79 / minute and a respiratory rate of 18 / minute, although his blood pressure was mildly elevated at 149/84 mmHg; he was afebrile with a temperature of 97.7 °F (36.5 °C). The patient’s room air oxygen saturation was 98%. The physical examination showed some mild expiratory wheezes bilaterally, but was otherwise entirely within normal limits.

Which of the following represents the most appropriate step for the patient’s management? (Click on the correct answer to be directed to the second of twelve pages)

1. Obtain a complete blood count
2. Obtain a travel history
3. Obtain serum chemistries
4. Perform chest radiography
5. All of the above

Cite as: Panse PM, Jokerst CE, Gotway MB. May 2020 imaging case of the month: still another emerging cause for infiltrative lung abnormalities. Southwest J Pulm Crit Care. 2020;20(5):147-62. doi: https://doi.org/10.13175/swjpcc027-20 PDF