Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Case Series
Year : 2022 | Month : June | Volume : 16 | Issue : 6 | Page : TR01 - TR04 Full Version

Pulmonary Cystic Lesions in Patients with COVID-19 Infection: A Case Series


Published: June 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/55309.16529
Neema Agarwal, Payal Jain, Tooba Naved Khan, Aakash Raja

1. Associate Professor, Department of Radiodiagnosis, Government Institute of Medical Sciences, Greater Noida, Uttar Pradesh, India. 2. Associate Professor, Department of Internal Medicine, Government Institute of Medical Sciences, Greater Noida, Uttar Pradesh, India. 3. Senior Resident, Department of Radiodiagnosis, Government Institute of Medical Sciences, Greater Noida, Uttar Pradesh, India. 4. Junior Resident, Department of Radiodiagnosis, Government Institute of Medical Sciences, Greater Noida, Uttar Pradesh, India.

Correspondence Address :
Dr. Neema Agarwal,
NIET, 19 Institutional Area, Knowledge Park 2, Greater Noida-201306, Uttar Pradesh, India.
E-mail: neemaagarwal@yahoo.com

Abstract

Computed Tomography has played a vital role in Coronavirus Disease 2019 (COVID-19) infection, caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) over the last two years. The typical features of COVID-19 on High Resolution Computed Tomography (HRCT) of chest including ground glass opacities and consolidation with a peripheral and lower lobar predilection have been very well documented in literature worldwide. However, thin-walled lucencies in the lung parenchyma called cysts is not very well documented. Authors thus present a case series comprising six SARS-CoV-2 Reverse Transcription-Polymerase Chain Reaction (RT-PCR) positive patients admitted to the hospital during the period 1st April 2021 to 31st May 2021 with lung cysts on HRCT. It was a retrospective study wherein details of the patients were drawn from the case record sheets and the clinical parameters along with HRCT chest findings were analysed, and correlations were drawn to study the cause, timing and significance of these cysts. In this study, the cysts were found to be thin-walled, varying in size from 5-20 mm in diameter and subpleural in distribution with no obvious lobar predilection.The immediately surrounding lung parenchyma showed features of maximal involvement by the atypical pneumonitis. All six cases had moderate to severe lung involvement entailing oxygen therapy. The high flow oxygen therapy and its duration along with degree of lung involvement, are important determinants of cystic degeneration. In the present case series, cystic changes were observed somewhere between day 15 to day 40 of the disease and thus a part of postacute fibrosis in COVID-19 infection.

Keywords

Coronavirus disease 2019, Computed tomography, Cystic lesions of the lungs

The second wave of Coronavirus Disease 2019 (COVID-19) infection in India was massive and took the nation by storm. The complications that came up with this infection were hazardous and unfamiliar. Computed Tomography (CT) images keeping up with COVID-19 pneumonitis include peripheral distribution of patches of ground glass opacities and consolidation, more so in the lower lobes. Subsequent findings with advanced stages of the disease include fibrosis, septal thickening, and architectural distortion (1),(2). To encounter thin-walled lucencies in the lung parenchyma called cysts is not very well documented. To date, no substantial study delineating the underlying aerodynamics has been published in India and very few worldwide. This case series comprises six Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Reverse Transcription-Polymerase Chain Reaction (RT-PCR) positive patients admitted to the hospital during the period 1st April 2021 to 31st May 2021 with lung cysts on High Resolution Computed Tomography (HRCT) of chest. This case series aimed to study the cause, timing, and significance of these lung cysts.

The study was commenced after the permission from the Institutional Scientific Research Committee and Ethics Committee. It was a retrospective study, and the details of the patients were drawn from the case record sheets available in the hospital Medical Records Section. The clinical parameters and HRCT chest findings were analysed by two radiologists with five year’s experience each, and correlations were drawn.

To begin with, authors came across such lung cysts in nine patients. The patients with a history of smoking, Chronic Obstructive Pulmonary Disease (COPD), pulmonary Koch’s, and any other chronic respiratory illness were excluded from the series, only 6 cases were studied (Table/Fig 1).

Case Report

Case 1

A 62-year-old male, a known diabetic, with SARS-CoV-2, RT-PCR confirmed COVID-19 infection, presented to emergency with peripheral capillary oxygen saturation (SpO2) of 68%. He was admitted to a level 1 facility for initial 13 days of illness but due to worsening of his clinical condition, he was transferred to our hospital and was admitted to the Intensive Care Unit (ICU). Patient was a non smoker, normotensive with no history of pre-existing chronic respiratory illness. His HRCT chest done on day 14 from symptom onset showed extensive, diffuse bilateral lung involvement with features of COVID-19 pneumonitis and Computed Tomography Severity Score (CTSS) of 21/25 (3). He was initially managed with Non Invasive Ventilation (NIV) for 7 days followed by High Flow Nasal Cannula oxygen (HFNC) for the next 7 days. A repeat CT chest done on day 28 of symptom onset showed an increase in CTSS to 24/25 with multiple small subpleural and intraparenchymal thin-walled cysts ranging from 14-19 mm in diameter, more so in the upper lobes. Also, there were mild bilateral pneumothorax and minimal pneumomediastinum which were managed conservatively. In the following week, patient oxygen demand decreased, and he was given 3-4 litersof oxygen/minute through a nasal cannula. The patient was then shifted to a General Ward and discharged a week later.

Case 2

A 64-year-old male with COVID-19 infection confirmed 20 days ago, was brought from home isolation with worsening cough and dyspnoea. He was a non smoker with no history of chronic respiratory illness but wasa known hypertensive and diabetic. On admission, his Random Blood Sugar (RBS) was 221mg/dL and SpO2 was 87% on room air. His HRCT was done on the day of admission (Day 21 from the symptom onset) and showed moderate lung involvement with a CTSS of 15/25. There were three peripheral thin-walled cysts, varying in size from 5-6 mm in diameter, one in the right middle and two in the left lower lobe, which were seen amidst the areas of ground glass attenuation (Table/Fig 2). The cysts were clear with no fluid within, and the surrounding parenchyma seemed no different from the parenchyma affected in other areas. During his hospital stay, he was on 7 L/min oxygen support by mask for the first 5 days, and then the oxygen support was tapered over the next 3 days before discharge.

Case 3

A 81-year-old diabetic male, diagnosed with COVID-19 related pneumonia, admitted to the hospital on day 18 of illness. The patient presented with shortness of breath with SpO2 of 85% and a respiratory rate of 28 breaths per minute. At this time, RT-PCR for SARS-CoV-2 was found to be negative.The HRCT chest done on the day of admission revealed moderate lung involvement with CTSS of 16/25 and 5-6 peripheral imperceptible thin-walled cysts measuring around 10-13 mm in diameter in subpleural location in right lower lobe and left upper lobe. No bacterial superinfections were found.Also, the CT showed minimal left pneumothorax, but the patient was haemodynamically stable. During his12 days of hospital stay, he was on oxygen support initially ona high flow mask and later tapered to nasal prongs.The pneumothorax wasmanaged conservatively, followed with chest radiographs, and did not require chest tube insertion.

Case 4

A 26-year-old male, driver by profession, with no documented co-morbidities, reported to the hospital with severe dyspnoea, cough, and fever. Patient was in home isolation for the first 2 weeks of illness, was admitted to a hospital with worsened symptoms in the third week and came to us when showed no improvement there. His SpO2 on ambient room air was 80% at the time of admission. He underwent HRCT chest on admission which showed severe bilateral pneumonitis with septal thickening, more so in the lower lobes. His CTSS was reported to be 20/25. Few (3-4) thin-walled cysts were found in bilateral upper and lower lobes (Table/Fig 3). The average size of the cysts was less than 10-20 mm. He was put on oxygen support with a venturi mask of 8 L/min on admission and transferred to ICU. His oxygen requirement reduced over the next week and he was discharged on the 14th day from the day of admission.

Case 5

A 68-year-old female patient, a known hypertensive, who came with dyspnoea and chest pain on the 22nd day of illness. Her nucleic acid test by RT-PCR was initially positive on a nasopharyngeal swab on the 5th day of illness but was negative when repeated in the hospital. With an oxygen saturation of 78% on room air, the patient was admitted to ICU and was given 10 L/min oxygen support.

On HRCT chest she showed ground glass attenuation with fibrotic bands and traction bronchiectasis in the lower lobes with a CT severity score of 20/25. Multiple (7-8) subpleural cysts (14-16 mm in diameter) were seen more so in the right lung (Table/Fig 4). She was significantly hypoxaemic, with falling of saturation even on 15 L/min oxygen via a non rebreather mask, a high respiratory rate of 42 breaths per minute, and tachycardia. Patient was required to put on 40 liters/min of oxygen therapy withHFNC for 14 days before the oxygen support could be gradually weaned.

Case 6

A 38-year-old female who was admitted on the 39th day of illness on clinical deterioration with shortness of breath and cough. She had no known co-morbidities and her SpO2 on admission was 64%. She had leuckocytosis and elevated inflammatory biomarkers in her blood reports initially. Her previous CT chest done elsewhere showed a CTSS of 18/25. Repeat CT done in the hospital on the day of admission showed worsened pneumonitis with CTSS of 25/25. There was fibrosis, more so subpleural and multiple (8-9) intraparenchymal cysts, varying between 13-18 mm in diameter (Table/Fig 5). She initially required NIV support in ICU for 8 days followed by 35 liters/min support by HFNC for the next 15 days. Oxygen support thereafter could be gradually tapered in another 10 days before discharge.

Discussion

The COVID-19 infection, caused by SARS-CoV-2, though may present as a multiorgan disease, has a predilection for the lungs. The CT, which has a sensitivity of 89-97%, has played a vital role in the pandemic, for patient triage even before the RT-PCR results, to predict the disease course,and to diagnose and confirm complications (4).

Now it has been clear that initially ground glass opacities and consolidation predominate having peripheral and lower lobar predilection. These findings peak at around 10-14 days. Thereafter they either resolve or progress in week 3 where consolidation may be admixed with reticular opacities. Post-acute fibrosis,now called Postacute Sequelae COVID-19 (PASC) can thereafter develop, wherein CT the multifocal ground glass and reticular opacities may persist, along with interlobular septal thickening; however, signs of fibrosis emerge including subpleural parenchymal bands with or without architectural distortion, traction bronchiectasis, areas of mosaic attenuation with emphysema and cysts (1),(2),(5),(6).

Acute Respiratory Distress Syndrome (ARDS), direct virus injury, and barotrauma due to mechanical ventilation have been attributed to the etiology of PASC lung. Radiologically, the extent of initial lung involvement may be a predictor for PASC (5).

There are few case reports on the association of COVID-19 with cystic diseases so far. As far as cysts are concerned, they must be differentiated from cavities as their etiologies differ. Cyst is defined as a well-defined, thin-walled (usually epithelial or fibrous, less than 3 mm in thickness), air or fluid containing lesion, 1 cm or more in diameter (7).

Commonly, cysts are found in subpleural areas of the lung and represent emphysema, bullae of honeycombing. Cystic disease related to COVID-19 has not been commonly reported with theprevalence cited in literature so far between 9% and 25% (8). Such cysts are usually well-defined, thin-walled (2-4 mm), variable in size, usually less than 2.5 cm; though larger cysts have also been described in a few case reports (8),(9).

During the second wave of COVID-19, we came across eight such patients who had cystic lesions in the lung parenchyma, six of whom did not have any plausible underlying condition predisposing them to the same which we included in this case series. None of the patients showing pulmonary cystic lesions was diagnosed with superadded infection during their hospital stay.

In the present case series, the cysts were found to be thin-walled and subpleural in distribution. The immediately surrounding lung parenchyma showed features of maximal involvement by the atypical pneumonitis. Similar findings were reported in a previous study wherein, the cysts were located in the region of peak disease activity (9). Also, all six of the presented cases cases had moderate to severe lung involvement as per CTSS. Authors assume that extensive lung involvement is suggestive of higher inflammatory activity in the region. Also, there is more likelihood of assisted ventilation requirements in such patients. The combination of these underlying factors probably results in predisposing patients with more severe diseases to have higher chances of developing cystic complications. In current case series, two patients received NIV, 2 required HFNC and the rest were on high flow or Venturi mask. Thus, authors found that though the mode of oxygen delivery was varying, yet the high flow oxygen therapy and its duration along with degree of lung involvement, are important determinants of cystic degeneration as cited in other studies (5),(7).

The aetiology of these cysts isstill unclear. Two schools of thought prevail, one believes that these cysts are secondary to parenchymal damage, fibrosis, and low compliance which may be associated with mechanical ventilation in some cases but can also arise in advanced ARDS. Others believe that they arise due to architectural distortion when consolidation resolves (10),(11).

Interestingly such cysts have not been reported in other viral pneumonia unless there was pre-existing interstitial lung disease or emphysema (9).This may be since the infection with COVID-19 and other coronaviruses cause persistent airflow obstruction which is not the case with other viral pneumonia (12). It is postulated that such airway obstruction by mucus plugs or fibromyxoid exudates may have a valve effect on the bronchus and persistent coughing or assisted ventilation may result in a sudden increase in intra-alveolar pressure and alveolar rupture resulting in subpleural cysts or even pneumothorax (13).Two out of six patients in the present case series developed pneumothorax.

In the presented cases, HRCT Chest was performed after the administration of high flow oxygen therapy had begun and cystic changes were observed somewhere between day 15 to day 40 of the disease. We contemplate it to be the time taken by inflammatory storm to bring about the evolution of pulmonary lesions and the effect of prolonged oxygen therapy administered to the patients. This time lag was also reported in other case reports (13),(14).

No definite correlation with any co-morbidities could be assessed. Probably bigger studies with more number of cases would be required to rule out any association.

Authors followed-up with the presented patients in Post COVID-19 Clinic in the hospital after their discharge. As per the protocol, regular follow-up was done with Clinical assessment, chest radiography and pulmonary rehabilitation. These patients improved clinically over time and did not develop obvious pneumothorax on chest radiography.Considering the radiation exposure, HRCT was not part of the follow-up protocol and so the progression or resolution of the cysts cannot be commented upon.

Conclusion

Authors conclude that prolonged oxygen therapy particularly high flow oxygen therapy like NIV or HFNC, in the backdrop of extensive parenchymal involvement by COVID-19 pneumonitis resulted in mechanical injury to the alveoli, resulting in cyst formation, predominantly in the subpleural distribution.

References

1.
Carotti M, Salaffi F, Sarzi-Puttini P, Agostini A, Borgheresi A, Minorati D, et al. Chest CT features of coronavirus disease 2019 (COVID-19) pneumonia: Key points for radiologists. Radiol Med. 2020;125:636-46. [crossref] [PubMed]
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DOI and Others

DOI: 10.7860/JCDR/2022/55309.16529

Date of Submission: Jan 29, 2022
Date of Peer Review: Mar 17, 2022
Date of Acceptance: May 06, 2022
Date of Publishing: Jun 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Feb 03, 2022
• Manual Googling: May 05, 2022
• iThenticate Software: May 11, 2022 (6%)

ETYMOLOGY: Author Origin

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