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 : July | Volume : 16 | Issue : 7 | Page : OR01 - OR05 Full Version

Pulmonary Cavity: An Additional Entity to the Spectrum of COVID-19 Complications


Published: July 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/55252.16663
Keertivardhan D Kulkarni, V Pranavi, Apoorva Ravi, HT Lathadevi, SM Biradar

1. Associate Professor, Department of Respiratory Medicine, Shri. B. M. Patil Medical College, Hospital and Research Centre, Vijayapura, Karnataka, India. 2. Postgraduate Student, Department of Respiratory Medicine, Shri. B. M. Patil Medical College, Hospital and Research Centre, Vijayapura, Karnataka, India. 3. Postgraduate Student, Department of Respiratory Medicine, Shri. B. M. Patil Medical College, Hospital and Research Centre, Vijayapura, Karnataka, India. 4. Professor, Department of Ear, Nose and Throat, Shri. B. M. Patil Medical College, Hospital and Research Centre, Vijayapura, Karnataka, India. 5. Professor, Department of General Medicine, Shri. B. M. Patil Medical College, Hospital and Research Centre, Vijayapura, Karnataka, India.

Correspondence Address :
Dr. V Pranavi,
House No. A105, NRI and PG Hostel, Shri. B.M Patil Medical College, Hospital and Research Centre, B.M. Patil Road, Vijayapura-586103, Karnataka, India.
E-mail: pranavireddy94@gmail.com

Abstract

The latest pandemic caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is known to manifest in various forms, ranging from a mild illness to a life-threatening condition. Though lung cavitation has not been commonly reported as a post Coronavirus Disease 2019 (COVID-19) infection complication, there has been a rise in the number of patients presenting with lung cavitation post the viral infection. In this case series, authors have reported four cases of lung cavitation developed post COVID-19 infection. Three out of four patients were newly diagnosed cases of diabetes, all received steroids as a part of treatment for COVID-19 infection. Three patients showed a temporary improvement in their condition after COVID-19 treatment, in the form of decreasing trends of inflammatory markers and decreased total count, but subsequently developed signs of super added infection during the course of their illness. Two patients had associated sino-orbital mucormycosis. Two patients required the support of non invasive ventilation and did not show clinical improvement, while one amongst the two succumbed to the infection. The cause for the development of lung cavities post COVID-19 infection is difficult to speculate it appears to be multifactorial with factors including isolated bacterial, fungal infections or bacterial and fungal co-infection, SARS-CoV-2 specific inflammatory pathways, and the immunosuppressive effects of glucocorticoids.

Keywords

Coronavirus Disease 2019, Co-infection, Fungal infections, Mucormycosis, Steroids

The pandemic of coronavirus remains to be a continuing problem worldwide, with the disease manifesting in various forms, leading to difficulties in devising a standard protocol for management. Although the mechanisms causing acute clinical presentation are mostly clear now, surviving the disease is the first battle among many along the long road to recovery, as there are post COVID-19 complications reported that are equally life threatening (1). The typical abnormalities that have been described commonly in Computed Tomography (CT) of the chest among COVID-19 infected patients are peripheral ground glass opacities, consolidation, linear opacities, crazy-paving pattern and interlobular sepal thickening (2). Few studies reported on the development of traction bronchiectasis and pleural effusions at late stages of severe disease but very few case reports have been published that reported the presence of lung cavitation as a COVID-19 infection squeal (3),(4). Cavitation in COVID-19 pneumonia may be due to the diffuse alveolar damage, intra-alveolar haemorrhage, and necrosis of parenchymal cells (5). This case series include four cases of cavitatory lesions in the lung that developed post COVID-19 infection.

Case Report

Case 1

A 55-year-old female was tested positive for COVID-19 infection, by nasopharyngeal swab for Reverse Transcription-Polymerase Chain Reaction (RT-PCR). The patient had no history of diabetes or any other debilitating conditions and no relevant family history. On admission, complete blood count, liver and renal function tests were within normal limits, CRP was >90 mg/L, D-dimer was 314 ng/mL and Interleukin-6- 4.2 pg/mL. Her High Resolution Computed Tomography (HRCT) scan of the thorax revealed multifocal well-defined patchy ground glass opacities in bilateral lung fields in subpleural distribution with a CT severity index of 8/25 (Table/Fig 1)a,b. Her Glycated hemoglobin (HbA1c) at the time of admission was 8.5%, with Fasting Blood Sugar (FBS) being 132 mg/dL, and Post Prandial Blood Sugar (PPBS) being 213 mg/dL.

She was started on intravenous (i.v.) inj. remdesivir with a loading dose of 200 mg, followed by 100 mg daily for 5 days, inj. piperacillin Tazobactam 4.5 gm i.v. TID, inj. methylprednisolone i.v. 80 mg/day, inj. low molecular weight heparin 0.6 mL subcutaneously BD, and inj. human actrapid titrated according to blood sugar values as a part of COVID-19 management for 7 days, and then discharged. The patient required no oxygen support during her stay in the hospital.

After three days of discharge, the patient complained of headache and watery discharge from the right eye followed by redness and swelling of face on the right side, associated with pain. On examination, her oxygen saturation was 89% at room air, there was complete ptosis of right eye with chemosis and absent perception to light, with no nasal discharge. She was re-admitted and provided oxygen support.

Magnetic Resonance Imaging (MRI) of brain, orbit and paranasal sinuses revealed peripherally enhancing mucosal collection in the right ethmoidal, right half of frontal and right maxillary sinus with an early orbital invasion seen at the base of right orbit, suggestive of fungal sinusitis (Table/Fig 1)c. She was started on inj. amphotericin B 50 mg/day i.v. infusion in 5% dextrose along with anticoagulants and Tab. posaconazole 100 mg TID, with careful monitoring of renal function tests and blood sugar levels and inj.human actrapid titrated according to it. On 7th day of her treatment, her C-Reactive Protein (CRP) showed a decreasing trend (20.2 mg/L), but D-dimer was persistently elevated (4766.75 ng/mL), with perception of light present in right eye, but her ocular movements were restricted.

During the treatment period, after five days of starting antifungals, the patient complained of increased cough with sputum production, which was blackish in colour. Chest X-ray showed cavity with air fluid level on left side suggestive of lung abscess (Table/Fig 1)d. The patient was started on antibiotic inj. meropenem 1 gm IV BD and was advised chest physiotherapy and postural drainage. Plain CT thorax showed subsegmental and segmental patches of consolidation with internal large cavitatory changes with air fluid levels within, in left upper and left lower lobe; suggestive of active infective lung parenchymal disease with possibility of pulmonary mucormycosis, though the typical reverse halo sign or bird's nest sign were not seen (Table/Fig 1)e. The patient's sputum samples were sent for aerobic culture and fungal culture, which revealed the presence of Klebsiella pneumoniae that was resistant to all antibiotics except fosfomycin, while fungal culture did not yield any results. The patient was later advised Functional Endoscopic Sinus Surgery (FESS), which was done at a higher centre where the scrapings showed no yield in fungal culture. Unfortunately, the patient succumbed to the infection.

Case 2

A 42-year-old male, RT-PCR for COVID-19 positive, presented with breathlessness with oxygen saturation of 82%. His medical history revealed no co-morbidities. On admission, his haemoglobin was 14 g/dL, with a total count of 18,320/μL, while his liver and renal function tests were within normal limits. His CRP was >90 mg/L and D-dimer was 4280.20 ng/mL, with HbA1c 7.7%. His FBS and PPBS values were 265 mg/dL and 309 mg/dL respectively. The HRCT of thorax revealed multiple bilateral patchy ground glass opacities with CT severity score of 16/25 as shown in (Table/Fig 2)a,b.

He was supplemented with oxygen and was started on inj. remdesivir 200 mg i.v. once a day on first day followed by 100 mg once a day for another four days, Inj. piperacillin tazobactam 4.5 gm i.v. TID, Inj. methylprednisolone i.v. 120 mg/day, Inj. low molecular weight heparin 0.6 mL subcutaneously BD and Inj. human actrapid titrated according to blood sugar values. The patient required non invasive ventilation after two days of admission due to fall in oxygen saturation levels, when the total count raised to 26,090/μL, while CRP and D-dimer showed a decreasing trend (10.3 mg/L and 2636.49 ng/mL, respectively). The antibiotic was changed to inj. meropenem 1 gm i.v. BD. The patient was maintained on non invasive ventilation for 13 days when the total count dropped down to 15,670/μL, with CRP and D-dimer showing persistently decreasing trends (<10 mg/L, and 1545 ng/mL, respectively), with gradual improvement in patient’s condition.

The patient was weaned off to oxygen support, when his cough worsened with expectoration after five days of weaning off. He also complained of an episode of hemoptysis, following which anticoagulants were stopped and a repeat HRCT thorax was ordered, which revealed diffuse randomly distributed areas of ground glass attenuation with interlobular septal thickening and alveolar exudates in bilateral lungs with an ill-defined thick walled cavitatory lesion with surrounding consolidation causing architectural distortion, volume loss in bilateral upper lobe and left lower lobe, along with left sided mild pleural effusion suggestive of organising lobar pneumonia with breakdown cavitation and septic emboli. This radiological findings were suggestive of pulmonary mucormycosis (Table/Fig 2)c,d. But the patient had no symptoms and signs of sino-orbital mucormycosis.

On further evaluation, his CRP raised to 224 mg/L, while his D- dimer showed a continuing decreasing trend (822 ng/mL) and total count raised to 20,998/μL, but the patient's oxygen requirement remained to be 8 litres/minute. The patient was subsequently started on Inj. amphotericin B 50 mg/day iv infusion in 5% dextrose, with careful monitoring of renal function tests and blood sugar levels, owing to the rise in mucormycosis cases among COVID-19 infected patients. For further management of cavitatory lesion in the lung, he was advised to consult a thoracic surgeon for surgical management, and hence referred after 5 days of treatment with antifungals. The trends of inflammatory markers and total count during the course of illness has been summarised in (Table/Fig 3).

Case 3

A 55-year-old male presented with complaints of right sided facial pain with swelling on the right side of the face of 3 days duration. He gave a history of abscess on the right cheek, that burst out with pus discharge. The patient had no history or contact with COVID-19 infection and suffered from no known co-morbidities. On evaluation, his complete blood count, liver and renal function tests were within normal limits. His FBS and PPBS values were 197 mg/dL and 226 mg/dL respectively, with HbA1c of 14.1%. CT of paranasal sinuses revealed minimal mucosal thickening of right maxillary sinus (Table/Fig 4)a. On suspicion of a sequelae of COVID-19 infection, patient was tested for COVID-19 antibodies, IgM was positive, while nasopharyngeal swab for RTPCR turned out to be negative. Due to IgM antibody positivity, the patient was further evaluated with HRCT thorax to rule out active COVID-19 infection, which revealed a cavitatory lesion in right upper lobe of the lung while the rest of the lung parenchyma was normal (Table/Fig 4)b,c, though the patient had no respiratory complaints. The patient had no previous history of tuberculosis either. The CT score was 2/25. The CRP levels were 421 mg/L, D-dimer was 796.03 ng/mL, IL-6 49.6 pg/mL and serum ferritin 861.3 ng/mL with total count of 18,628/μL. His sputum analysis was negative for AFB and later was advised to undergo FESS, and the scrapings were subjected to histopathological examination, which were suggestive of mucormycosis and aspergillosis in bilateral maxillary sinus. The patient was started on Inj. Amphotericin B 50mg/day iv infusion in 5% dextrose, keeping a check on the blood sugar levels and titrating them accordingly. After one week of Inj. amphotericin, the patient was discharged with oral posaconazole 200 mg TID, while CRP levels reduced to 29.4 mg/L and D-dimer was 202 ng/mL and total count of 10,101/μL. The patient was reviewed after 2 weeks when renal function tests were within normal limits, as the patient's blood sugar levels were kept in control with Inj. human actrapid and Inj. lantus. The patient was also advised to consult a thoracic surgeon for the resection of affected segment of the lung. The trends of inflammatory markers and total count during the course of illness has been summarised in (Table/Fig 5).

Case 4

A 46-year-old female presented with complaints of low grade, intermittent fever with dry cough and breathlessness. She turned RT-PCR positive for COVID-19 infection. Her room air saturation was 88%, hence given oxygen support at 6 l/min that improved her saturation to 94%. Her blood panel revealed anemia (Hb- 9.6 g/dL), with normal white blood cell count and platelets. Her liver and renal function tests were within normal limits, while CRP was elevated with a value of 67.3 mg/L, with a normal D-dimer level (370 ng/mL). She was a known diabetic for 6 years and was on regular medication. Her HbA1c was 7.2% with FBS being 178 mg/dL and PPBS being 209 mg/dL and total count was 11,232/μL.

The HRCT thorax at the time of admission showed multiple patchy areas of consolidation with adjacent ground glass opacities and pleural thickening involving bilateral lung fields, with a CT severity score of 22/25 (Table/Fig 6)a,b. She was started on Inj. remdesivir 200 mg in 100 mL normal saline on day 1 followed by 100 mg OD for the next 4 days, Inj. methylprednisolone 40mg BD, Inj. lenox 0.4 mL subcutaneous BD, antibiotics and Inj.human actrapid according to sliding scale.

The patient had a fall in saturation on the third day of admission and did not improve even with 15 L/min of oxygen. Hence, she required non invasive ventilation, and with an FiO2 of 80%, she maintained saturation of 96%. Her repeated values of CRP and D- dimer on the third day showed an increasing trend with levels being, >90 mg/L and 1400.70 ng/mL respectively, while white blood cell count raised to 11,500/μL, with further fall in hemoglobin levels (8.6 g/dL). After three days, CRP (125 mg/L) and D-dimer (2376 ng/mL) showed an increasing trend, with total blood count being 14,375/μL, and no improvement in the condition of the patient for 12 days. The dosage of Inj. methylprednisolone was increased to 80 mg BD, and Inj. lupenox to 0.6 mL subcutaneous BD, with Inj. remdesivir extended to a total of 10 days. After 12 days, the levels of inflammatory markers showed a decreasing trend, with CRP was 14.8 mg/L and D-dimer was 494 ng/mL. Her IL-6 levels were 4.9 pg/mL, and the patient’s FiO2 requirement on non invasive ventilation reduced to 60%. The patient was on non invasive ventilation for another 10 days, where her CRP, D-dimer and complete blood count were continuously monitored. Her hemoglobin levels improved to 12.7 g/dL, while total count raised to 15000/μL, with CRP and D-dimer reaching normal limits. The patient was gradually weaned off to oxygen on 23rd day, while she maintained saturation of 95% with 12 L/min. On the 32nd day, the patient developed increased breathlessness, with productive cough, sputum being greenish in colour, mucoid in consistency, quantity of less than one teaspoon/day, with no blood staining.

A repeat HRCT thorax was advised, owing to progressive breathlessness, which revealed moderate to large sized subpleural areas of ground glass attenuation in bilateral lungs, with a thick-walled cavity lesion in the posterior segment of the right lower lobe and in the left upper lobe with adjacent consolidation that was suggestive of necrotising pneumonitis, likely fungal aetiology like mucormycosis (Table/Fig 6)c,d. Her CRP levels were 164 mg/L, D-dimer was 4000 ng/mL, total count 20,175/μL. She was empirically started on Inj.amphotericin B 50 mg/day i.v. infusion in 5% dextrose, while her sputum analysis was insignificant. The patient did not improve with continuous oxygen support and later succumbed to the infection after 6 days. The trends of inflammatory markers and total count during the course of illness has been summarised in (Table/Fig 7).

Among the four COVID-19 infected patients, the age group involved was between 42-55 years, with a male to female ratio of 1:1. All the patients suffered from diabetes mellitus, and received steroids as a part of COVID-19 treatment. Patients with moderate and severe COVID-19 infection required non invasive Ventilation support and their clinical condition deteriorated. It was also observed that two patients with mild COVID-19 infection had associated probable sino-orbital mucormycosis. The details of the patients along with outcomes have been summarised in (Table/Fig 8).

Discussion

The survivors of the pandemic are in constant dread, along their road to recovery, regarding the complications that arise, which range from persistent fatigue, dyspnea to thromboembolic events and pulmonary fibrosis, whilst lung cavitation has been an uncommon finding on CT thorax among COVID-19 infected patients (2),(6).

On reviewing the literature, Chen Y et al., Anguish B et al., and few others reported the occurrence of lung cavities after COVID-19 infection (6),(7). The incidence of cavitatory lung lesions as a complication of COVID-19 infection has been reported to vary from 1.7% to 11% in several studies (3),(4) In a retrospective study by Zoumot Z et al., 11% incidence rate of lung cavitation amongst the patients with severe COVID-19 infection, admitted in Intensive Care Unit (ICU), was reported, while 3.3% of the patients with mild COVID-19 infection developed pulmonary cavity (8).

A cavity is an air-filled space forming within an area of pulmonary consolidation, mass or nodule, as a result of liquefication of the necrotic portion of the lesion and the discharge of this necrotic material via the bronchial tree (8). This exact process seems to have occurred in our patients as cavities formed in areas of the lung where ground glass opacities were seen in early stages. Cavitatory lung lesions are usually related to fungal, mycobacterial, autoimmune, parasitic or neoplastic aetiologies, uncommonly caused by viral pneumonias even in severe infection, but have been observed in COVID-19 patients. The velocity of development of cavitatory lesions can be atypical to mycobacterial infections, with supportive evidence of negative acid-fast bacilli on smear of respiratory specimens, and hence regarded as a complication of COVID-19 pneumonia.

Cavities in the lung have been reported as a post COVID-19 squeal, usually during the recovery phase of illness, i.e, during the third week of acquiring the infection. Chen Y et al., reported about a 34-year-old male who developed a large cavity in 3rd week of illness and improved without the use of antibiotics (6). Another case report by Selvaraj V et al., stated cavity formation during the third week in a 52-year-old male (9). Similarly, in the present case series, three patients developed lung cavitation during their third week of illness.

In a study by Amalnath D et al., 22 patients were included and 14 of them were on non invasive ventilation. Ten among the 14 patients on NIV succumbed to death, indicating the correlation of severity of illness with clinical outcome. Similarly, the present series showed that there was requirement of NIV among patients with moderate and severe COVID-19 infection and there was no clinical improvement observed among them (10).

Three patients in the present case series received intravenous steroids as a treatment for COVID-19, which suppress the immune system impairing innate immunity, providing an environment for the opportunistic pathogens, especially in diabetic population. One patient had infection with bacterial organism known to cause lung cavitation. Hence, it is difficult to speculate whether bacterial infection and/or invasive fungal co-infection may have contributed to the development of the cavities, or if the infections were opportunistic. Another cause might be attributed to pulmonary infarction that leads to cavity formation, but it is less likely since all the patients received prophylactic doses of injection of low molecular weight heparin. Thus, the causes of cavity in a post COVID-19 patient appears to be multifactorial with factors including isolated bacterial, fungal infections or bacterial and fungal co-infection, SARS-CoV-2 specific inflammatory pathways, and the immunosuppressive effects of glucocorticoids.

With the rising incidence of Cavitatory lung lesions as a sequelae to COVID-19 infection, there is a need for the follow-up of recovered and convalescent patients, despite a successful treatment for COVID-19. Since the cause still remains unknown, there is a need for further studies to delineate the pathology and etiology, so as to provide further evidences to the existing literature regarding the lung cavities following COVID-19 infection.

Conclusion

The clinical spectrum of post COVID-19 infection still remains unclear, with the advent of new lung lesions. The subsequent development of lung cavitation in COVID-19 infected individuals warrants vigilant monitoring of patients through regular follow ups, especially the immunocompromised, for early recognition and definitive treatment of the disease. The rapid course of development of lung cavities following the viral illness implies the need for further studies to determine the causative factors. Further, there is also a need for the clinicians to be aware of the evolving CT findings in COVID-19 and appropriate follow-up of convalescent patients with COVID-19 to ensure complete recovery.

References

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DOI and Others

DOI: 10.7860/JCDR/2022/55252.16663

Date of Submission: Jan 28, 2022
Date of Peer Review: Mar 15, 2022
Date of Acceptance: May 14, 2022
Date of Publishing: Jul 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Feb 01, 2022
• Manual Googling: May 05, 2022
• iThenticate Software: Jun 30, 2022 (11%)

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