CME INDIA Presentation by Dr N K Singh, Admin.
These days whatever cases come with history of fever with chest findings in HRCT thorax, most of us think about COVID-19. It is fully justified too. But many times, some basic diagnosis with basic tests can clear the dilemma. We present you 2 cases for your review.
CME INDIA Scenario 1:
45 yr. old lady. Diabetic, on metformin 2 gm and Glimiperide 1mg. Developed fever 20 days back. Initially managed at home with Azithromycin, Paracetamol etc… Random 178, No weight loss. On 17th October, came to me with history of cough, dry, no obvious SOB, maintaining saturation. Initial hemogram – Nothing remarkable. How to proceed?
CME INDIA Discussion
Dr Basab Ghosh, Agartala: It is COVID-19.
Dr Noni G Singha, Manipur: SARS CoV2 Antibody (Total) testing to rule out post COVID-19 first. Rest symptomatic. Xray is rotated so showing shifting of cardiac shadow to left and also showing falls cardiomegaly. Apart from that lung fields nothing significant. Tests to rule out post COVID.
Dr N K Singh: What suggests it is rotated?
Dr Noni G Singha, Manipur: Sterno – clavicular distance.
Dr S K Goenka, Begusarai: Medial end of both clavicles are almost equidistant from the spine. So, it doesn’t look rotated.
Dr P D Gokhale, Jamshedpur: I also feel so. Lateral lying down X ray but clinical examination and stony dullness if you get, just put needle to get fluid as we used to do in my internship days.
Dr Meena Chhabra, Delhi: IgG antibody COVID-19, CBC, ESR, CRP, LFT, Ferritin and D-Dimer.
Dr S K Goenka, Begusarai: For me, it looks like Parapneumonic effusion, left side.
Dr Harish Darla, Mysore: Looks like pericardial effusion/ collapse consolidation….
Dr N K Singh: Well, patient did not go for blood tests, but I insisted for HRCT. I have now reports.
After seeing CT, what to do?
Dr P D Gokhale, Jamshedpur: Koch’s? Put needle and get fluid though you may not succeed as effusion doesn’t seem to be large. I am not sure about mediastinal lymphadenopathy occurs in post COVID lung disease. Azithromycin can be started. If it’s Koch’s, wait till confirmation.
Dr Noni G Singha, Manipur: Please do antibody (total) it will give clue. Findings in CT chest may not be evident of CXR. If anything, suspecting Koch’s than better to avoid antibiotic which may have mild antitubercular effects which may interfere with further workup. One may give in such situation Co Amoxiclav or to some extent Sultamicin.
Dr Atri Gangopadhyay, Pulmonologist, Ranchi: There appears to be a left lower lobe collapse, as heart shifted away from right irrespective of rotation, along with silhouette of left cardiac border. I would want to advice:1. Rtpcr 2. COVID IgG antibody 3. The CT scan is suggestive of left lower lobe consolidation collapse.
Dr Noni G Singha Manipur: Dr Atri, SARS COV 2 IgG man not develop in all patients. So we are not sure of COVID 19. Total Antibody testing might give more diagnostic yield.
Dr Rajan Chaudhary, Sr Radiologist, Patna: Sir, possible mild Cardiomegaly and left sided small effusion or lung base haziness. No evidence of COVID on X-ray. Can be left lung base consolidation and small effusion. Technical issues there too. Mild rotation.
Dr Somnath, Hyderabad: Sir. Please wait and watch. It might turn out to COVID-19 as per my clinical experience. You can do biochemistry related to COVID CRP, ferritin, LDH, d dimer and PCT. Continuously monitor spo2. I had a bad experience with the same presentation but consolidation was in upper lobe (Rt).
Dr Molio, Maregoan, Goa: CT chest to rule out left lower zone pneumonia. Pulmonary embolism. COVID pneumonia.
Dr Premchand Singh, Imphal: CXR rotated? Consolidation Lt basal area.
Dr Rajesh Naik, Maregoan, Goa: Looking like tubercular: Can u tap that fluid under ultrasound guidance. See for ADA and protein. If you could get that fluid for exam you can clinch the diagnosis.
Dr P R Parthsarathy, Chest Physician, Chennai: CT has some of the features of COVID & some which doesn’t point to COVID. There is nothing to suggest post-COVID also. Basic investigations – CBC, ESR, & of course RTPCR. Tuberculosis has to be kept in mind.
Dr Kapil Sud, Internist, Delhi: Is post COVID pleural effusion quite common. Looks like tubercular.
Dr Bela Sharma, MD Med., Fortis Gurgaon, Haryana: Will require further investigation, can’t base diagnosis and management on CT only.
Dr Ashutosh, DNB Med., Hindalco Hosp., Renukut: Sir this cxr is showing homogenous opacity in rt lower zone with positive silhouette sign, probably the lesion is in lingular lobe. Or area adjacent to heart. It’s a consolidation. Pneumonia. Ground glass opacity in left lung.
Dr Gita Arora, MD medicine, Bharatpur, Rajasthan: Repeat pcr with markers r required to manage further.
Further Course
Courtesy Dr Nishith Kumar, Pulmonologist, Ranchi
- rtPCR-Negative.
- Sputum examination came positive for both AFB Stain.
- CBNAAT…MTB.
Advised to start ATT
- Sputum AFB – Positive.
- Sputum MTB CBNAAT- MTB detected.
- Symptomatic since more than 3 weeks. Diabetic.
- Chest Radiology S/o Unilateral consolidation along with minimal pleural effusion.
- Centrilobular nodules can be observed in a wide variety of lung pathology. They are usually seen with a bronchiolitis eg infection with Endobronchial spread like tuberculosis.
- Unilateral disease is rare and pleural effusion is not a usual radiological feature associated with COVID-19.
CME INDIA Scenario 2
Dr R K Gupta, Yamunanagar: Similar patient presented 20 days post COVID diagnosis. Moderate pleural effusion. 1.5 L tapped. Fluid: Proteins 1.7 G%u350 cells/cmm. Lympho 90%. Polys 10%. Fluid ADA 29.ESR 115. TLC 12900/cm. Polys 70%. Patients diabetic. Age 55yrs.What is the opinion regarding pleural effusion? I think it is post COVID. Patient also has low grade fever-rays:
Dr N K Singh: In this case, you had rtPCR positivity. So, clearly, post COVID effusion.
Dr R K Gupta, Yamunanagar: Yes, COVID-19 R PCR POSITIVE. CBNAAT of Fluid for TB Negative.
Dr R K Gupta, Yamunanagar: Do we need to do anything. Underlying lung post fluid tapping shows consolidation.
Dr N K Singh: Are you continuing steroids.
Dr R K Gupta, Yamunanagar: No already stopped 7 days back.
Dr N K Singh: Many pulmonologists use methylprednisolone 8 to 16 mg od for 3 weeks to 4 weeks. Radiological clearance takes 3 months. If symptomatic-Low dose steroid needed. Can watch and wait.
CME INDIA Learning Points:
- The COVID-19 infection rate has been found high in patients with active tuberculosis.
- COVID-19 may be tragic for the patient with latent tuberculosis.
- Currently, it is important to bear in mind the COVID-19 infection in evaluating the patients with respiratory symptoms.
- It is high time that ruling out the COVID-19 infection in all the patients with any pattern of lung involvement to avoid missing the potential cases.
- One study reported that the percentage of pleural effusion is 8% in patients with mild symptoms compared with 28% in patients critically ill with COVID-19.
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I’m Dr R K Gupta Yamunanagar
As regards my case I started with Steroids. PT improved but Pleural fluid about 2 L removed again in second sitting.
I started ATT 4 DRUGS . Now it is 10 days back I will give u the results next week.
PT is Diabetic
Diabetic Pt. Collapse Consolidation lower or middle lobe ,
Ist possibility of Tuberculosis should be kept in mind.
Especially if already 3 weeks of history.
Even otherwise Middle or Lower lobe Consolidation in Diabetics Tuberculosis should be ruled out.