PMC:7340597 / 6530-21011 JSONTXT

{"target":"https://pubannotation.org/docs/sourcedb/PMC/sourceid/7340597","sourcedb":"PMC","sourceid":"7340597","source_url":"https://www.ncbi.nlm.nih.gov/pmc/7340597","text":"3 Results\n\n3.1 Clinical features\nDuring the study period, seven patients underwent postmortem needle core biopsy of the lungs. Patients age ranged from 58 to 83 years (median 74 year) and five patients were male. None of the patients had a history of (chronic) pulmonary disease. One patient used immunosuppressive medication before hospital admission, in this case a short course of prednisolone. Median time from hospital to ICU admission was 0 days (interquartile range 0–4). Time from hospital admission to death ranged from 12 to 36 days. Patients deceased at median of 21(range 9–36) ventilated days. In five out of seven patients ICU stay was complicated by pulmonary embolism. Adopting the proposed definition of CAPA by van Arkel et al. [9], six patients were classified as having probable CAPA (Table 1 ), based on a positive GM on BAL fluid. In those patients, combination antifungal therapy with voriconazole and anidulafungin was started. Three out of six patients were on corticosteroids (60 mg prednisolone daily) at the time of CAPA diagnosis and corticosteroid treatment was terminated. Indication for steroid treatment in these patients was a suspicion of an organizing pneumonia on chest CT or signs of progression to fibrosis. Nosocomial infections including signs for pulmonary aspergillosis were excluded by bronchoscopy with BAL before steroid treatment was started. Radiologic findings of chest CT and histologic results of the lungs biopsies of all seven patients are shown in Table 2 .\nTable 1 Patient characteristics and clinical course.\nCase Sex, age (years) Medical history Total hospital days Total ventilated days Berlin classification of ARDS Compliance phenotype PE BAL fluid GM and culture (days post hospital admission) CAPA Chloroquine Prednisolone use during hospital admission Duration of prednisolone treatment\n1 M, 77 None 12 10 Severe Low Yes GM negative No Yes No\n2 F, 73 None 20 16 Severe High Yes GM index 4.4 (day 19) Aspergillus fumigatus Probable No Yes 8 days\n3 F, 58 None 30 26 Severe Low Yes GM index 3.4 (day 20) Probable Yes Yes 5 days\n4 M, 68 None 21 21 Moderate Low Yes GM index 5.7 (day 1) Aspergillus fumigatus Enterococcus faecium Probable Yes No\n5 M, 78 HT, CKI 22 21 Moderate Low No GM index 4.3 (day 20) Enterococcus faecium Probable Yes Yes 2 days\n6 M, 83 HT, DM 13 9 Moderate Low No GM index 1.7 (day 11) Probable Yes No\n7 M, 74 None 36 36 Severe Low Yes GM index 4.4 (day 24) Enterococcus faecalis Probable Yes Yes 4 days\nARDS acute respiratory distress syndrome; BAL broncho-alveolar lavage; CAPA, COVID-19 associated pulmonary aspergillosis; CKI, chronic kidney injury; DM, diabetes mellitus; GM, galactomannan; HT, hypertension; PE pulmonary embolism.\nTable 2 Radiological Chest CT scan and histological findings.\nCase Radiological findings Histological findings description Diagnosis\n1 GGO, crazy paving, non-dependent consolidation, subpleural sparing, segmental and subsegmental PE Intra-alveolar fibromyxoid/fibroblastic bodies (25%), micro-thrombi, thrombi in lager vessels, hyperplasia with atypia, multinucleated giant cell, intranuclear inclusion bodies, no hyphae OP\n2 GGO, crazy paving, resolving consolidation, bronchiectasis, segmental and subsegmental PE Extensive fibrosis with destruction of alveolar structures, hyperplasia with atypia, multinucleated giant cell, intranuclear inclusion bodies, no hyphae Fibrosis\n3 GGO, large dependent consolidation, bronchiectasis, subsegmental PE Inflammatory infiltrate, hyaline membranes, sporadic intra-alveolar fibroblastic plug, micro-thrombi, hyperplasia with atypia, multinucleated giant cell, intranuclear inclusion bodies, no hyphae DAD\n4 GGO, crazy paving, non-dependent consolidation, bronchiectasis, segmental and subsegmental PE Intra-alveolar fibroblastic tissue, with a diffuse component of fibrinous exudate, widening of alveolar septa, micro-thrombi, hyperplasia with atypia, multinucleated giant cell, intranuclear inclusion bodies, no hyphae AFOP\n5 GGO, consolidation Intra-alveolar fibromyxoid/fibroblastic bodies (32%), micro-thrombi, hyperplasia with atypia, multinucleated giant cell, intranuclear inclusion bodies, no hyphae OP\n6 GGO, consolidation Intra-alveolar fibromyxoid/fibroblastic bodies (80%), widening of alveolar septa, micro-thrombi, hyperplasia with atypia, multinucleated giant cell, intranuclear inclusion bodies, no hyphae OP\n7 GGO, crazy paving, consolidation, bronchiectasis, subsegmental PE Intra-alveolar fibromyxoid/fibroblastic bodies (27%), mild widening of alveolar septa, micro-thrombi, hyperplasia with atypia, multinucleated giant cell, intranuclear inclusion bodies, no hyphae OP\nAFOP acute fibrinous and organizing pneumonia, DAD diffuse alveolar damage, GGO, ground glass opacities; OP organizing pneumonia; PE pulmonary embolism.\nTo further investigate histopathologic findings we now present the detailed clinical course of four patients with four different histopathological characteristics. Because of complexity and importance of the distinct patterns and their relation with radiologic findings and treatment, we preferred to discuss them separately in more detail. Chest CT imaging of the four discussed patients are shown in Fig. 1 .\nFig. 1 Chest CT scans of case 1–4. For each patient image A represents chest CT at hospital admission, image B follow up CT-scan (note: chest CT of case 4 was not repeated). 1A: bilateral areas of GGO, patchy subpleural non-dependant consolidations 1B: progression of dens subpleural consolidations with air-bronchograms. 2A GGO in both lungs, combined with crazy-paving pattern, subtle bronchiectasis are present in affected areas. 2B GGO persisted, without progression to consolidations, more pronounced fibrotic reticulation with traction bronchiectasis. 3A diffuse bilateral GGO with large gravity dependant consolidations. 3B persistent GGO and consolidation, newly formed cyst-like lesions in middle and ventral regions. 4A bilateral areas of GGO, patchy non-dependant peripheral consolidations with mild bronchiectasis.\n\n3.2 Case 1 – Organizing pneumonia\nA 77-year old male without significant medical history was evaluated in our emergency department (ED) with complaints of general weakness, fever and dyspnoea. Initial chest CT showed extensive bilateral areas of ground-glass opacity with both central and peripheral distribution, patchy subpleural non-dependant consolidations and areas with subpleural sparing (Fig. 1-1A). Soon after admission patient was in need of mechanical ventilatory support and developed acute renal failure for which renal replacement therapy was initiated. After six days of mechanical ventilation chest CT-angiography showed pulmonary emboli along with new areas of ground-glass opacity and progression of dens subpleural consolidations with air-bronchograms (Fig. 1-1B). A nosocomial infection was ruled out by bronchial culture. Patient's neurologic status deteriorated and CT head revealed brain ischemia due to infarction of the area supplied by the left and right posterior cerebral artery. The patient died 12 days after admission.\nPostmortem pathologic examination revealed that the overall architecture of the lung tissue remained intact. However, a prominent amount of fibromyxoid or fibroblastic bodies was present in the alveoli with surrounding histiocytes (Fig. 2A . The extent of involved lung tissue was estimated at around 25% (Table 2). No remnants of hyaline membranes or prominent alveolar fibrinous exudate were found. Microthrombi in small blood vessels of the alveolar septa were seen, as well as an organizing thrombus in a larger sized vessel (Fig. 2E). The histologic findings in this case point towards an epithelial, and vascular phenotype of a SARS-CoV2 infection. No fungi were present in de PAS-D stain. This histologic pattern is characteristic for an organizing pneumonia.\nFig. 2 Microscopic lung findings. A, case 1: intra-alveolar fibroblastic bodies, consistent with organizing pneumonia, (H\u0026E, 10×) B, case 2: loss of alveolar architecture with extensive fibrosis (H\u0026E; 10×) C, case 3: inflammatory infiltrate with neutrophils and lymphocytes, note the hyaline membranes (arrows), suggestive for diffuse alveolar damage. (H\u0026E, 20×) D, case 4: prominent fibrinous exudate in alveoli as seen in AFOP (H\u0026E; 10×) E: thrombus in larger vessel (H\u0026E, 5×) F: cytopathogenic changes in pneumocytes due to viral infection seen in all cases: hyperplasia, multinucleated giant cells (asterisks), intranuclear inclusion bodies (H\u0026E, 40×).\n\n3.3 Case 2 – Fibrosis\nA 73-year old female was transferred to our ICU due to shortage of ICU beds in a nearby hospital. Prior to ICU admission, she was healthy but complained of diarrhoea and shortness of breath. Non-contrast chest CT at initial hospital admission showed multiple bilateral areas of ground-glass opacity along the bronchovascular bundles and periphery. There were some small areas of consolidation in the upper lobes. Subtle bronchiectasis were present in affected areas (Fig. 1-2A). Her respiratory condition required mechanical ventilation in prone position due to ARDS. After seven days, prednisolone treatment was started because of lack of improvement. Repeat chest CT-angiography showed segmental pulmonary emboli in the right lung. Ground-glass opacities persisted while the consolidations had disappeared. A reticular pattern combined with GGO was more pronounced with increasing traction bronchiectasis (Fig. 1-2B). BAL was performed twice, but GM and culture showed no signs of additional fungal infection. After one week of high dose glucocorticoid therapy BAL was repeated with a GM index 4.4. Fungal cultures showed growth of Aspergillus fumigatus. Therefore, prednisolone treatment was discontinued and antifungal treatment initiated. CT head was performed because of the development of an epileptic insult and showed small foci of haemorrhage in both frontal lobes. Neurologic condition worsened and progressive cerebral haemorrhage on follow up CT head was seen with poor prognosis. Palliative treatment was started and the patient deceased 27 days after onset of symptoms. Microscopic examination of lung tissue of this case showed an almost complete loss of normal lung architecture. Alveolar structures were unrecognizable and replaced by extensive fibrosis (Fig. 2B). What remained were several foci of pneumocytes, bronchial epithelium, and blood vessels without thrombi. In the PAS-D stain no fungi were observed. The prominent pattern in this patient is pulmonary fibrosis.\n\n3.4 Case 3 – Diffuse alveolar damage\nA 58-year old female was admitted to the ICU and needed mechanical ventilation due to severe hypoxemia. Chest CT-angiography showed dubious unilateral sub-segmental pulmonary emboli and diffuse bilateral ground-glass opacities with anteroposterior gradient along with large dependant consolidations (Fig. 1-3A). On the 8th day of mechanical ventilation, BAL was performed and CT-scan was repeated because of deteriorating pulmonary condition with increasing inflammatory parameters. Chest CT-angiography showed bilateral sub-segmental pulmonary emboli, persistent ground-glass opacities and consolidation. Newly formed coarse cyst-like lesions in the middle and ventral regions (non-dependant regions) were noted, probably due to ventilator induced lung injury (Fig. 1-3B). Considering lack of respiratory improvement and progression of fibrosis on radiological imaging prednisolone was started. After five days prednisolone was stopped because of a positive GM index of 3.4 from repeated BAL fluid. Fungal culture remained negative though. Her respiratory status stabilised but remained critical. After pausing the sedation, the patient remained unresponsive and CT head showed ischemia with small areas of haemorrhage. In light of her pour neurologic and respiratory prognosis, treatment was ended and patient expired after 26 days on ventilator support.\nIn the core needle biopsy specimens the lung tissue largely preserved its preexisting architecture. Histologic findings included an inflammatory infiltrate consisting of neutrophils and lymphocytes, and only a sporadic intra-alveolar fibroblastic plug. The striking, distinctive feature of this case was the presence of thin, delicate hyaline membranes along the alveolar wall (Fig. 2C). Again, micro thrombi were observed in this case. No fungi could be demonstrated in the PAS-D stain. Together with the clinical characteristics, these histologic findings were suggestive of diffuse alveolar damage.\n\n3.5 Case 4 – Acute fibrinous and organizing pneumonia\nA 68-year old male without medical history of cardiopulmonary disease, was presented at the ED in a critical condition with fever and dyspnoea. Patient was in need of endotracheal intubation and mechanical ventilation in prone position to improve his oxygenation. To exclude secondary infection, BAL was performed and revealed a positive GM and cultured Aspergillus fumigatus and Enterococcus faecium. Antifungal therapy was added to his treatment regimen. Chest CT-angiography showed segmental pulmonary emboli along with extensive bilateral areas of ground-glass opacity with reticulation and multiple patchy non-dependant peripheral consolidations. In contrast to normal areas, the abnormal areas showed mild bronchiectasis (Fig. 1-4A). The patient remained unresponsive after cessation of sedative medication. CT head showed extensive bilateral cerebellar ischemia with small haemorrhagic components. After three weeks of mechanical ventilation his respiratory status worsened and treatment was ended due to poor prognosis. The patient passed away 21 days after hospital admission.\nBiopsy specimens showed a pattern of lung injury, that was partially identical to that of case 1. Intra-alveolar depositions of fibroblastic tissue were found, consistent with organizing pneumonia. However, a predominant, diffuse component of fibrinous exudate in the alveoli was present, which was not the case in the aforementioned case with organizing pneumonia. Other histologic findings were a chronic inflammatory infiltrate, and mild interstitial changes, including widening of alveolar septa. Microthrombi in small septal blood vessels were also observed. Neither remnants hyaline membranes nor prominent eosinophils were present. Additional PAS-D stain did not show any fungi. The overall histologic pattern of this case was classified as acute fibrinous and organizing pneumonia (AFOP), Fig. 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