Search

Despite a dissecting aortic aneurysm being a surgical emergency, it is frequently misdiagnosed in the Emergency Department. It is no surprise that the thoracic aorta's walls can rupture catastrophically with over 200 million litres of blood travelling through it in an average lifetime. Chest pain +1 (symptom) should prompt a differential diagnosis of a thoracic aortic dissection. Unfortunately, up to 33% of aortic dissection patients are misdiagnosed in the ED. Although the diagnostic imaging of choice is the CT aortogram, the question is whether transthoracic Echocardiography (TTE) is a robust enough imaging modality to rule in or rule out the presence of a type A thoracic dissection on first presentation in the ED and if it is helpful in the ED without immediate access to a cardiothoracic surgeon? This case highlights the importance of Point-of-care ultrasonography (POCUS) in helping with risk stratification and patient streaming in the emergency department. The likelihood of missing an ascending thoracic aorta pathology is reduced if the image acquisition is of good quality.

Typical radiological findings in patients with SARS-CoV-2 pneumonia consist of the presence of bilateral pulmonary opacities (both ground-glass attenuations and consolidations) with a peripheral or subpleural distribution, often involving the posterior regions of both lungs specifically. Although interstitial pneumonia represents the hallmark of COVID-19, the clinician should remember that sudden worsening gas exchange may have different aetiology. Pneumothorax and pneumomediastinum are well-known complications of invasive mechanical ventilation. However, since the beginning, the development of spontaneous pneumothorax and pneumomediastinum was reported in COVID-19 patients, without risk factors. The exact mechanism for the development of spontaneous pneumothorax and pneumomediastinum in COVID-19 patients is still unclear, and findings suggest that these clinical manifestations can be interpreted as an index of lung disease severity associated with complicated hospital courses, worst prognosis and increase in mortality rate. We report a case of a SARS-CoV-2 infected obese male patient, in quarantine and without risk factors, presenting to the emergency department for severe dyspnea due to COVID-19 pneumonia complicated by spontaneous pneumothorax and pneumomediastinum.

Chronic kidney disease (CKD) is characterized by loss of kidney function and generally it is associated with several alterations in pulmonary functions, including restriction, obstruction, and impaired diffusion capacity. It became challenging to maintain oxygenation in a CKD patient associated with COVID 19 on non-invasive ventilation (NIV). In patients with end stage renal disease (ESRD), several factors likes, fluid overload, anaemia, immune suppression, extraosseous calcification, malnutrition, electrolyte imbalance, and acid-base disorder affecting the lungs indirectly. Here we are reporting NIV failure in two COVID 19 patients during dialysis. Both patients were stable on NIV before starting dialysis and underwent oxygen desaturation and shifted to invasive mechanical ventilation during hemodialysis. The possible mechanism of the oxygen desaturation is alveolar hypoventilation in the absence of hypercapnia, which may be due to the removal of CO2 from the body by some route (dialysate) other than the lungs.

COVID pandemic has been a cause of extensive morbidity and mortality worldwide. Patients with severe COVID have been observed to suffer from remnant lung damage, fibrosis and oxygen dependency. These patients have still an unpredictable course and outcome. The outcome of these patients is not clearly defined yet. The signs and symptoms in such patients persisting even 4 weeks after acute COVID-19 has been recently named as "Long COVID". In the present case series, we present the course and outcome of two such ‘Long COVID’ patients who presented with severe hypoxemic respiratory failure. These patients were managed with a prolonged application of Non-invasive ventilation with high flow oxygen and alongwith glycaemic control, steroids and antibiotics. The patients showed tremendous response to the treatment and could be weaned from NIV after about three weeks of therapy. These cases demonstrate the utility of NIV, even in severe hypoxemic respiratory failure, in Long COVID.

Kounis syndrome (KS) is an acute coronary syndrome developing as a consequence of an anaphylactic or allergic reaction. Multiple mediators (especially histamine) released by mast cells, platelets, and some immune cells may lead to coronary vasospasm or thrombosis and cause an acute coronary syndrome. A clinical case of the KS in a hospitalized patient being treated for the COVID-19-associated pneumonia is presented. A 62-year-old woman was treated for COVID-19-associated pneumonia. In 15 min after the beginning of the Moxifloxacin infusion, the patient complained of severe headache, crushing chest pain, abdominal pain, severe general weakness, shortness of breath. Hypotension and decrease in SpO2 developed. Immediately performed ECG showed the ST-segment elevation in leads I and aVL. There were reciprocal changes in leads III, aVF, V3-V6. Troponin I was slightly elevated. Coronary angiography showed no hemodynamically significant coronary artery lesions. The KS type 1 was diagnosed. Repeated ECG in 2 hours showed isoelectric ST segments in all leads. It may be difficult to diagnose KS. Clinical signs of an allergic or anaphylactic reaction should raise the suspicion of KS. Moxifloxacin as well as other fluoroquinolones may be associated with the development of KS. We suggest a possible association of COVID-19 with KS. However, this issue requires further observation.