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Background and objectiveLong-term pulmonary sequelae following SARS-CoV-2 pneumonia are not yet confirmed, however preliminary observations suggests a possible relevant clinical, functional and radiological impairment. The aim of this study was to identify and characterise pulmonary sequelae caused by SARS-CoV-2 pneumonia at 6-month follow-up.MethodsIn this multicenter, prospective, observational cohort study, patients hospitalised for SARS-CoV-2 pneumonia and without prior diagnosis of structural lung diseases were stratified by maximum ventilatory support (“oxygen only”, “continuous positive airway pressure (CPAP)” and “invasive mechanical ventilation (IMV)”) and followed up at 6 months from discharge. Pulmonary function tests and diffusion capacity for carbon monoxide (DLCO), 6 minutes walking test, chest X-ray, physical exam and modified Medical Research Council (mMRC) dyspnoea score were collected.ResultsBetween March and June 2020, 312 patients were enrolled (83, 27% women; median [IQR] age 61.1 [53.4,69.3] years). The parameters that showed the highest rate of impairment were DLCO and chest-X-ray, in 46% and 25% of patients, respectively. However, only a minority of patients reported dyspnoea (31%), defined as mMRC ≥ 1, or showed a restrictive ventilatory defects (9%). In the logistic regression model, having asthma as comorbidity was associated with DLCO impairment at follow-up, while prophylactic heparin administration during hospitalisation appeared as a protective factor. Need for invasive ventilatory support during hospitalisation was associated with chest imaging abnormalities.ConclusionDLCO and radiological assessment appear to be the most sensitive tools to monitor patients with COVID-19 during follow-up. Future studies with longer follow-up are warranted to better understand pulmonary sequelae.Summary at a glanceDLCO and radiological assessment are the most sensitive tools to monitor COVID-19 patients at 6-month follow-up. Invasive ventilatory support is a risk factor for detection of radiological abnormalities, but not for DLCO impairment, at follow-up. Whileuse of prophylactic heparin acts as a protective factor on the development of DLCOimpairment.

Background: Long-term pulmonary sequelae following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia are not yet confirmed; however, preliminary observations suggest a possible relevant clinical, functional, and radiological impairment. Objectives: The aim of this study was to identify and characterize pulmonary sequelae caused by SARS-CoV-2 pneumonia at 6-month follow-up. Methods: In this multicentre, prospective, observational cohort study, patients hospitalized for SARS-CoV-2 pneumonia and without prior diagnosis of structural lung diseases were stratified by maximum ventilatory support (“oxygen only,” “continuous positive airway pressure,” and “invasive mechanical ventilation”) and followed up at 6 months from discharge. Pulmonary function tests and diffusion capacity for carbon monoxide (DLCO), 6-min walking test, chest X-ray, physical examination, and modified Medical Research Council (mMRC) dyspnoea score were collected. Results: Between March and June 2020, 312 patients were enrolled (83, 27% women; median interquartile range age 61.1 [53.4, 69.3] years). The parameters that showed the highest rate of impairment were DLCO and chest X-ray, in 46% and 25% of patients, respectively. However, only a minority of patients reported dyspnoea (31%), defined as mMRC ≥1, or showed restrictive ventilatory defects (9%). In the logistic regression model, having asthma as a comorbidity was associated with DLCO impairment at follow-up, while prophylactic heparin administration during hospitalization appeared as a protective factor. The need for invasive ventilatory support during hospitalization was associated with chest imaging abnormalities. Conclusions: DLCO and radiological assessment appear to be the most sensitive tools to monitor patients with the coronavirus disease 2019 (COVID-19) during follow-up. Future studies with longer follow-up are warranted to better understand pulmonary sequelae.

Acute Exacerbation (AEx) is a frequent complication of Idiopathic Pulmonary Fibrosis (IPF) associated with high mortality. To date there is no evidence-based therapy for AEx of IPF (AEx-IPF). Our aim was to evaluate the effectiveness in terms of survival of intravenous pulse doses of high-dose corticosteroid and cyclophosphamide in a cohort of patients with AEx-IPF. We performed a retrospective analysis on patients with AEx-IPF referred to the Respiratory Unit at San Gerardo hospital, Monza, Italy, from 2009 to 2013. AEx-IPF diagnosis was made according to Collard criteria (Collard HR et al , AJRCCM 2007; 176:636–43). All patients were treated with daily pulse doses of methylprednisolone (1000 mg) for three days, followed by monthly pulse doses of cyclophosphamide (600mg/m 2 of body surface area, maximum dose 1 g) in association with maintenance-dose of oral prednisone (0.5 mg/kg). We identified 11 patients with AEx-IPF (7 males, median age 68 years). A median of 4 monthly pulse doses of cyclophosphamide were administered. Overall survival at 3 months was 73%, at 6 months 63%, at 12 months 55%, at 18 months 45% and at 2 years 27%. Six patients died because of respiratory failure. A patient died because of breast cancer and one due to lung cancer. Overall survival in our cohort is better compared to the ones reported in patients not treated with systemic immunosuppressive therapy (Song JW et al , ERJ 2011; 37:356–363). Immunosuppressive agents, such as cyclophosphamide, in addiction to high-dose corticorteroids might improve short- and long-term outcomes of AEx-IPF. Randomized-controlled trials on large cohorts of patients are needed to confirm our observation.

A subset of patients who present with acute respiratory symptoms will develop acute hypoxic respiratory failure with bilateral lung infiltrates and may fulfill clinical criteria for the acute respiratory distress syndrome. There is a wide variety of well-known etiologies, including infection/sepsis, shock, trauma, aspiration, oxygen toxicity and many others. A few cases occur without an apparent cause or underlying context such as acute interstitial pneumonia (AIP), cryptogenic organizing pneumonia (COP), acute eosinophilic pneumonia (AEP), while others occur as a rapid deterioration of previously diagnosed or undiagnosed chronic interstitial lung disorders (ILD), such as idiopathic pulmonary fibrosis (IPF), nonspecific interstitial pneumonia (NSIP), hyper-sensitivity pneumonitis (HP), collagen vascular disease with ILD (CVD-ILD). These patients need a correct setting and management, especially regarding their oxygenation. It’s very important to identify cases that have a treatable or potentially reversible cause, and distinguish them from those in whom the etiology is unknown and the response to therapy is likely to be poor. Primarily pulmonary infection, heart failure, pulmonary thromboembolism, drug toxicity and collagen vascular diseases should be excluded. The most important diagnostic tools are clinical features, radiologic pattern, bronchoalveolar lavage, transbronchial lung biopsy and surgical biopsy. Fast diagnosis and prompt beginning of therapy are of pivotal importance.

To the Editor: A 61-yr-old Caucasian female was referred to our outpatient clinic for persistent cough, right scapular pain and purulent sputum for the past 9 months. Her past medical history was consistent with a diagnosis of pneumonia almost 20 yrs previously. She reported no allergies and was not taking any medications at home. She lived in an urban setting working as a hairdresser, and had no pets at home. She had received all the standard vaccinations based on the Italian law, including diphtheria, smallpox, tetanus, hepatitis A and typhus. She was married and had two daughters in good health. She went on vacation to Cuba 2 yrs previously, India (Rajasthan) 1 yr previously and Portugal 6 months ago. Her history of present illness was consistent with cough and mucopurulent sputum without fever for 9 months prior to visiting our clinic. She reported a scapolar right pain that had occurred 15 days prior to admission to the hospital which was not related to positioning or breathing. A negative chest radiograph had been performed 3 months prior to the visit, and at that point she was treated with oral prednisone (25 mg every 24 h for 15 days) with no evidence of clinical improvement. Finally, she underwent a chest computed tomography (CT) scan with the evidence of lung opacities with enhancement in the medium lobe and in the lingual (fig. 1a …