A 52 year old lady , with known asthma comes to the ED department with complaints of weakness, fatigue, difficulty in breathing .

 A 52 year old lady , with known asthma comes to the ED department with complaints of weakness, fatigue, difficulty in breathing .

She says she had a high grade fever almost 4 days ago. On examination , at the moment she is afebrile. Her Blood pressure is 100/60 mmHg and Oxygen saturation is 89 Percent on Air.

There are bilateral wheeze on auscultation on inspiration and motivation expiration.

You decide to organise an HRCT / High resolution computed tomography, the images of which are shown below :

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1. What are the findings on HRCT?

2. Name some causes of these findings and most likely Diagnosis in this patient?

3. Which inflammatory markers are used to monitor response to treatment in such cases?

4. What are treatment options ?

Answers given in comments section.

1. What are the findings on HRCT? 

HRCT shows ground glass appearance / opacities in both lung fields. 

Ground glass is glass whose surface has been ground to produce a flat but rough (matte) finish, in which the glass is in small sharp fragments.

Ground-glass opacification/opacity (GGO) is a descriptive term referring to an area of increased attenuation in the lung on computed tomography (CT) with preserved bronchial and vascular markings.

 It is a non-specific sign with a wide etiology including infection, chronic interstitial disease and acute alveolar disease.

Ground glass opacification is also used in chest radiography to refer to a region of hazy lung radiopacity, often fairly diffuse, in which the edges of the pulmonary vessels may be difficult to appreciate .

The use of the term ground glass derives from the industrial technique in glassmaking whereby the surface of normal glass is roughened by grinding it.

2. Name some causes of these findings and most likely Diagnosis in this patient? 

The patient in question has diffuse ground glass opacification of both lung fields. Broadly speaking, the differential for ground-glass opacification can be split into :

A .Infectious processes (opportunistic vs non-opportunistic)

B .Chronic interstitial diseases

C . Acute alveolar diseases

D. Other causes 

In this lady given the current scenario and having a recent history of sore throat and fever , we need to consider Covid 19 pneumonitis associated SARS as one of top diagnosis and should under take Covid 19 PCR . Covid 19 antibodies should be performed and any exposed family members be advised to undertake Covid 19 testing and exercise extreme caution.

3. Which inflammatory markers are used to monitor response to treatment in such cases? 

The comminly used inflammatory markers used to monitor course of Covid 19 pneumonitis and SARS include : 

FBC / Full Blood count inclusing White cell count. 

CRP , 

Myoblobin , 

D- dimer levels , 

Ferritin , 

Interleukin 6 Levels and 

Procalcitonin apart from Covid 19 PCR and Antibodies , throat swabs for Flu detection.

 Also patient should be attached to cardiac monitor and any arrythmias be detected and treated earlier. 

Renal profile is also very important to monitior.

If possible an Echocardigram and Arterial Blood gases should also be done as well to decide course of disease.

4. What are treatment options ? 

Treatment is manly supportive and consists of high flow oxygen to maintain O2 levels more than 95 in healthy patoents and more than 89 in COPD patients. 

Intravenous cortiscosteroids such as Dexamethasone or hydrocortosone are also useful. 

For old patients with high risk if DVT or thrombsois , daily Loprin is also useful . 

Heparin may also be given at discretion of consultant. 

Broad spectrum antibiotics are useful such as Tazocin 4.5 Gram tds. ABC/ Airway breathing Circulation should be maintained at all times. 

Intravenous fluids to avoid severe AKI . intake output record is a must. Remdesivir and tocilizumab have beneficial effects in Covid pneumonitis . 

Indomethacin that has anti interleukin storm effect is also of value.

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