COVID-19: Wann muss ich an MIS-A denken?

Multisystem inflammatory syndrome in adults (MIS-A) came to attention back in June 2020, when the United States Center for Disease Control and Prevention (CDC) received initial reports regarding patients who had presented delayed and multisystem involvement of the disease, with clinical course resembling multisystem inflammatory syndrome in children (MIS-C). This study introduces a case of MIS-A, where the patient presented 3 weeks after initial COVID-19 exposure. His clinical course was consistent with the working definition of MIS-A as specified by the CDC. Aggressive supportive care in the intensive care unit, utilization of advanced heart failure devices, and immunomodulatory therapeutics (high-dose steroids, anakinra, intravenous immunoglobulin) led to clinical recovery. Management of MIS-A is a topic of ongoing research and needs more studies to elaborate on treatment modalities and clinical predictors.

Eosinopenie als Biomarker des Schweregrads einer COVID-19-Infektion

<b>Background:</b> Studies on the role of eosinophils in coronavirus disease 2019 (COVID-19) are scarce, though available findings suggest a possible association with disease severity. Our study analyzes the relationship between eosinophils and COVID-19, with a focus on disease severity and patients with underlying chronic respiratory diseases. <b>Methods:</b> We performed a retrospective analysis of 3018 subjects attended at two public hospitals in Madrid (Spain) with PCR-confirmed SARS-CoV-2 infection from January 31 to April 17, 2020. Patients with eosinophil counts less than 0.02×10⁹/L were considered to have eosinopenia. Individuals with chronic respiratory diseases (n = 384) were classified according to their particular underlying condition, i.e., asthma, chronic pulmonary obstructive disease, or obstructive sleep apnea. <b>Results:</b> Of the 3018 patients enrolled, 479 were excluded because of lack of information at the time of admission. Of 2539 subjects assessed, 1396 patients presented an eosinophil count performed on admission, revealing eosinopenia in 376 cases (26.93%). Eosinopenia on admission was associated with a higher risk of intensive care unit (ICU) or respiratory intensive care unit (RICU) admission (OR:2.21; 95%CI:1.42–3.45; <i>p &#x3c;</i>0.001) but no increased risk of mortality (<i>p &#x3e;</i>0.05). <b>Conclusion:</b> Eosinopenia on admission conferred a higher risk of severe disease (requiring ICU/RICU care), but was not associated with increased mortality. In patients with chronic respiratory diseases who develop COVID-19, age seems to be the main risk factor for progression to severe disease or death.

Pleureaergüsse: Zytohistologie als wesentliche Option zum Ausschluss oder zur Bestätigung einer bösartigen Ursache

The International System for Reporting Serous Fluid Cytology (TIS) was recently developed. Given its novelty, most studies looking into the risk of malignancy (ROM) of serous effusion diagnostic categories were published before the development of TIS. We searched the database of our department for pleural effusions diagnosed in the last five years, excluding those without a corresponding pleural biopsy. Cases were reviewed and reclassified according to the TIS. A cytohistological correlation was performed. In total, 350 pleural effusion specimens with one or more corresponding pleural biopsies were included. After reclassification, 5 (1.43%) were nondiagnostic (ND), 253 (72.29%) were negative for malignancy (NFM), 7 (2.00%) had atypia of unknown significance (AUS), 14 (4.00%) were suspicious for malignancy (SFM), and 71 (20.57%) were malignant (MAL). Calculated ROM was 40% for ND, 20.16% for NFM, 42.86% for AUS, 78.57% for SFM, and 100% for MAL. Effusion cytology sensitivity and specificity were 60.29% and 98.56%, respectively. This is the first publication looking into the cytohistological correlation of a retrospective cohort of pleural effusions based on the TIS. We add to the body of data regarding the ROM for TIS categories, highlighting areas of potential future research.

ARDS: Hohe Aussagekraft der elektrischen Impedanztomographie für Diagnostik und Therapie

<b>Background:</b> In acute respiratory distress syndrome (ARDS), non-ventilated perfused regions coexist with non-perfused ventilated regions within lungs. The number of unmatched regions might reflect ARDS severity and affect the risk of ventilation-induced lung injury. Despite pathophysiological relevance, unmatched ventilation and perfusion are not routinely assessed at the bedside. The aims of this study were to quantify unmatched ventilation and perfusion at the bedside by electrical impedance tomography (EIT) investigating their association with mortality in patients with ARDS and to explore the effects of positive end-expiratory pressure (PEEP) on unmatched ventilation and perfusion in subgroups of patients with different ARDS severity based on PaO₂/FiO₂ and compliance. <b>Methods:</b> Prospective observational study in 50 patients with mild (36%), moderate (46%), and severe (18%) ARDS under clinical ventilation settings. EIT was applied to measure the regional distribution of ventilation and perfusion using central venous bolus of saline 5% during end-inspiratory pause. We defined unmatched units as the percentage of only ventilated units plus the percentage of only perfused units. <b>Results:</b> Percentage of unmatched units was significantly higher in non-survivors compared to survivors (32 [27–47]% vs. 21 [17–27]%, <i>p</i> &#x3c; 0.001). Percentage of unmatched units was an independent predictor of mortality (OR 1.22, 95% CI 1.07–1.39, <i>p</i> = 0.004) with an area under the ROC curve of 0.88 (95% CI 0.79–0.97, <i>p</i> &#x3c; 0.001). The percentage of ventilation to the ventral region of the lung was higher than the percentage of ventilation to the dorsal region (32 [27–38]% vs. 18 [13–21]%, <i>p</i> &#x3c; 0.001), while the opposite was true for perfusion (28 [22–38]% vs. 36 [32–44]%, <i>p</i> &#x3c; 0.001). Higher percentage of only perfused units was correlated with lower dorsal ventilation (<i>r</i> = − 0.486, <i>p</i> &#x3c; 0.001) and with lower PaO₂/FiO₂ ratio (<i>r</i> = -0.293, <i>p</i> = 0.039). <b>Conclusions:</b> EIT allows bedside assessment of unmatched ventilation and perfusion in mechanically ventilated patients with ARDS. Measurement of unmatched units could identify patients at higher risk of death and could guide personalized treatment.

NSCLC: Früherkennung von Rezidiven mittels zirkulierender Tumor-DNA

Approximately 30% of patients with non-small-cell lung cancer (NSCLC) present with localized/non-metastatic disease and are eligible for surgical resection or other «treatment with curative intent». Due to the high prevalence of recurrence after treatment, adjuvant therapy is standard care for most patients. The effect of adjuvant chemotherapy is, however, modest, and new tools are needed to identify candidates for adjuvant treatments (chemotherapy, immunotherapy, or targeted therapies), especially since expanded lung cancer screening programs will increase the rate of patients detected with localized NSCLC. Circulating tumor DNA (ctDNA) has shown strong potential to detect minimal residual disease (MRD) and to guide adjuvant therapies. In this manuscript, we review the technical aspects and performances of the main ctDNA sequencing platforms (TRACERx, CAPP-seq) investigated in this purpose, and discuss the potential of this approach to guide or spare adjuvant therapies after definitive treatment of NSCLC.

Pneumothoraxmanagement nach bronchoskopischer Lungenvolumenreduktion mit Einwegventilen. Ein aktuelles Expertenstatement

For selected patients with advanced emphysema, bronchoscopic lung volume reduction with one-way valves can lead to clinically relevant improvements of airflow obstruction, hyperinflation, exercise capacity, and quality of life. The most common complication of this procedure is pneumothorax with a prevalence of up to ±34% of the treated patients. Patients who develop a pneumothorax also experience meaningful clinical benefits once the pneumothorax is resolved. Timely resolution of a post-valve treatment pneumothorax requires skilled and adequate pneumothorax management. This expert panel statement is an updated recommendation of the 2014 statement developed to help guide pneumothorax management after valve placement. Additionally, mechanisms for pneumothorax development, risk assessment, prevention of pneumothorax, and outcomes after pneumothorax are addressed. This recommendation is based on a combination of the current scientific literature and expert opinion, which was obtained through a modified Delphi method.

Malignes Melanom ohne Primärtumor, das als solitärer pulmonaler Rundherd imponiert: ein Fallbericht

<b>Hintergrund:</b> Solitäre pulmonale Rundherde sind der häufigste Zufallsbefund in der Thoraxbildgebung. Ihre Behandlung ist in verschiedenen Leitlinien klar definiert, wobei Risikokalkulatoren für Lungenkrebs der Goldstandard sind. Eine solitäre intramuskuläre Metastase eines malignen Melanoms in Verbindung mit einem solitären pulmonalen Rundherd ohne Primärtumor ist selten. <b>Fallbericht:</b> Ein 57-jähriger weißer Mann wurde mit einem solitären pulmonalen Rundherd in unser Lungenkrebszentrum überwiesen. Wir führten zunächst eine Positronen-Emissions-Tomographie durch, gefolgt von einer ultraschallgestützten Stanzbiopsie einer intramuskulären solitären Läsion, die auf der Computertomographie-Aufnahme nicht zu erkennen gewesen war, und diagnostizierten ein metastasiertes malignes Melanom. Es erfolgte eine Resektion des solitären pulmonalen Rundherds, die das metastasierte Melanom ebenfalls bestätigte. Eine primäre Hautläsion fand sich nicht. Der Patient erhielt eine orale zielgerichtete Therapie und ist 5 Jahre später krankheitsfrei. <b>Schlussfolgerungen:</b> Kliniker, die mit solitären pulmonalen Rundherden zu tun haben, sollten an mögliche andere extrathorakale Malignome denken, auch wenn keine offensichtliche Vorgeschichte vorliegt. Eine Resektion der Lungenmetastase kann bei einem metastasierten malignen Melanom mit unbekanntem Primärtumor von Nutzen sein.

Erweiterte Formen der roboterassistierten Lungenresektion

Während der Lungenkrebs weiterhin die häufigste krebsbedingte Todesursache in den USA darstellt, bildet die Chirurgie in kurativer Intention weiterhin eine tragende Säule der Therapie. Seit mehr als einem Jahrzehnt kommen dabei im Rahmen der Lungenresektion bei nicht kleinzelligem Bronchialkarzinom (NSCLC) auch roboterassistierte Systeme zum Einsatz. Zu lokal begrenzteren Formen der Resektion wie z.B. Keilresektionen oder Lobektomien liegen umfangreiche Daten vor, die eine Reduktion der Krankenhausverweildauer und der postoperativen Schmerzen ebenso belegen wie verbesserte Raten der Lymphknotendissektion und des Auftretens von Komplikationen. Das roboterassistierte Vorgehen bietet eine Vielzahl technischer Vorzüge, z.B. bessere Optik, natürliche Handbewegungen für den Operateur bei der Steuerung der Instrumente sowie präzise Identifizierung der Gewebeebenen und entsprechend ergonomischer und sicherere Dissektion. Aufgrund dieser Vorteile wächst auch das Anwendungsspektrum für roboterassistierte Resektionen. In der vorliegenden Übersichtsarbeit werten wir die vorliegenden Daten zu erweiterten Formen der roboterassistierten Lungenresektion aus, insbesondere die Resektion nach Induktionstherapie, Manschetten-Lobektomie und Pneumonekto­mie. Darüber hinaus werden die Indikationen für diese komplexeren Resektionen betrachtet und die Daten und Outcomes aus der Erfahrung anderer Einrichtungen mit diesen Eingriffen wiedergegeben. Abschließend beschreiben wir die Strategie und Sichtweisen in unserer eigenen Einrichtung im Hinblick auf die genannten drei Formen der erweiterten Lungenresektion. Während die Anwendbarkeit und die Sicherheit der roboterassistierten Chirurgie bei diesen komplexen Lungenresektion noch Gegenstand kontroverser Debatten sind, hoffen wir durch Darstellung der vorliegenden Evidenz und Evaluierung der Wirksamkeit und Sicherheit für NSCLC-Patienten zur Klärung beizutragen.

Pleuraerguss bei Patienten mit Psoriasis-Arthritis: An Nebenwirkungen von TNF-α-Blockern denken

Psoriatic arthritis (PsA) is a chronic inflammatory disease associated with psoriasis. Pulmonary involvement is a rare extraarticular manifestation of the disease characterized by rigidity of the chest wall and apical pulmonary fibrosis. Pleural effusion is uncommon in PsA. We present four cases of patients with PsA who developed pleural effusions. We report for the first time a PsA patient who was drug-naïve and developed unilateral pleuritis. We also describe one PsA case with pleuritis while he was on methotrexate (MTX) and two PsA cases on tumor necrosis factor (TNF) inhibitors. The literature review revealed six cases with pleural effusion, which were drug-induced. These patients presented pleural effusions while they were treated with MTX (2 patients) and TNF inhibitors (4 patients). In PsA patients with pleuritis, a detailed investigation to rule out infections is necessary. In addition, increased pharmacovigilance will detect cases of drug-induced serositis.