A total of 689 patients were admitted with COVID-19 pneumonia between February 23rd and July 3rd 2020, of whom 330 had asymptomatic or mild disease, 359 had evidence of pneumonia and 110 were admitted to Intensive Care for treatment of respiratory failure. One hundred and seventy eight patients had CT scans of the chest and all patients who had cavitary lung disease on CT scan were identified. Twelve patients with COVID-19 disease developed lung cavitation, comprising 1.7% (n=12/689) of all admissions, 3.3% (n=12/359) of patients who developed COVID-19 pneumonia, and 11% (n=12/110) of patients admitted to the ICU. Table 1 describes their baseline characteristics, clinical variables and outcomes.
Median (range) age was 47 (37 to 67) years, 50% (n=6/12) had diabetes mellitus, 42% (n=5/12) were hypertensive and one had chronic lung disease in the form of chronic obstructive pulmonary disease (COPD). None had received prior immunosuppression. All 12 were males, required invasive mechanical ventilation, and the median (range) time from symptom onset to invasive mechanical ventilation was 8 (3-15) days. Three were admitted directly via our institution’s Emergency Department and intubated within 24 hours, and nine patients were transferred from other hospitals within 72 hours of intubation. At the time of this data review six of the 12 patients had died, two patients are recovering in hospital and undergoing rehabilitation, and four have been discharged home.
Most patients had completed a course of Hydroxychloroquine (83 % n=10/12) and antivirals (favipilavir or lopinavir/ritonavir) (92%, n=11/12) in the early stages of their illness. All 12 patients received Tocilizumab as clinical evidence of a CRS became apparent accompanied by deteriorating respiratory status and progressively worsening disease on imaging. Overall, this represented 9%f patients with COVID-19 who received tocilizumab in our institution.
Table 1: Patient characteristics and outcomes of those who developed pulmonary cavitation.
|
Patient 1
|
Patient 2
|
Patient 3
|
Patient 4
|
Patient 5
|
Patient 6
|
Patient 7
|
Patient 8
|
Patient 9
|
Patient 10
|
Patient 11
|
Patient 12
|
Age
|
54
|
44
|
67
|
49
|
60
|
51
|
42
|
38
|
42
|
50
|
36
|
42
|
BMI
|
30.9
|
30.4
|
31.3
|
29.2
|
25.1
|
29.4
|
26.3
|
21.5
|
30.1
|
19.8
|
24
|
27.7
|
Comorbidities
|
DM, HT
|
HT
|
DM
|
DM
|
COPD
|
HT
|
HT
|
|
DM, HT
|
DM
|
DM
|
DM
|
On admission
|
Time from symptom onset to intubation (days)
|
6
|
12
|
9
|
7
|
5
|
5
|
8
|
15
|
3
|
9
|
10
|
8
|
P/F ratio
|
48.8
|
41.6
|
49.7
|
33.0
|
46.1
|
47.0
|
65.3
|
41.8
|
70.5
|
100.1
|
109.4
|
104.5
|
SOFA score (points)
|
24
|
21
|
24
|
25
|
23
|
23
|
16
|
21
|
25
|
23
|
18
|
17
|
Neutropenia
|
|
|
|
|
|
|
|
|
|
|
Y
|
|
Leucocytes (x10*9/L)
|
0.49
|
1.35
|
0.3
|
2.78
|
0.6
|
1.1
|
1.66
|
1.03
|
0.46
|
2.91
|
1.62
|
2.63
|
During the admission
|
NM blockade
|
Y
|
Y
|
Y
|
Y
|
Y
|
Y
|
Y
|
Y
|
Y
|
|
|
Y
|
VTE
|
|
DVT and PE
|
|
|
|
PE
|
DVT
|
|
|
DVT
|
|
|
CVA
|
Y
|
|
|
|
|
|
|
|
|
Y
|
|
|
CRRT/IHD
|
|
Y
|
Y
|
Y
|
Y
|
Y
|
|
|
Y
|
|
|
Y
|
ECMO
|
|
|
|
|
|
|
Y
|
Y
|
Y
|
|
|
|
Proned
|
Y
|
Y
|
Y
|
Y
|
Y
|
Y
|
|
Y
|
Y
|
Y
|
|
|
Tracheostomy
|
Y
|
|
Y
|
Y
|
Y
|
Y
|
Y
|
Y
|
Y
|
|
|
|
Days of systemic CS
|
17
|
15
|
19
|
24
|
11
|
14
|
14
|
25
|
18
|
9
|
6
|
5
|
+ve fungal cultures or serology
|
|
Y
|
Y
|
Y
|
|
Y
|
|
|
Y
|
|
|
|
Treated for fungal infection
|
Y
|
Y
|
Y
|
Y
|
|
Y
|
Y
|
|
Y
|
|
|
Y
|
Duration of hospital stay (days)
|
37
|
25
|
53
|
33
|
53
|
74
|
56
|
57
|
57
|
56
|
47
|
40
|
Outcome
|
|
Deceased
|
Deceased
|
Deceased
|
Deceased
|
Deceased
|
Deceased
|
Likely to survive
|
Likely to survive
|
Discharged home
|
Discharged home
|
Discharged home
|
Discharged home
|
BMI= Body Mass Index, P/F ratio = PaO2/FiO2, SOFA = Sequential Organ Failure Assessment, NM = neuromuscular, Y=yes, VTE = venous thromboembolism, DVT= deep vein thrombosis, PE=pulmonary embolus, CVA = cerebrovascular accident, CRRT = continuous renal replacement therapy, IHD = intermittent hemodialysis, ECMO = extracorporeal membrane oxygenation, CS= corticosteroids
Imaging characteristics:
Upon admission all patients had baseline chest X-rays which did not reveal any evidence of cavitary disease. All 12 patients had the recognized range of imaging features expected in severe COVID-19 lung disease with; bilateral ground glass opacities predominantly in the peripheries, some with centrally located opacities, most had consolidation and air bronchograms, and roughly half had crazy paving pattern and interlobular septal thickening. In 10 patients all five lobes were affected, and in two patients the disease spared two lobes. The median (range) number of days between symptom onset and the first CT demonstrating cavitation was 36 (21 to 54) days, and between intubation and the first CT demonstrating cavitation 28 (13 to 49) days. Table 2 describes the cavities in detail. In short, five of the 12 patients had solitary cavities with size ranging between 30 mm to 100 mm in diameter. All patients with more than one cavity had bilateral cavitation. The appearances and morphology of the cavities amongst the group were similar with to that of pulmonary abscesses with thick but smooth walls containing internal debris and air fluid levels. Pulmonary infarcts were excluded as the CT studies were performed with IV contrast excluding pulmonary emboli. All five lobes contained cavities in a similar proportion, with a predilection for the costophrenic angles and the apices.
Table 2: Characteristics of the pulmonary cavities and related events.
|
Patient 1
|
Patient 2
|
Patient 3
|
Patient 4
|
Patient 5
|
Patient 6
|
Patient 7
|
Patient 8
|
Patient 9
|
Patient 10
|
Patient 11
|
Patient 12
|
No. of Cavities (n)
|
1
|
8
|
8
|
3
|
1
|
1
|
2
|
1
|
9
|
3
|
1
|
5
|
Largest Cavity (mm)
|
50
|
85
|
60
|
30
|
30
|
30
|
70
|
100
|
54
|
52
|
50
|
40
|
Bilateral
|
|
Y
|
Y
|
Y
|
|
|
Y
|
|
Y
|
Y
|
|
Y
|
Location of Cavities
|
No. lobes with cavities (n)
|
1
|
5
|
5
|
3
|
1
|
4
|
2
|
1
|
4
|
3
|
1
|
3
|
RUL
|
|
Y
|
Y
|
Y
|
|
|
|
Y
|
Y
|
Y
|
Y
|
|
RML
|
|
Y
|
Y
|
|
Y
|
Y
|
|
|
Y
|
|
|
|
RLL
|
|
Y
|
Y
|
|
|
Y
|
Y
|
|
Y
|
Y
|
|
Y
|
LUL
|
|
Y
|
Y
|
Y
|
|
Y
|
Y
|
|
Y
|
|
|
Y
|
LLL
|
Y
|
Y
|
Y
|
Y
|
|
Y
|
|
|
|
Y
|
|
Y
|
Clinical Events
|
Developed Pneumothorax
|
|
|
|
Y
|
|
|
|
Y
|
Y
|
|
|
Y
|
Developed Hemoptysis
|
|
|
Y
|
|
|
|
Y
|
|
Y
|
|
|
Y
|
Treated for Invasive fungal infection
|
Y
|
Y
|
Y
|
Y
|
|
Y
|
Y
|
|
Y
|
|
|
Y
|
Bacterial organisms in Sputum/BAL
|
K. pneumoniae
|
ECC
|
MRSA
|
|
S. maltophilia, C. koseri
|
MSSA, S. maltophilia
|
S. marcescens, S. maltophilia, ECC
|
K. pneumoniae
|
Acinetobacter, MRSA
|
ESBL K. pneumoniae, MRSA
|
MRSA
|
K. pneumoniae
|
Y= Yes, RUL = Right upper lobe, RML = Right middle lobe, RLL = Right lower lobe, LUL = Left upper lobe, LLL = Left lower lobe, BAL = Bronchoalveolar Lavage, MRSA = Methicillin-resistant Staphylococcus aureus, MSSA = Methicillin-sensitive Staphylococcus aureus, K. pneumoniae = Klebsiella pneumonia, ECC = Enterobacter cloacae complex, S. maltophilia = Stenotrophomonas maltophilia, S. marcescens = Serratia marcescens, ESBL = Extended spectrum beta-lactamase