Evidence for a thromboembolic pathogenesis of lung cavitations in severely ill COVID-19 patients

Abstract

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing coronavirus disease 2019 (COVID-19) induces lung injury of varying severity, potentially causing severe acute respiratory distress syndrome (ARDS). Pulmonary injury patterns in COVID-19 patients differ from those in patients with other causes of ARDS. We aimed to explore the frequency and pathogenesis of cavitary lung lesions in critically ill patients with COVID-19. Retrospective study in 39 critically ill adult patients hospitalized with severe acute respiratory syndrome coronavirus 2 including lung injury of varying severity in a tertiary care referral center during March and May 2020, Berlin/Germany. We observed lung cavitations in an unusually large proportion of 22/39 (56%) COVID-19 patients treated on intensive care units (ICU), including 3/5 patients without mechanical ventilation. Median interquartile range (IQR) time between onset of symptoms and ICU admission was 11.5 (6.25–17.75) days. In 15 patients, lung cavitations were already present on the first CT scan, performed after ICU admission; in seven patients they developed during a subsequent median (IQR) observation period of 48 (35–58) days. In seven patients we found at least one cavitation with a diameter > 2 cm (maximum 10 cm). Patients who developed cavitations were older and had a higher body mass index. Autopsy findings in three patients revealed that the cavitations reflected lung infarcts undergoing liquefaction, secondary to thrombotic pulmonary artery branch occlusions. Lung cavitations appear to be a frequent complication of severely ill COVID-19 patients, probably related to the prothrombotic state associated with COVID-19.

Acinetobacter: A Rare Cause of Rapid Development of Cavitary Lung Lesion Following COVID-19 Infection

“…It is thought that the inflammation and subsequent bronchiectasis that can develop with COVID-19 pneumonia can create a breeding ground for bacteria, which can lead to cavitation development [ 7 ]. Additionally, there have been cases reported where cavitations did not exhibit any positive cultures, and those who did grow positive cultures were the minority of patients with this complication [ 8 ]. Rather, these cases suggest that there is a thrombotic effect of the COVID-19 virus that leads to the development of cavitations [ 7 , 8 ].…”

“…Additionally, there have been cases reported where cavitations did not exhibit any positive cultures, and those who did grow positive cultures were the minority of patients with this complication [ 8 ]. Rather, these cases suggest that there is a thrombotic effect of the COVID-19 virus that leads to the development of cavitations [ 7 , 8 ].…”

Study to assess aetiology, clinical and imaging characteristics of post Covid-19 pulmonary cavitation

“…Pulmonary cavitation in COVID-19 pneumonia may be multifactorial, with contributing factors could be bacterial, mycobacterial, fungal coinfection, the immunosuppressive effects of glucocorticoids and tocilizumab, thromboembolic pathway leading to infarct lading to cavitation[ 21 ] or SARS-CoV-2 itself through inflammatory phase can be the cause of cavitation. [ 22 ]…”

Automated Quantitative Lung CT Improves Prognostication in Non-ICU COVID-19 Patients beyond Conventional Biomarkers of Disease

“…Recent theories on COVID-19 pathophysiology have focused on vasculitis-like anomalies or immune-mediated thrombosis in which viral alveolitis drives inflammation, endotheliopathy, and microvascular injury, leading to vascular tone dysregulation and pulmonary intravascular coagulopathy [5][6][7][8][9][10][11][12]. Postmortem reports and pathological specimens from COVID-19 patients showed DAD together with pulmonary infarction, small pulmonary vessel and capillary thrombosis, and hemorrhage [65,[67][68][69][70][71][72].…”

“…There are different reasons for clinical uncertainties and therapeutic failure in COVID-19. In fact, recent evidence has reconsidered the pathobiogenesis of COVID-19, shifting the attention from a dominant primary lung injury to all vasculitis-like anomalies and immune-mediated thrombosis [5][6][7][8][9][10][11][12].…”