The Use of Corticosteroids or Tocilizumab in COVID-19 Based on Inflammatory Markers

SEMI-COVID-19 Network.[Background] The inflammatory cascade is the main cause of death in COVID-19 patients. Corticosteroids (CS) and tocilizumab (TCZ) are available to treat this escalation but which patients to administer it remains undefined.[Objective] We aimed to evaluate the efficacy of immunosuppressive/anti-inflammatory therapy in COVID-19, based on the degree of inflammation. .[Design] A retrospective cohort study with data on patients collected and followed up from March 1st, 2020, to May 1st, 2021, from the nationwide Spanish SEMI-COVID-19 Registry. Patients under treatment with CS vs. those under CS plus TCZ were compared. Effectiveness was explored in 3 risk categories (low, intermediate, high) based on lymphocyte count, C-reactive protein (CRP), lactate dehydrogenase (LDH), ferritin, and d-dimer values.[Patients] A total of 21,962 patients were included in the Registry by May 2021. Of these, 5940 met the inclusion criteria for the present study (5332 were treated with CS and 608 with CS plus TCZ).[Main Measures] The primary outcome of the study was in-hospital mortality. Secondary outcomes were the composite variable of in-hospital mortality, requirement for high-flow nasal cannula (HFNC), non-invasive mechanical ventilation (NIMV), invasive mechanical ventilation (IMV), or intensive care unit (ICU) admission.[Key Results] A total of 5940 met the inclusion criteria for the present study (5332 were treated with CS and 608 with CS plus TCZ). No significant differences were observed in either the low/intermediate-risk category (1.5% vs. 7.4%, p=0.175) or the high-risk category (23.1% vs. 20%, p=0.223) after propensity score matching. A statistically significant lower mortality was observed in the very high–risk category (31.9% vs. 23.9%, p=0.049).[Conclusions] The prescription of CS alone or in combination with TCZ should be based on the degrees of inflammation and reserve the CS plus TCZ combination for patients at high and especially very high risk.Peer reviewe

Metástasis cutáneas como forma de presentación de una neoplasia digestiva diseminada

Case report: A 89-year-old man presented to the emergency room department with a 1-month history of spontaneous 13x10 mm crusty, nodular lesion in his right hand palm (image 1). Two weeks before presentation he had initiated an ambulatory evaluation because of a pulmonary mass in the right upper lobe. The lesion was painful, had intermittent bleeding, with no fever nor suppuration. He had received a 7-days course of amoxicillin/clavulanate without any improvement. The patient was referred to the Dermatology Department, where a skin biopsy was performed: skin tissue infiltration by metastatic adenocarcinoma, probably from gastrointestinal origin (according to immunohistochemistry). Because of the age and bad prognosis, and according to the patient preferences, more invasive tests were avoided. The lesion partially improved with local radiotherapy, but new nodules appeared at his left eyebrow (image 2) and at the 4º finger of his right hand. Due to the bad progression, palliative treatment was initiated and the patient finally deceased. Discussion: Cutaneous metastases are a very rare form of presentation of disseminated neoplasms. Breast cancer and melanoma are the most common primary neoplasms, followed by lung, colon, head and neck. Cutaneous metastases portend a poor prognosis and are often an indicator of widespread disease. Treatments include excision of the metastases, chemotherapy, immunotherapy, radiation, and/or palliative care

Comparison of Lung Ultrasound versus Chest X-ray for Detection of Pulmonary Infiltrates in COVID-19

Point-of-care lung ultrasound (LUS) is an attractive alternative to chest X-ray (CXR), but its diagnostic accuracy compared to CXR has not been well studied in coronavirus disease 2019 (COVID-19) patients. We conducted a prospective observational study to assess the correlation between LUS and CXR findings in COVID-19 patients. Ninety-six patients with a clinical diagnosis of COVID-19 underwent an LUS exam and CXR upon presentation. Physicians blinded to the CXR findings performed all LUS exams. Detection of pulmonary infiltrates by CXR versus LUS was compared between patients categorized as suspected or confirmed COVID-19 based on reverse transcriptase-polymerase chain reaction. Sensitivities and correlation by Kappa statistic were calculated between LUS and CXR. LUS detected pulmonary infiltrates more often than CXR in both suspected and confirmed COVID-19 subjects. The most common LUS abnormalities were discrete B-lines, confluent B-lines, and small subpleural consolidations. Most important, LUS detected unilateral or bilateral pulmonary infiltrates in 55% of subjects with a normal CXR. Substantial agreement was demonstrated between LUS and CXR for normal, unilateral or bilateral findings (Κ = 0.48 (95% CI 0.34 to 0.63)). In patients with suspected or confirmed COVID-19, LUS detected pulmonary infiltrates more often than CXR, including more than half of the patients with a normal CXR