1) COVID-19 can cause persistent radiological changes and lung function abnormalities even after discharge from the hospital. Regular follow-up is recommended, especially for severe cases. 2) COVID-19 has been shown to cause multi-system involvement beyond the lungs, including cardiovascular, neurological, renal and other organ systems. It can present atypically without respiratory symptoms. 3) Post-COVID care including pulmonary rehabilitation is important as many patients have long-term effects. Emerging treatments like anti-fibrotics are being studied to prevent long-term pulmonary fibrosis in severe cases.

1. FOLLOW UP OF COVID19 CASES POST
DISCHARGE & Atypical presentation and
System involvement seen in COVID19
• PRESENTER
• Dr Ajay Tripathi
• JR dept of Medicine RDGMC

2. 2 CASE REPORTS OF
RAPIDLLY PROGRESSIVE
ORGANISING
PENUMONIA WITH
FIBROTIC FRETURE
PULISHED BY Division of Pulmonary
Medicine, b Division of
Rheumatology, Department of
Medicine, c Center for Infection
Diseases and Infection Control, Keio
University
School of Medicine, Shinjuku, Tokyo,
Japan.
∗ Correspondence: Hiroki Kabata,
Division of Pulmonary Medicine,
Department of
Medicine, Keio University School of
Medicine, 35 Shinanomachi,
Shinjuku, Tokyo

4. Respiratory follow-up
of patients with
COVID-19 pneumonia
Peter M George 

,1,2 Shaney L Barratt 

,3,4 Robin Condliffe,5 Sujal R Desai,6
Anand Devaraj,6 Ian Forrest,7 Michael A Gibbons,8 Nicholas Hart,9
R Gisli Jenkins 

,10 Danny F McAuley,11 Brijesh V Patel,12 Erica Thwaite,13
Lisa G Spencer13
• A review and guidance
published in “Throax ” journal
August 2020 , published by BMJ
group
• This guidance has been adopted
by British Thoracic society (BTS)
and British Society of Thoracic
imaging (BSTI)

5. • Typical cases of COVID-19 pneumonia, the chest X-ray (CXR)
shows multiple bilateral peripheral opacities
• CT scan with regions of ground-glass
• opacification and consolidation, which variably comprise foci of
oedema, organising pneumonia and diffuse alveolar damage

6. COVID-19 PNEUMONIA IMAGING AND
SPECIFIC RESPIRATORY COMPLICATIONS FOR
CONSIDERATION

7. In a longitudinal CT study of 90 patients with COVID-19, 94% of individuals had
residual changes on CT at discharge (median duration of 24 daysafter symptom onset) with ground-
glass opacity the most common pattern.
In a study of 110 patients with COVID-19, almost half (50%) had impairment of the
transfer factor of the lung for carbon monoxide (TLco) at time of discharge (Avg 20 days fr mild to
mod disease and 34 days fr severe disease.) The Tlco was lower in patient with more severe disease
and was more sensitive paramatre then other like FVC and TLC
In a study of SARS survivors, 12 weeks after discharge, 36% of patients had residual CXR
abnormalities and at 6 months, these were still present in 30% CXR abnormalities were correlated
with lung function test parameters including FVC, TLco and TLC
Similarly, in MERS survivors, at a median follow-up point of 6 weeks (range 32–230 days), 36%
of patients had residual CXR changes, the vast majority of which
were due to pulmonary fibrosis.1

8. • Data suggest majority of patient at discharged with COVID19 has
persistant radiological changes
• In SARS and MERS by 12 week approx.2/3rd patients had full cxr
resolution , and those persisted due to pulmonary fibrosis

9. Recommendations fr COVID19 Respiraory
follow up, fr ICU HDU or mod- severe cases

10. Recommendations fr COVID19 Respiraory
follow up, fr ward pt / mild cases

11. If the CXR changes have not satisfactorily resolved at 12 week follow up and/ or the patient
has ongoing respiratory symptoms, consider the Following
►► Full pulmonary function testing.
►► Walk test with an assessment of oxygen saturation.
►► Echocardiogram.
►► Sputum sample if expectorating for microbiological analysis.
►► Referral to rehabilitation services if not already done.
►► A new diagnosis of PE or post-PE complications if diagnosed during the acute illness.
If pt is clinically improving but CXR has still persistant changes , a repeat assessment at 6-8
weeks is recommended with supportive therapies and physiotherapy and spirometric
exercis

12. Role of Anti Fibrotic therapy
pirfenidone
Journal Article1 --COVID-19 Patients
with Pulmonary Fibrotic Tissue:
Clinical
Pharmacological Rational of
Antifibrotic Therapy
Antonio Vitiello1 & Chiara Pelliccia2 &
Francesco Ferrara1
Accepted: 24 August 2020
# Springer Nature Switzerland AG
2020

13. Journal Article 2
Pirfenidone in patients with unclassifiable
progressive fibrosing interstitial lung disease: a
double-blind, randomised, placebo-controlled,
phase 2 trial
Publised by Lancet respiratory medicine Feb 2020,
discuss use of Pirfenidone in Unclassified
Pulmonary fibrosis
Between May 15, 2017, and June 5, 2018,
253 patients were randomly assigned to
receive 2403 mg pirfenidone (n=127) or
placebo (n=126)
Over 24 weeks, predicted mean change in
FVC measured by site spirometry was
lower in patients given pirfenidone than
placebo (treatment difference 95·3 mL [95%
CI 35·9 to 154·6], p=0·002). Compared with
the placebo group, patients in the
pirfenidone group were less likely to have a
decline in FVC of more than 5% (odds ratio
[OR] 0·42 [95% CI 0·25 to 0·69], p=0·001)
or more than 10% (OR 0·44 [0·23 to 0·84],

14. Role of Anti Fibrotic therapy
pirfenidone
Pirfenidone used in treatment of Idiopathic
pulmonary fibrosis
In IPF The dose of pirfenidone ranges up to
40 mg/kg per day (to maximum of 2403 mg
per day) in three divided doses.
In COVID 19 , it is being used at doses
starting 400mg / day to 1600mg / day in
divided doses.
Started when fibrotic organizing phase of
COVID pneumonia starts
Some opinions regarding its early use as it
has inti inflammatory property also
Definative trials are underway

15. Atypical presentation and
System involvement seen
in COVID19
Systemic procogulative state
Venous thrombosis is known
cases of atrial thrombosis being seen
also
REPORTED IN JOURNAL – ANNALS OF
VASCULAR SURGERY SEPTEMBER 2020
ISSUE
CASE SERIES OF 3 CASES

17. CNS CASE SERIES
SARS-CoV-2 Viral Sepsis with
Meningoencephalitis
Mitkumar Dharsandiya, Kinjal Shah, Ketan Patel,
Tushar Patel1, Amrish Patel1, Atul Patel
Departments of Infectious Diseases and
1Pulmonary and Critical Care Medicine, Sterling
Hospital, Ahmedabad, Gujarat, India

18. Continuous EEG FIndings in
patients with COVID‐19 infection
admitted to a New
York academic hospital system
Jacob Pellinen , Elizabeth Carroll ,
Daniel Friedman , Michael Boa ,
Patricia Dugan , David E. Friedman ,
Deana Gazzola , Amy Jongeling ,
Alcibiades J. Rodriguez , Manisha
Holmes
First published: 02 September 2020
JOURNAL -- EPLIPSIA

19. Guillain Barre syndrome associated with
COVID-19 infection: A case report Zahra
Sedaghata, Narges Karimib,⇑ aNeurology
Resident, Department of Neurology, School
of Medicine, Mazandaran University of
Medical Sciences, Sari, Iran
bToxoplesmosis Research Center,
Immunogenetics Research Center, Clinical
Research Development Unit of Bou Ali Sina
Hospital, School of Medicine, Mazandaran
University of Medical Sciences, Sari, Iran

20. CVS SYSTEM
Suspected myocardial injury in patients
with COVID-19: Evidence from
front-line clinical observation inWuhan,
China☆
Qing Deng a,1, Bo Hua,1, Yao Zhang a,
HaoWanga, Xiaoyang Zhou b,Wei Hua,
Yuting Chenga, Jie Yan b,
Haiqin Ping b, Qing Zhoua,⁎
a Echo Lab, Department of Ultrasound
Imaging, Renmin Hospital of Wuhan
University, Wuhan 430060, China
b Department of Cardiology, Renmin
Hospital of Wuhan University, Wuhan

21. “With short-term follow-ups and front-line clinical data analysis, our
study has revealed that there was evidence of myocardial injury in
COVID-19 patients during hospitalization and 14 (12.5%) patients had
presented abnormalities similar to myocarditis, especially the elevation
in cardiac troponin I.We have discovered the characteristic change over
time for cardiac troponin I: Most of patients had normal levels of troponin
at admission, that in 42 (37.5%) patients increased during hospitalization,
especially in those that died. Troponin levels were significantly
increased in the week preceding the death. In the absence of typical
signs on echocardiography and ECG, though the clinical evidence in
our study can't exclude myocardial injury and myocarditis directly
caused by the 2019 novel coronavirus, we consider that the elevation
in cardiac troponin I was more likely related to systemic disorders and
could be the warning sign for the death of patients with COVID-19,
which should be paid more attention to in clinical practice

22. AKI AND RENAL TROPISM
OF COVID19
Clinicopathological Features and
Outcomes of Acute
Kidney Injury in Critically Ill COVID-
19 with Prolonged
Disease Course: A Retrospective
Cohort
Peng Xia,1 Yubing et al

23. Published in
LANCET.com on Aug
29 2020
Here, we
present data from a post-mortem
series of 63 patients who had
SARS-CoV-2 respiratory infection
(appendix pp 2–3), linking SARS-CoV-2
renal tropism to clinical outcome and
acute kidney injury.
In this cohort, SARS-CoV-2 RNA
was found in 38 (60%) of 63 patients.
Presence of SARS-CoV-2 RNA in the
kidney was associated with older age
and an increased number of coexisting
conditions (figure). Furthermore,
SARS-CoV-2 RNA was associated
with a reduction in patients’ survival
time, obtained by calculating the
time interval between COVID-19
diagnosis and date of death (figure).
These findings support a potential
correlation between extra-respiratory
viral tropism, disease severity, and
increased risk of premature death
within the first 3 weeks of disease

24. Miscellaneous case
presentations
A coronavirus disease 2019 (COVID-
19) patient with bilateral
orchitis: A case report
Published in The American Journal of
Emergency Medicine
27 August 2020
A 37-year-old previously healthy male
presented to the emergency department
(ED) complaining of bilateral testicular
warmth and discomfort as well as fevers,
anorexia, myalgias, fatigue, and non-
productive cough. He noted that these
constitutional symptoms progressed for the
past 10 days, with the bilateral testicular
pain developing over the past 3 days. The
patient was diagnosed with COVID-19 by
nasopharyngeal polymerase chain reaction
at an outpatient clinic 15 days prior to
presentation to the ED. His review of
systems was otherwise unremarkable
USG REVELED B/L TESTICIULAR INFLAMMATION,
THERE IS CONCERN OF LONG TERM SPERMATIC
QUALITY AND FERTILITY ISSUES UNDER
INVESTIGATION

25. IN SUMMARY
We are in a era of with COVID19 where both
acute presentation and chronic care of cases
shall be needed
Post covid care , rehablitaion is very imp
COVID19 looks like a multisystem disorder
and has various atypical presentations sans
respiratory system, it also has wide impact
overall