Journal of Clinical Practice

Dear Colleagues!

The main idea of our journal is to provide description and analysis of clinical cases with severe, rare and difficult for diagnoses diseases, occurred in the clinics of Federal Medical-Biological Agency of Russia. Such clinical analysis is aimed to develop “clinical” type of thinking, always have been the characteristic feature of Russian/USSR medical school. The journal purpose is also to improve scientific discussions and cooperation between physicians of different specialties.

Revival of historical traditions in our journal is the one of the components of continuing education, which is especially important in “closed” territories, where doctors can`t regularly participate in clinical conferences. An important aspect is to provide a printed tribune for any doctor who has an interesting clinical observation and wish to share his experience with colleagues. That is why we named our journal "Clinical Practice" and address it, first of all, those skilled in applied medicine. Of course, we also publish the results of original researches, clinical guidelines, current reviews and medical news. The journal is multidisciplinary and we hope that it will be interesting to doctors of different specialties. The journal is published by means of the Federal Research and Clinical Center of FMBA of Russia. Placement of all materials, except for advertising, are free of charge to authors.

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Current Issue

Vol 11, No 2 (2020)

Original Research
Clinical characteristics of patients admitted to an ICU with COVID-19. Predictors of the severe disease
Klypa T.V., Bychinin M.V., Mandel I.A., Andreichenko S.A., Minets A.I., Kolyshkina N.A., Troitsky A.V.
Abstract

Background. Providing an efficient care to the patients of the most severely affected category — ICU patients — has become one of the serious problems appearing in the COVID-19 pandemics. A typical patient’s clinical portrait in ICUs of COVID centers is very similar in different countries, however, the key to improve the treatment results for critically ill patients has not yet been found. Currently, 160 patients have been treated in the ICU of the FRCC of the FMBA of Russia. To May 16, 2020, the lethality in the ICU was 48.9% by the closed cases, the lethality among the patients on ventilation was 57.9%. The aim of the study is to identify predictors of the severe pneumonia caused by the SARS-CoV-2 virus, and to describe the clinical characteristics of patients admitted to an intensive care unit of the COVID-center of the Federal Research Clinical Center of FMBA of Russia.

Methods. In this report, we describe the clinical, laboratory and instrumental data of 70 patients admitted to the ICU, and discuss the found predictors of the severe COVID-19 pneumonia course.

Results. The following factors have been determined which contribute to the development of the severe course of the disease and to the risk of the unfavorable outcome: male gender, age older than 70.5 years, initial lymphocytopenia of lower than 0.98×109/l, neutrophil to lymphocyte ratio of higher than 7.75, D-dimer level of higher than 0.85 µg/ml, IL-6 of higher than 184.7 pg/ml, procalcitonin of higher than 0.22 ng/ml, hyperglycemia of higher than 9 mmol/l, signs of myocardial damage (high-sensitive troponin Т of higher than 22 pg/ml, echocardiography data), signs of the presence of a secondary bacterial infection and a severe vitamin D deficiency (lower than 9.9 ng/ml). The pathophysiological basics for the contribution of each factor to the severe course of the disease are provided.

Conclusions. Clinical features of the patients change in course of pandemia. These influenced by changes in treatment approaches and new discoveries in disease pathophysiology. Above mentioned predictors of severe course of disease is partly modifiable and we are able to influence them and perhaps achieve better results in treatment of severe patients with COVID-19

Journal of Clinical Practice. 2020;11(2):6-20
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Pulmonary pathology of the new coronavirus disease (COVID-19). The preliminary analysis of post-mortem findings
Zabozlaev F.G., Kravchenko E.V., Gallyamova A.R., Letunovsky N.N.
Abstract

Background. Currently, the patho- and morphogenesis of the new coronavirus infection (COVID-19) is being studied in depth. A comparative analysis of the morphological changes in the lungs of deceased patients is of importance, for various time periods after the onset of the first clinical symptoms. The clinical and morphological comparison should help to increase the qualified medical care for patients in the resuscitation profile and reduce the hospital mortality.

The aim of the study was to formulate a working hypothesis for a conceptual scheme of clinical and morphological phases of development of the new coronavirus infection (COVID-19).

Methods. An analysis of 80 fatal cases was carried out in the COVID-center of the Federal Research Clinical Center of FMBA of Russia. Along with the assessment of macro- and microscopic changes in the respiratory tract, additional histochemical van Gieson staining was applied and immunohistochemical studies were performed to assess the condition of the COVID-19-affected lungs.

Results. The revealed features of diffuse alveolar damage in the case of the new coronavirus infection (COVID-19) made it possible to present a working hypothesis of the pathomorphogenesis of COVID-19 interstitial pneumonia. It proceeds through 3 phases: fulminant, persistent and fibrotic. Each phase is conditionally limited by certain time parameters and is characterized by certain morphological signs Dysregulatory activation of monocytic phagocytes, development of generalized microthrombosis, persistent signs of the exudative phase, pathological repair, progressive intraalveolar and interstitial fibrosis are the main links in the pathomorphogenesis of COVID-19 interstitial pneumonia. In response to the penetration of SARS-CoV-2, the T-cell immunity reactions prevail at the exudative and proliferative stages. At the fibrotic stage, the overall number of T-lymphocytes is drastically decreased, the cells of humoral immunity are not revealed. The CD8+ T-lymphocytes prevailing over CD4+ T-lymphocyte helpers is probably related to the autoimmune damage mechanisms.

Conclusions. Damage to the lungs with the development of COVID-19 interstitial pneumonia is the main cause of the severe course of the disease and deaths. The revealed features of the pathomorphogenesis of the clinical and morphological phases of COVID-19 interstitial pneumonia will improve the quality of diagnosis and treatment of a new coronavirus infection (COVID-19).

Journal of Clinical Practice. 2020;11(2):21-37
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Safety and efficacy of convalescent plasma for COVID-19: the preliminary results of a clinical trial
Baklaushev V.P., Averyanov A.V., Sotnikova A.G., Perkina A.S., Ivanov A.V., Yusubalieva G.M., Novikova O.N., Shikina V.E., Dupik N.V., Kedrova A.G., Sanzharov A.E., Shirshova E.V., Balionis O.I., Valuev-Elliston V.T., Zakirova N.F., Glazov Y.N., Panukhina I.A., Soloviev N.A., Vinokurov A.G., Ivanov Y.V., Vasilev V.N., Klypa T.V., Troitsky A.V.
Abstract

Background. The lack of effective etiotropic therapy for COVID-19 has prompted researchers around the globe to seekr various methods of SARS-CoV-2 elimination, including the use of convalescent plasma.

Aim. The aim of this work was to study the safety and efficacy of the convalescence plasma treatment of severe COVID-19 using the plasma containing specific antibodies to the receptor binding domain (RBD) of SARS-CoV-2 S protein in a titer of at least 1:1000.

Methods. A single-center, randomized, prospective clinical study was performed at the FRCC FMBA of Russia with the participation of 86 patients who were stratified in two groups. The first group included 20 critically ill patients who were on mechanical ventilation the second group included 66 patients with moderate to severe COVID-19 and with spontaneous respiration. The patients in the second group were randomized into two cohorts in a ratio of 2:1. In the first cohort (46 patients), pathogen-reduced convalescent plasma was transfused (twice, 320 ml each), in the second cohort (20 patients) a similar amount of non-immune freshly frozen plasma was transfused to the patients.

Results. The use of plasma of convalescents in patients with severe COVID-19 being on mechanical ventilation does not affect the disease outcome in these patients. The mortality rate in this group was 60%, which corresponds to the average mortality of COVID patients on mechanical ventilation in our hospital. In the second group, clinical improvement was detected in 75% and 51%, for convalescent and non-immune plasma, respectively. Of the 46 people who received convalescent plasma, three patients (6.5%) were transferred to mechanical ventilation, two of them died. In the group receiving non-immune plasma, the need for mechanical ventilation also arose in three patients (15%), of which two died. The hospital mortality in the group of convalescent plasma was 4.3%, which is significantly lower than the average COVID-19 hospital mortality at our Center (6.73%) and more than two times lower than the hospital mortality in the control group (n=150), matched by age and by the disease severity.

Conclusions. Thus, we demonstrated a relative safety of convalescent plasma transfusion and the effectiveness of such therapy for COVID-19 at least in terms of the survival of hospitalized patients with severe respiratory failure without mechanical ventilation. In the absence of bioengineered neutralizing antibodies and effective etiotropic therapy, the use of hyperimmune convalescent plasma is the simplest and most effective method of specific etiopathogenetic therapy of severe forms of COVID-19.

Journal of Clinical Practice. 2020;11(2):38-50
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The capabilities of MRI in the lung lesions diagnosis in patients with COVID-19
Lesnyak V.N., Zhuravleva V.A., Averyanov A.V.
Abstract

Backgrounds. The imaging diagnostic methods have become particularly important during the COVID-19 pandemic, and computed tomography of the thorax (CT) is considered to be the “gold standard” in the cases of lung lesions and in the evaluation of changes in the pulmonary parenchyma in dynamics. However, it is well known that the CT method is associated with a significant radiation dose, especially given the fact that repeated, and often reiterated control CT-tests are required for many patients who suffer COVID-19 or have recovered from the disease. In order to reduce the potential radiation exposure and receive some additional diagnostic information, we applied the magnetic resonance imaging (MRI) method for viral pneumonia at the FRCC of FMBA of Russia, which was redesigned as a center for the treatment of patients with COVID-19.

Aim. The aim is to evaluate the possibilities of the lung MRI in the diagnosis of pneumonia caused by the new coronaviral infection, to describe the specific symptoms of lung parenchyma lesions using various pulse sequences, and compare the results with the CT data.

Methods. The article is based on the practice of applying high-resolution computed tomography (HRCT) and MRI of the lungs in 15 patients with pneumonia caused by COVID-19.

Results. The comparison of the HRCT data and T2-weighted images (T2-WI) in 100% of cases revealed a complete correlation in the size, number and position of the lung tissue areas with reduced air saturation by the type of ground glass opacity and the consolidation zones. The level of linear and reticular changes detection in MRI reached 73.3%. Free fluid in the pleural cavities in a moderate and minimal volume was revealed on T2-WI in 12 patients (80% of cases), while it was not diagnosed by HRCT in all the cases. The mediastinal and intra-pulmonary lymph nodes were visualized distinctly. In T1-weighted images (T1-WI), the areas of ground glass opacity were either not visualized, or were represented by smaller areas when compared to the HRCV data and reticular changes were also displayed worse. In 73.3% cases, the consolidation zones on T1-WI fully corresponded or were almost similar in characteristics to changes visualized by HRCT. At the same time, it is worth noting that performing T1-WI out phase more clearly displayed the consolidation zones when compared to T1-WI in phase. Foci of increased signal on T1-WI with fat suppression were registered in 3 patients against the background of consolidation sites which in comparison with the data of T2-WI, would suggest the presence of parenchymal hemorrhages.

Conclusion. Lung MRI is a fairly sensitive method for identifying areas of ground glass opacity and consolidation, reticular changes and lymphadenopathy, and is superior to HRCT when displaying pleural effusion. Chest MRI may be recommended as a diagnostic method for suspected pulmonary COVID-19 lesion in children and pregnant women in order to exclude ionizing radiation exposure, as well as for monitoring the condition of lung tissue after viral pneumonia, if the patient was previously exposed to a high radiation dose.

Journal of Clinical Practice. 2020;11(2):51-59
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Reviews
The nervous system damage in COVID-19
Belopasov V.V., Yachou Y., Samoilova E.M., Baklaushev V.P.
Abstract

Based on the available publications, the article systematizes the data on the forms of damage to the central nervous system in СOVID-19 patients. We discuss the diagnostic approaches (laboratory, instrumental and radiological) and the therapeutic tactics for different nosological forms from cranial mononeuropathies to acute inflammatory Guillain-Barré polyneuropathy and severe damage to the brain and spinal cord with acute hemorrhagic necrotizing encephalopathy and myelopathies. Pathogenetically, neurological disorders in COVID-19 can be caused by a “cytokine storm”, hypoxemia, homeostasis disorders (encephalopathy of critical illness), neurotropic and neurovirulence features of SARS-CoV-2 (isolated damage to the cranial nerves, focal and diffuse lesions of the central nervous system), and mixed effects of these factors. COVID-19 affects the course of chronic neurological diseases, especially related with neuroimmune disorders. All of the above determines the need for a multidisciplinary approach to the treatment of COVID-19 and its complications with the mandatory participation of a neurologist.

Journal of Clinical Practice. 2020;11(2):60-80
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Concerning the neurotropy and neuroinvasiveness of coronaviruses
Voitenkov V.B., Ekusheva E.V.
Abstract

At the present moment of COVID-19 development, we may propose some preliminary thoughts on its direct and distant sequels. In our review we suggest that the novel SARS-CoV-2 virus, as well as other members of the Coronaviridae family, may possess neurotropic and neuroinvasive features; they may enter the nervous system via the intranasal way and directly infect the human brain, causing lesions in the brainstem nuclei of the cardiorespiratory center. We assume that such a lesion may worsen the respiratory distress and lead to the respiratory failure in some patients. Taking this into consideration, immunomodulating and antiviral drugs that utilize the intranasal way of delivery may help in the prevention and treatment of COVID-19 in those contacting with COVID-19-infected patients. All these proposals are preliminary and need an in-depth investigation involving randomized experimental, clinical and pathomorphological studies.

Journal of Clinical Practice. 2020;11(2):81-86
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Case report
Pneumocystis pneumonia mimicking COVID-19
Averyanov A.V., Sotnikova A.G., Lesnyak V.N.
Abstract

Background. The new coronavirus infection COVID-19 caused by a SARS-CoV-2 zoonotic beta-coronavirus has radically transformed the conventional concept of the immune system’s participation in an infectious process. The successful application of anti-interleukin monoclonal antibodies and inhibitors of Janus kinases in COVID-19, traditionally contraindicated in infections, testifies that the immune response to the pathogen may be more dangerous than the infection itself. However, when prescribing the immunosuppressive therapy to COVID-19 patients, one should not forget that some interstitial pneumonias caused by opportunistic microflora, such as Pneumocystis Jirovecii, have similar clinical and radiological manifestations.

Clinical case description. A 29-year old female patient was admitted to the infectious disease hospital with complaints of a febrile temperature, shortness of breath at rest, low-productive cough, pronounced weakness. She had been ill for 14 days, the SARS-CoV-2 RNA was detected at the pre-hospital stage. After the admission, a chest CT scan was performed showing a subtotal lung damage with the characteristic radiological manifestations of interstitial pneumonia in the form of ground glass opacity regions, presence of “air traps”, that was initially attributed to bilateral viral pneumonia (СТ-3/4). The subsequent examination confirming primary HIV infection and a sputum analysis positive for P. Jirovecii allowed us to establish a correct clinical diagnosis of pneumocystis pneumonia against the background of HIV infection and a mild COVID-19 course, administer a co-trimoxazole therapy and obtain a favorable outcome.

Conclusion. This observation demonstrates the necessity of applying an individual approach to each patient admitted to a COVID hospital and performing a differential diagnosis, even when COVID-19 is confirmed by the laboratory work, in order not to miss other interstitial pneumonias, in particular, pneumocystis pneumonia appearing against the background on immunodeficiency.

Journal of Clinical Practice. 2020;11(2):87-92
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A clinical case of successful application of a new treatment method for severe COVID-19
Samoylov A.S., Udalov Y.D., Kruglyakov N.M., Terekhov D.А., Bagzhanov G.I., Ochkin S.S.
Abstract

COVID-19, formerly coronavirus infection 2019-nCoV, is a potentially severe acute respiratory infection caused by the SARS-CoV-2 coronavirus (2019-nCoV). It is a dangerous disease that can occur both in the form of a mild acute respiratory viral infection and in a severe form with the development of bilateral polysegmental viral pneumonia, specific complications of which may include acute respiratory distress syndrome, resulting in the respiratory failure with a high risk of death. Due to the absence of etiotropic therapy for the coronavirus infection, pathogentic treatment becomes of primary importance. We present a clinical case of a severe form of COVID-19 in a 33-year-old man to whom we administered a new method of pathogenetic treatment of this disease based on immunosuppresiive therapy followed by therapeutic plasma exchange and infusion of non-specific human immunoglobulin.

Journal of Clinical Practice. 2020;11(2):93-100
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Bilateral polysegmentary pneumonia caused by SARS-CoV-2 in a transplanted liver recipient
Ishenko R.V., Golovincki S.V., Akhmedianov A.R., Voskanyan S.E., Kolyshev I.Y.
Abstract

Background. In December 2019, the humanity met a previously unknown infectious disease (COVID-19) caused by a new coronavirus called SARS-CoV-2. An important role in the treatment of COVID-19 belongs to anti-inflammatory and immunosuppressive drugs. In this regard, the cases of the disease in patients undergoing long-term immunosuppressive therapy, for example, organ transplant recipients, are of particular interest. We present our clinical observation of COVID-19 in a liver recipient patient, which, apparently, is the first in the Russian Federation.

Clinical case description A 54-year-old man, 10 years ago at the A.I. Burnazyan Center underwent transplantation of the right lobe of the liver after resection of hepatocellular carcinoma, T2N0M0, and due to liver cirrhosis as a result of НСV hepatitis. At the time of hospitalization, he had been constantly receiving immunosuppressive monotherapy with everolimus. The patient was transferred to an infectious disease hospital due to a positive PCR test for SARS-CoV-2 RNA. No signs of respiratory failure were found upon admission. Subsequently, a mild course of COVID-19 was observed, without signs of an acute inflammatory reaction, with normal CRP values and a slight increase of ferritin. 7 days after the treatment, the patient was discharged for outpatient observation.

Conclusion. This clinical case is of interest not only by the success of the treatment of the new coronavirus infection COVID-19 in an immunocompromised patient — a recipient of a liver transplant, but also by the fact that the disease manifested itself primarily as a transient increase in hepatic aminotransferases, which can be attributed to the gastrointestinal manifestations of COVID-19.

Journal of Clinical Practice. 2020;11(2):101-106
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Features of case management with neuromuscular disease during COVID-19. Clinical impression
Karpova O.V., Udalov Y.D., Samoylov A.S., Kudryavtsev R.A.
Abstract

The new COVID-19 coronavirus infection, which has become a pandemic, is a very dangerous disease, the clinical picture of which can vary from mild to extremely severe forms of the course. Currently, there are no complete data on the pathogenetic mechanism of SARS-CoV-2, but there are extensive data on the probable risk factors for the development of extremely severe forms of COVID-19. The study of such factors becomes most suitable in terms of preventing their development and influence on the course of the disease in individuals with compromised immune systems and patients with impaired neuromuscular transmission. The article describes two clinical cases of extremely severe COVID-19 in patients with impaired neuromuscular transmission. Based on the analysis of the course of diseases, the conclusions are made about the possible aggravation and mutual activation of the immunopathological process with the launch of the cascade mechanism of the “cytokine storm”. An assumption has been made about the influence of human leukocyte antigen (HLA) on the severity of COVID-19, which is confirmed by a positive dynamics against the background of administration of IVIG, glucocorticosteroids (GCS), virusinactivated plasma and extracorporeal detoxification methods.

Journal of Clinical Practice. 2020;11(2):107-117
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Discussion
Changing the tactics of X-RAY endovascular treatment of patients with acute coronary syndrome with intermediate and severe degrees of coronary lesions on the SYNTAX scale in the conditions of the COVID-19 pandemic
Bocharov A.V., Popov L.V.
Abstract

This article shows the changes in the structure of patients with acute coronary syndrome admitted to the Department of X-ray Surgery of the Regional Vascular Center, associated with the quarantine measures due to the COVID-19 coronavirus infection. The modified tactics of endovascular treatment of acute coronary syndrome in the context of the COVID-19 pandemic is presented.

Journal of Clinical Practice. 2020;11(2):118-121
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