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Pulmonary fibrosis 4 months after COVID-19 is associated with severity of illness and blood leucocyte telomere length
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  • Published on:
    Response to Raja and colleagues
    • Claire McGroder, Physician, Pulmonary and Critical Care Medicine Columbia University Irving Medical Center
    • Other Contributors:
      • Mary Salvatore, Radiologist
      • Eric A. Hoffman, Radiology and Biomedical Imaging Investigator
      • Matthew Baldwin, Physician, Pulmonary and Critical Care Medicine
      • Christine Kim Garcia, Physician, Pulmonary and Critical Care Medicine

    We thank A. Raja and colleagues for their interest in our article on risk factors for fibrotic-like changes after severe COVID-19 infection (1). We agree that identification and management of post-COVID fibrosis continues to be impeded by the lack of consensus definitions and we look forward to further studies that help describe the natural history of post-COVID pulmonary manifestations.

    The authors propose that lung fibrosis be classified into different ILDs by the pattern of lung parenchymal abnormalities six months after the initial COVID illness has resolved. We agree with the authors that persistent radiographic abnormalities are an adverse outcome of COVID that deserve future study, but we disagree with their proposed classification of patterns. We believe that recognition of fibrotic interstitial lung abnormalities (ILAs), as opposed to non-fibrotic ILAs, help prognosticate which abnormalities are less likely to resolve over time (2). Han et al (3) recently demonstrated that individuals with post-COVID fibrotic ILAs at six months had persistent fibrosis at 1-year, suggesting that fibrotic ILAs rarely resolve completely. Ultimately, serial imaging, quantitative measures of fibrosis (4), and assessment of pharmaceutical interventions (5), will be key to fully understanding the trajectory of post-COVID fibrosis.

    Secondly, the authors report that disease severity did not significantly impact the development of particular parenchymal abnormalities on CT...

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    Conflict of Interest:
    None declared.
  • Published on:
    View from South East Asia on Post-COVID Fibrotic Lung Disease
    • Ahsan R. Raja, Medical Student Aga Khan University Hospital, Karachi, Pakistan
    • Other Contributors:
      • Maheen Zakaria, Medical Student
      • Murtuza Hassan, Medical Student
      • Ali Bin S. Zubairi, Professor and Section Head of Pulmonary & Critical Care Medicine

    Dear Editor,

    We read with interest McGroder et al’s study on the radiographic findings of patients four months after severe COVID-19 and the associated risk factors. Hürsoy and colleagues’ comment (1) on the paper was equally thought-provoking. We would like to further this discussion by contributing some of our observations from the pulmonology clinic at a major academic medical center in South East Asia.

    It has been tremendously challenging globally to achieve precision in the diagnosis of Interstitial Lung Disease (ILD) post-COVID as invasive testing such as lung biopsies are performed sparingly. Histopathological pulmonary findings have largely remained inaccessible since COVID survivors are hypoxic so biopsies pose a high risk for the patient, and healthcare personnels are reluctant to perform such high-risk procedures. Hence, we are left to derive our diagnosis from radiological data and pulmonary function tests (PFTs) of the patient.

    We propose that a consensus definition be reached for the diagnosis of post-COVID ILD, one that incorporates well-accepted radiological terms (used to represent any interstitial lung disease). We recommend that lung fibrosis only be classified as ILD if the lung parenchymal abnormalities persist for a minimum of six months after the COVID infection has resolved. Post-COVID ILD should then be further subclassified based on distinct radiological patterns. In our retrospective cohort study, four patterns of post-COV...

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    Conflict of Interest:
    None declared.
  • Published on:
    Response to Hursoy and colleagues
    • Claire F. McGroder, Physician, Pulmonary and Critical Care Medicine Columbia University Irving Medical Center
    • Other Contributors:
      • Matthew R. Baldwin, Physician, Pulmonary and Critical Care Medicine
      • Mary M. Salvatore, Radiologist
      • Eric A. Hoffman, Radiology and Biomedical Imaging Investigator
      • Christine Kim Garcia, Physician, Pulmonary and Critical Care Medicine

    To the editor,

    We thank N. Hürsoy and colleagues for their interest in our study of patients four months after severe COVID-19 [1]. We agree that there needs to be continued development of terms describing the radiographic appearance of post-COVID fibrotic-like patterns. We acknowledge that without the benefit of histopathology or serial imaging, our ability to define pulmonary fibrosis is limited.

    The authors posit that parenchymal bands, irregular densities, and ground glass opacities, may be considered fibrotic-like patterns. We have included irregular densities, characterized as reticulations or traction bronchiectasis, as fibrotic-like changes. We did not include parenchymal bands [2], as these can be associated with atelectasis, which is common in COVID and can disappear over time [3]. Similarly, we did not include isolated ground glass opacities as fibrotic-like changes, as these have been found to decrease over time in CT lung cancer screening cohorts [4] and in other post COVID-19 cohorts [5, 6].

    A priori, we evaluated for both previously established interstitial lung abnormality categories [7], as well as categories of radiographic abnormalities reported in Acute Respiratory Distress Syndrome (ARDS) survivors using an established scoring system [8]. This inclusive approach should facilitate meta-analyses and comparisons with future studies of COVID-19 survivors, interstitial lung disease studies, and studies of non-COVID ARDS survivors. Fu...

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    Conflict of Interest:
    None declared.
  • Published on:
    Different Views About Post-Covid Fibrotic-Like Patterns
    • Nur Hürsoy, Radiologist Recep Tayyip Erdogan University, Faculty of Medicine
    • Other Contributors:
      • Dilek Karadogan, Pulmonologist
      • Aycan Yüksel, Pulmonologist
      • Metin Akgün, Pulmonologist

    Dear Editor,

    We have read with great interest the article investigating the relationship between computed tomography (CT) findings of the patients with fibrotic-like patterns and telomere length after four months of acute COVID-19 infection. According to the literature and our experience, post-COVID interstitial lung disease is a potential public health problem. Thus, we aimed to share our concerns about the fibrotic-like patterns in this group of patients.

    Post-COVID fibrosis is not as the same as the other interstitial lung diseases. In the article, the authors describe CT findings of fibrotic-like patterns as limited to reticulation, honeycomb cysts, and traction bronchiectasis. However, post-COVID fibrosis CT findings were shown to be more varied and may include parenchymal bands, irregular densities, and ground-glass areas (1–3). As we move towards the future, all of us need to create a common language, a lingua franca in the definition of post-COVID fibrosis. To achieve this, we need brainstorming and close cooperation.

    It will also be helpful to elaborate the characteristics of the non-fibrotic pattern in the table. The clinical importance of the ground glass areas, which persist four months after active infection but not defined as fibrotic, is unknown. We consider that these patterns cannot be separated from fibrotic-like patterns precisely. Additionally, we can also classify parenchymal bands as fibrosis-like appearance. In our experience...

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    Conflict of Interest:
    None declared.