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Superior vena cava (SVC) syndrome resulting from obstruction of the blood flow to the superior vena cava is rarely reported to present with life-threatening hemoptysis. The pathogenesis and the underlying mechanism are still not well described in the literature. We report a unique case of a 27-year-old man known to have end-stage kidney disease (ESKD) on hemodialysis that presented with shortness of breath and life-threatening hemoptysis that developed during the dialysis session. Computerized tomography with contrast (CTPA) confirmed the presence of a large, calcified thrombus within the SVC along with the formation of multiple collaterals which was diagnostic for SVC syndrome. Attempts for revascularization and stenting failed, and the patient had a prolonged and stormy course while admitted, including difficult alternative dialysis access that unfortunately resulted in death eventually. Here we are highlighting the importance of recognition of hemoptysis as a presentation of SVC syndrome by explaining the underlying pathogenesis and possible management options.

Severe acute respiratory syndrome coronavirus 2 infection can be severe and fatal due to cytokine storm. Therapeutic plasma exchange (TPE) potentially mitigates the harmful effects of such cytokines. We investigated the use of TPE, as rescue therapy, in patients with severe Coronavirus disease 2019 (COVID-19) infection.A retrospective analysis on COVID-19 patients admitted to the intensive care unit and treated with TPE from April 17, 2020 to July 2, 2020. This group was compared with COVID-19 patients who received standard therapy without TPE. The following outcomes were analyzed: changes in laboratory parameters, length of hospital stay (LOS), days on mechanical ventilation, mortality at days 14 and overall mortality.A total of 95 patients were included, among whom 47% (n = 45) received TPE. Patients who received TPE had reductions in C-reactive protein (P = .002), ferritin (P .001) and interleukin-6 (P = .013). After employing entropy-balancing matching method, those on TPE were also more likely to discontinue inotropes (72% vs 21%; P .001). However, they were more likely to be associated with longer LOS (23 vs 14 days; P = .002) and longer days on ventilatory support (14 vs 8 days; P .001). Despite marginal mortality benefit at 14-days (7.9% vs 24%; P = .071), there was no significant differences in overall mortality (21% vs 31%; P = .315) between the groups.TPE was effective in reducing inflammatory markers in patients with severe COVID-19 infection, however, further research is warranted.

Objectives: The aim of this study is to assess the correlation between the severity of the initial chest x-ray abnormalities in patients with confirmed diagnosis of coronavirus disease 2019 (COVID-19) and the final outcomes. Methods: Retrospectively, we identified serial chest radiographs of 64 patients (57 men, 7 women, with mean age of 50 years) admitted to the Royal Hospital between March 15, 2020 and May 30, 2020 with confirmed diagnosis of COVID-19. The chest radiographs were examined for presence, extent, distribution and progression pattern of radiological abnormalities. Each lung field was divided into 3 zones on each CXR and a score was allocated for each zone. The scores (0 [normal], 1 [mild] to 4 [severe]) for all six zones per chest radiographic examination were summed to provide a cumulative chest radiographic score (range, 0–24). Results: The initial CXR was abnormal in 60 patients (93.8%). The most common finding was ground glass opacity (58/64, 90.6%), followed by consolidation (50/64, 78.1%). The majority of the patients had bilateral (51/64, 85%), multifocal (57/64 95%) combined central and peripheral (36/64, 60%) lung abnormalities. The median score of initial CXR for deceased patients was significantly higher than those who recovered (17 vs 11 respectively; P = 0.009). Five CXR evolution patterns were identified: type I (initial radiograph deteriorates then improves), type II (fluctuate), type III (static), type IV (progressive deterioration) and type V (progressive improvement). Conclusion: Higher baseline chest radiograph score is associated with higher mortality rate and poor prognosis in those with COVID-19 pneumonia. Keywords: SARS-CoV-2; COVID-19; Chest X-ray; Scoring System; Pneumonia; Prognosis; Outcome; Severity; Consolidation; Ground-glass.

Highlights • Therapeutic plasma exchange (TPE) associated with lower 28 days mortality and marginally associated with lower all-cause mortality. • The TPE group had higher extubation rates compared to the controls. • The TPE group was associated with improved laboratory and ventilatory parameters when compared to the control cohort., Objectives To evaluate the therapeutic use of plasma exchange in COVID-19 patients compared to controls. Methods Case series of critically ill adult men and non-pregnant women, ≥18 years of age, with laboratory confirmed COVID-19, was conducted at the Royal Hospital, Oman, from April 17th to May 11th, 2020. Therapeutic plasma exchange (TPE) was performed on patients admitted to intensive care unit (ICU) with confirmed or imminent acute respiratory distress syndrome (ARDS) or severe pneumonia. Analysis was performed using univariate statistics. Results A total of 31 COVID-19 patients were included with an overall mean age of 51 ± 15 years (range: 27-76 years), 90% (n = 28) were males, and 35% (n = 11) of the patients had TPE as a mode of treatment. The TPE group was associated with higher extubation rates than the non-TPE cohort (73% versus 20%; p = 0.018). Additionally, patients on TPE had a lower 14 days (0 versus 35%; p = 0.033) and 28 days (0 versus 35%; p = 0.033) all-cause mortality compared to patients not on TPE. However, all-cause mortality was only marginally lower in the TPE group compared to the non-TPE group (9.1% versus 45%; p = 0.055; power = 66%). Laboratory and ventilatory parameters also improved with the TPE. Conclusions The use of TPE in severe COVID-19 patients has been associated with improved outcomes, however, randomized controlled clinical trials are warranted to draw final conclusive findings.

Introduction To identify the clinical characteristics and outcomes of hospitalized patients with COVID-19 in Oman. Methods A case series of hospitalized COVID-19 laboratory-confirmed patients between February 24th through April 24th, 2020, from two hospitals in Oman. Analyses were performed using univariate statistics. Results The cohort included 63 patients with an overall mean age of 48 ± 16 years and 84% (n = 53) were males. A total of 38% (n = 24) of the hospitalized patients were admitted to intensive care unit (ICU). Fifty one percent (n = 32) of patients had at least one co-morbidity with diabetes mellitus (DM) (32%; n = 20) and hypertension (32%; n = 20) as the most common co-morbidities followed by chronic heart and renal diseases (12.8%; n = 8). The most common presenting symptoms at onset of illness were fever (84%; n = 53), cough (75%; n = 47) and shortness of breaths (59%; n = 37). All except two patients (97%; n = 61) were treated with either chloroquine or hydroxychloroquine, while the three most prescribed antibiotics were ceftriaxone (79%; n = 50), azithromycin (71%; n = 45), and the piperacillin/tazobactam combination (49%; n = 31). A total of 59% (n = 37), 49% (n = 31) and 24% (n = 15) of the patients were on lopinavir/ritonavir, interferons, or steroids, respectively. Mortality was documented in (8%; n = 5) of the patients while 68% (n = 43) of the study cohort recovered. Mortality was associated with those that were admitted to ICU (19% vs 0; p = 0.009), mechanically ventilated (31% vs 0; p = 0.001), had DM (20% vs 2.3%; p = 0.032), older (62 vs 47 years; p = 0.045), had high total bilirubin (43% vs 2.3%; p = 0.007) and those with high C-reactive protein (186 vs 90 mg/dL; p = 0.009) and low corrected calcium (15% vs 0%; p = 0.047). Conclusions ICU admission, those on mechanical ventilation, the elderly, those with high total bilirubin and low corrected calcium were associated with high mortality in hospitalized COVID-19 patients.

Objectives: We sought to identify the chest radiography differences at presentation between two groups of hospitalized confirmed COVID-19 patients; intubated group compared to non-intubated group. Methods: We retrospectively collected the data of confirmed hospitalized COVID-19 patients at the Royal Hospital, Muscat, Oman, from March to April 2020. Radiographic and clinical data were collected from the hospital and radiology information systems and compared between two groups based on intubation status. Results: Twenty-six patients confirmed to have COVID-19 by reverse-transcriptase polymerase chain reaction test were included in the study; 15/26 were non-intubated, and 11/26 were intubated. Overall, 88.5% were males in the intubated group. Respiratory symptoms were the most common presentation (84.6%) followed by fever (76.9%), with no statistical difference between the two groups. There was a statistically significant difference in having diabetes mellitus (p = 0.020) in which 8/11 and 4/15 were recorded to have diabetes mellitus in the intubated and non-intubated groups, respectively. Other comorbidities showed no statistically significant difference. The radiographic analysis redemonstrates the peripheral lower zone distribution but no statistically significant difference among the two groups. There were no differences between the intubated and non-intubated chest radiography in laterality involvement, central and peripheral distribution, and lesions type. However, upper zones involvement was more noted in the intubated group with 10/11 (90.9%) compared to 7/15 (46.7%) in non-intubated cases (p = 0.036). There were higher numbers of zone involvement in intubated cases than non-intubated cases: 9/11 (81.8%) of intubated patients had 10–12 areas of involvement on chest radiographs compared to 3/15 (20.0%) in the non-intubated group. Half of the cases were discharged home; 3/11 from the intubated group and 10/15 from the non-intubated group. Five patients died from the intubated group (5/11) versus 3/15 from the non-intubated group. Five patients are still hospitalized (three from the intubated group and two from the non-intubated group). Conclusions: The radiographic findings among intubated and non-intubated hospitalized COVID-19 patients demonstrate differences in the number of zones involved. More upper zone involvement was noted in the intubated group. Male sex and diabetes mellitus carried a poorer prognosis and were more associated with the intubated group.

The authors regret the unintentional error made in the above-mentioned case report; in Case report paragraph 4 line 6 and 7: “suggestive of metabolic acidosis with increased anion gap of 53 mEq/L normal range 8-16mEq/L” has been changed to “suggestive of metabolic acidosis with normal anion gap of 9mEq/L (normal range 8-16mEq/L”). The authors would like to apologise for any inconvenience caused.

The ongoing outbreak of COVID-19 has been expanding worldwide. As of 17 April 2020, the death toll stands at a sobering 147,027 and over two million cases, this has been straining the health care systems all over. Respiratory failure has been cited as the major cause of death but here we present a case about a patient who instead succumbed to severe metabolic acidosis with multiple organ failure.

Malaria is a potentially life-threatening disease caused by Plasmodium spp. which are transmitted by female Anopheles mosquitoes. Plasmodium falciparum infection has a high mortality if untreated, but it has an excellent prognosis if diagnosed early and treated appropriately [1]. We report late onset pancreatitis occurring after treatment for severe P. falciparum malaria which was thought to be drug induced.