Lung ultrasound (LUS), a rapid, bedside, goal-oriented diagnostic test, can be quantitatively assessed, and the scores can be used to evaluate disease progression. However, little data exists on predicting prolonged mechanical ventilation (PMV) and successful extubation using serial LUS scores. We examined the relationship of PMV with successful extubation in patients with severe coronavirus disease (COVID-19) by using two types of serial LUS scores. One LUS score evaluated both the pleura and lung fields, while the other assessed each separately (modified-LUS score). Both LUS scores were determined for 20 consecutive patients with severe COVID-19 at three timepoints: admission (day-1), after 48 h (day-3), and on the seventh follow-up day (day-7). We compared LUS scores with the radiographic assessment of the lung oedema (RALE) scores and laboratory test results, at the three timepoints. The PMV and successful extubation groups showed no significant differences in mortality, but significant differences occurred on day-3 and day-7 both LUS scores, day-7 RALE score, and day-7 PaO2/FiO2 ratio, in the PMV group (p<0.05); and day-3 and day-7 modified-LUS scores, day-7 C-reactive protein levels, and day-7 PaO2/FiO2 ratio, in the successful extubation group (p<0.05). The area under the curves (AUC) of LUS scores on day-3 and day-7, modified-LUS scores on day-3 and day-7,RALE score on day-7, and PaO2/FiO2 ratio on day-7 in the PMV group were 0.98, 0.85, 0.88, 0.98, 0.77, and 0.80, respectively. The AUC of modified-LUS scores on day-3 and day-7, C-reactive protein levels on day-7, and PaO2/FiO2 ratio on day-7 in the successful extubation group were 0.79, 0.90, 0.82, and 0.79, respectively. The modified-LUS score on day 7 was significantly higher than that on day 1 in PMV group (p<0.05). While the LUS score did not exhibit significant differences. The serial modified-LUS score of patients with severe COVID-19 could predict PMV.

Background Subarachnoid hemorrhage and thyroid storm are similar in their clinical symptomatology, and diagnosis of these conditions, when they occur simultaneously, is difficult. Here, we report a rare case of concurrent subarachnoid hemorrhage and thyroid storm we encountered at our hospital. Case presentation The patient was a 52-year-old woman. While bathing at home, the patient experienced a sudden disturbance of consciousness and was brought to our hospital. The main physical findings upon admittance were Glasgow Coma Scale score of E1V2M4, elevated blood pressure (208/145 mmHg), and tachycardia with atrial fibrillation (180 bpm) along with body temperature of 36.1 °C. Brain computed tomography revealed subarachnoid hemorrhage associated with a ruptured aneurysm of the posterior communicating artery branching from the left internal carotid artery, and aneurysm clipping was performed. Blood tests upon admission revealed high levels of free T3 and free T4 and low levels of thyroid-stimulating hormone. Upon determining that the patient had hyperthyroidism, thiamazole was administered. However, due to continuous impaired consciousness, fever, and persistence of tachycardia, the patient was diagnosed with thyroid storm. Oral potassium iodide and hydrocortisone were added to the treatment. The treatment was successful as the patient’s symptoms improved, and she became lucid. In this case, we believe that in the presence of untreated hyperthyroidism, the onset of subarachnoid hemorrhage induced thyroid storm. Tachycardia of 130 bpm or higher, which is the diagnostic criterion for thyroid storm, rarely occurs with subarachnoid hemorrhage. Therefore, we believe it is an important factor for recognizing the presence of the thyroid storm. In this case, clipping surgery was prioritized which resulted in a favorable outcome. However, it is possible that invasive surgery may have exacerbated thyroid storm, suggesting that treatment should be tailored as per patient’s condition. Conclusion If a pulse rate of 130 bpm or higher is observed alongside subarachnoid hemorrhage, we recommend considering the possibility of concomitant thyroid storm and testing for thyroid hormone. If concomitant thyroid storm is present, we believe that a treatment plan tailored to the patient’s condition is critical, and early diagnosis will lead to a favorable outcome for the patient.

Background: Some patients with severe coronavirus disease (COVID-19) who present with fibrosis on computed tomography (CT) require prolonged mechanical ventilation (PMV). Lung ultrasound (LUS), a rapid, bedside test, has been reported to have findings consistent with those of CT. Thus, this study aimed to assess whether serial LUS scores could predict PMV or successful extubation in severe COVID-19 patients.Methods: LUS was performed for 20 consecutive severe COVID-19 patients at three time points: admission (day 1), after 48 h (day 3), and seventh-day follow-up (day 7). We compared the LUS score with the results of chest X-rays and laboratory tests at three time points. Moreover, we assessed LUS score to determine the inter-rater reliability (IRR) of the results among examiners.Results: While there were no significant differences in mortality in each PMV and successful extubation groups, there were significant differences in LUS scores on day 3 and day 7; XP score on day 7; and P/F ratio on day 7 in the PMV group (p<0.05). There were significant differences in LUS scores on days 3 and 7, C-reactive protein (CRP) levels on day 7, and P/F ratio on day 7 in the successful extubation group (p<0.05). The areas under the curves (AUCs) of LUS score on days 3 and 7, XP score on day 7, and P/F ratio were 0.88, 0.98, 0.77, and 0.80, respectively in the PMV group; and the AUCs of LUS score on days 3 and 7, CRP levels on day 7, and P/F ratio 0.79, 0.90, 0.82, and 0.79, respectively, in the successful extubation group. Variations in serial LUS scores exhibited significant differences between the groups. The serial LUS score on day 7 was higher than that on day 1 in the PMV group but lower in the successful extubation group (p<0.05). However, there was slight IRR agreement in the LUS score changes on days 1 to 7 (κ= 0.15 [95% CI: 0-0.31]). Conclusions: The serial LUS score of severe COVID-19 patients could predicted PMV and successful extubation. To overcome IRR disagreement, the automatic ultrasound judgement, such as deep learning, would be needed.