Tanaffos Respiration Journal
Volume:21 Issue: 4, Autumn 2022

The world is currently struggling with the COVID-19pandemic. Measures to control the COVID-19 pandemic have affected other health problems and diseases, including tuberculosis (TB) and its control. The present narrative review aimed at reviewing published literature on the impact of the COVID-19 pandemic on TB control.

English language databases, including PubMed, ISI, Scopus, and Google Scholar, were searched using the keywords "Tuberculosis, COVID-19, and Coronavirus" to find relevant articles.

Problems and limitations in financial and human resources, as well as medical and laboratory services caused by the COVID-19 pandemic, contribute to the reduction in the number of newly diagnosed patients with TB. More effort in identifying patients with TB is of great importance, and if the global number of newly diagnosed patients with TB decreases by 25% for three consecutive months due to the COVID-19 pandemic, the TB mortality rate will increase by 13%. An increase in the TB mortality rate means the failure of TB control programs to reach the targets of the Global End TB Strategy.

According to the latest statistics released by the Ministry of Health, the incidence of TB in Iran has not yet reached fewer than 100 cases per million population. On the other hand, being a neighbor with countries with a high risk of TB is a serious threat to Iran. Therefore, further effort to control TB during the COVID-19 pandemic is particularly important.

Coronavirus disease 2019 (COVID-19), a highly contagious infectious disease, has had a catastrophic effect on the world’s demographics resulting in more than 2.9 million deaths worldwide till January 2021. It can lead to systemic multi-organ complications; in particular, venous and arterial thromboembolism risk is significantly increased. Venous thromboembolism (VTE) occurs in 22.7% of patients with COVID‐19 in the ICU and 8% in non‐ICU hospitalized patients. Studies evaluating thromboprophylaxis strategies in patients with COVID‐19 are needed to improve the prevention of VTE. VTE is the most commonly reported thrombotic complication, with higher incidence rates among critically ill patients. Several vaccines have been licensed and are currently used to combat the COVID-19 pandemic. Also, several cases of vaccine-induced thrombosis have been reported. Vaccination remains the most critical measure to curb the COVID-19 pandemic. There is a broad consensus that the benefits of vaccination greatly outweigh the potential risks of rare vaccine side effects, such as vaccine-induced immune thrombotic thrombocytopenia (VITT). Therefore, the importance of vaccination should be emphasized. This statement aims to focus on VITT.

COVID-19 disease began to spread all around the world in December 2019 until now; and in the early stage it may be related to high D-dimer level that indicates coagulation pathways and thrombosis activation that can be affected by some underlying diseases including diabetes, stroke, cancer, and pregnancy and it also can be associated with Chronic obstructive pulmonary disease (COPD). The aim of this article was to analyze D-dimer levels in COVID-19 patients, as D-dimer level is one of the measures to detect the severity and outcomes of COVID-19. According to the results of this study, there is a higher level of D-dimer as well as concentrations of fibrinogen in the disease onset and it seems that the poor prognosis is linked to a 3 to 4-fold increase in D-dimer levels. It is also shown that 76% of the patients with ≥1 D-dimer measurement, had elevated D-dimer and were more likely to have critical illness than those with normal D-dimer. There was an increase in the rates of adverse outcomes with higher D-dimer of more than 2000 ng/mL and it is associated with the highest risk of death at 47%, thrombotic event at 37.8%, and critical illness at 66%. It also found that diabetes and COPD had the strongest association with death in COVID-19. So, it is necessary to measure the D-dimer levels and parameters of coagulation from the beginning as well as pay attention to comorbidities that can help control and management of COVID-19 disease.

Extracellular vesicles (EVs) may accelerate cell death during the course of infection. Mycobacteria could invade the host’s immune system and survive in the host by modulation of miRNAs. MiRNAs' differential expressions can serve as biomarkers. This study evaluates THP-1 monocyte cell death by EVs from serum of patients with mycobacteria and assesses serum-derived exosomal miRNAs to increase or decrease THP-1 monocyte cell death. EVs were purified from serum of patients with mycobacteria and cultured with THP-1 monocyte. The cell death was determined via annexin V-FITC and PI staining. The microRNA was isolated from serum-derived EVs of the patients. Expression level of Hsa-miR-20a-5p, Hsa-miR-29a, Hsa-miR-let7e, and Hsa-miR-155 was assessed using qRT-PCR. Cell death was accelerated in 10 and 5 µg/ml concentrations of the EVs (p<0.05). Minimum cell death was seen in 2.5 and 1.2 µg/ml concentrations (p<0.05). In tuberculosis (TB) patients, expression of miR-20a-5p, miR-29a, and miR-let7e were significantly enhanced (p≤0.0001), but miR-155 expression reduced. ROC analysis showed diagnostic biomarkers of miRNAs with an AUC=0.6933 for miR-20, AUC=0.6011 for miR-29a, AUC=0.7322 for miR-let7e, and AUC=0.7456 for miR-155 for active tuberculosis. Expression of miR-let7e, 20a, and 29a in M. avium vs. M. tuberculosis was overexpressed (P≤0.01, P≤0.0001, and P≤0.0001, respectively). Also miRs let7e and 20a expression was accelerated in M. abscessus vs. M. tuberculosis (P≤0.0001 and P≤0.002, respectively). EVs accelerates cell death and may not be ideally considered for drug delivery and vaccine developments. Circulating exosomal microRNA MiR-20, miR-let7e, and miR-155 facilitate development of potential biomarkers of pulmonary tuberculosis and non-tuberculosis.

Hajj is one of the main challenges of public health and infection control. Hajj-associated respiratory tract infections are very common during the pilgrimage. Studies have shown that human rhinovirus (HRV) is one of the most common causes of respiratory illnesses among pilgrims. The aim of this study was to investigate the prevalence and genotypes of HRV among Iranian pilgrims with severe acute respiratory infection (SARI) during the 2017 Hajj season.
Throat swabs or washes were collected from 104 pilgrims with SARI and transported to the National Influenza Center, School of Public Health, Tehran University of Medical Sciences. Specimens were screened for HRV by Nested PCR with primers for 5΄UTR, and virus genotypes were determined using PCR with VP4-VP2 primers and sequencing method.
Twenty-one cases were positive for HRV (20.19 %). The HRV species and types of 8 positive samples were: HRV-A21 (1/8, 12.5%), followed by HRV-B91 (3/8, 37.5%) and HRV-C (4/8, 50%) un-typed.
This study showed that HRV has a high prevalence in Iranian Hajj pilgrims. As there is no vaccine or antiviral therapy for HRV, prevention methods are the best way for infection control.

The clinical characteristics of COVID-19 are diverse from a simple common cold symptom to acute respiratory distress syndrome (ARDS). In the present study, we attempted to identify the associated factors in surviving COVID-19 intensive care unit (ICU) patients based on their clinical characteristics.
This retrospective study was performed on 114 laboratory‑confirmed COVID‑19 patients admitted to the intensive care units of Hormozgan University of Medical Sciences, Iran. Demographic, medical, clinical manifestations at admission time, and outcome data were obtained from the patient’s medical records.
Of 114 participants included in this study, 64.9% were men. Their mean age was approximately 54 years old, 69.3% of them died and 30.7% of them were discharged. The mortality rate was 2.96 times higher in people who had ARDS compared to their counterparts, 1.37 times higher in people under non-invasive ventilation, and 3.56 times higher in people under invasive mechanical ventilation.
Three common underlying diseases among them were hypertension in 34.2%, diabetes in 23.7%, and cardiovascular diseases in 17.5% of them. Alive and dead patients significantly differed only in the following laboratory tests: D-dimer, urea, troponin, Procalcitonin, and ferritin.
The mortality rate among COVID-19 patients admitted to ICU is generally high. Dyspnea, as the initial presentation and comorbidity, especially hypertension, diabetes, and cardiovascular diseases, may be associated with a higher risk of developing severe disease and consequent mortality. Therefore, D-dimer, urea, troponin, Procalcitonin, and ferritin at the time of hospital admission could predict the severity of the disease and its probable mortality.

Inspiratory muscle training has been introduced as one of the effective methods in pulmonary rehabilitation, and attention to this technique in patients with COVID-19 is still being studied. In the present study 52 patients who have undergone the period of the COVID-19 disease were randomly divided into two groups. In the control group, in addition to the routine treatment prescribed by a specialist physician, rehabilitation was performed by performing diaphragmatic breathing exercises, pursed-lips breathing, chest expansion, and simple stretching exercises. In the intervention group in addition to the rehabilitation program provided to the control group, patients used an inspiratory muscle training device. This pulmonary rehabilitation program was performed twice a day and 30 repetitions each time with a two-minute rest after every 10 exercises. After 4 weeks, patients in both groups were referred to the hospital for re-assessment of the distance of the 6-minute walk test, SF-12 questionnaire results, dyspnea, and S-index. To compare quantitative variables between the two groups we utilized a student t-test. Type one error was put at P≤0.05. The comparison of 6MWT values shows that the mean of this index in the intervention group is significantly higher than the control group (p = 0.002). Also, the S-index of the two groups showed a significant difference (p=0.024). Results show a significant increase in the SF-12 quality of life questionnaire in patients using IMT (p=0.001). IMT improves pulmonary functions, 6MWT, and SF-12 Questionnaire in recovered COVID-19 patients.

High anxiety is a common mental symptom in COVID-19 patients, mainly due to the unknown nature of the disease and the home isolation of patients for recovery. The aim of this study is to determine the impact of the virtual training of relaxation techniques, including Jacobson and Benson techniques, on the anxiety of home-isolated patients with COVID-19.
This clinical trial was conducted in 2020 in Hamadan Sina Hospital, where 60 COVID-19 patients were randomly allocated to an experimental (n = 30) and a control (n = 30) group. Both groups received the usual care. However, in addition to the usual care, COVID-19 patients in the experimental group received relaxation technique training, including Jacobson and Benson techniques, in the form of pamphlets and instructional videos according to the schedule (twice a week for 4 weeks) via WhatsApp. The Spielberger Anxiety Inventory was filled out by subjects before and after the intervention.
The mean scores of explicit, implicit, and overall anxiety were not significantly different between the control and experimental groups prior to the intervention (P>0.05). However, the mean score of explicit, implicit, and overall anxiety in the control and experimental groups differed significantly after the intervention (p<0.05).
The results of this study showed that Jacobsen and Benson relaxation techniques are effective in reducing anxiety among COVID-19 patients. Therefore, it is recommended to perform complementary therapeutic interventions for these patients, in addition to the administration of medications.

Pulmonary hypertension (PH) is a hemodynamic and pathophysiological disease defined by a mean pulmonary artery pressure of  ≥20 mm Hg. Pulmonary hypertension severity and prognosis play an essential role in the management of these patients. The aim of this study was to evaluate the prognostic value of platelet to lymphocyte ratio (PLR) and neutrophil to lymphocyte ratio (NLR) in patients with PH referred to Masih Daneshvari Hospital, Tehran, Iran.
A total of 61 patients with PH referred to Masih Daneshvari Hospital in Tehran were enrolled. Patients’ information such as age, sex, type of PH, echocardiographic data, and blood cell count, including platelet, lymphocyte, and neutrophil count, hemoglobin, and RDW, were collected in each follow-up.
Out of 61 patients with PH, 27 (44.3%) were male, and 34 (55.7%) were female. The mean age of the patients was 43.19 ± 2.25 years. Our results showed that during hospitalization, PLR decreased from 13.2 to 9.7, and NLR also decreased from 4.49 to 3.08. Neither PLR nor NLR was associated with gender. However, both PLR and NLR showed a significant difference between deceased vs. discharged patients and were significantly lower in the patients who died.
Both PLR and NLR decreased during hospitalization in patients with PH, and this decrease was greater in the patients who died, suggesting these indicators as potential prognostic markers for the disease.

Appropriate respiratory support is crucial for improving the clinical outcomes of critically ill patients infected with the SARS-CoV-2 virus. This study aimed to investigate the different modalities of respiratory support and clinical outcomes in patients with COVID-19 in intensive care units (ICUs).
In a retrospective study, we enrolled 290 critically ill COVID-19 patients who were admitted to the ICUs of four hospitals in Mazandaran, northern Iran. Data were extracted from the medical records of all included patients, from December 2019 to July 2021. Patients' demographic data, symptoms, laboratory findings, comorbidities, treatment, and clinical outcomes were collected.
46.55% of patients died. Patients with ≥2 comorbidities had significantly increased odds of death (OR=5.88, 95%CI: 1.97-17.52, P=0.001) as compared with patients with no comorbidities. Respiratory support methods such as face mask (survived=37, deceased=18, P=0.022), a non-rebreather mask (survived=39, deceased=12, P<0.001), and synchronized intermittent mandatory ventilation (SIMV) (survived=103, deceased=110, P=0.004) were associated with in-hospital mortality. Duration of respiratory support in nasal cannula (survived=3, deceased=2, P<0.001), face mask (survived=3, deceased=2, P<0.001), a non-rebreather mask (survived=3, deceased=2, P=0.033), mechanical ventilation (survived=5, deceased=6, P<0.019), continuous positive airway pressure (CPAP) (survived=3, deceased=2, P<0.017), and SIMV (survived=4, deceased=5, P=0.001) methods were associated with higher in-hospital mortality.
Special attention should be paid to COVID-19 patients with more than two comorbidities. As a specific point of interest, SIMV may increase the in-hospital mortality rate of critically ill patients with COVID-19 connected to mechanical ventilation and be associated with adverse outcomes.

Anthracosis is caused by several factors and is a risk factor for cancer and tuberculosis. This study investigated the prevalence of anthracosis and the associated factors in autopsy specimens from the Guilan Office of the Iranian Legal Medicine Organization. This retrospective study examined the medical records of autopsy specimens (>18 years) in the Guilan Office of the Iranian Legal Medicine Organization in 2019 for pulmonary anthracosis. Data were extracted from the autopsy findings, and demographic characteristics, occupational information, tuberculosis or pulmonary cancer history, and anthracosis were recorded in a checklist. SPSS version 16 was used to analyze the collected data. The study included 190 autopsy specimens with a 32.1% anthracosis prevalence. Forty-five (23.7%) subjects had anthracofibrosis. Individuals with agricultural carriers or who worked in tobacco fields had the highest prevalence of anthracosis. The frequency of pulmonary cancer and tuberculosis was significantly higher in the specimens with anthracosis (anthracosis group) than in the non-anthracosis group (P<0.05). The use of traditional cooking and heating methods, as well as exposure to carbon and smoke in the workplace, were significantly higher in the anthracosis group than in the non-anthracosis group (P<0.05). The results of the current study revealed that occupational exposure, tuberculosis, pulmonary cancer, and traditional indoor cooking and heating methods were all associated with anthracosis.

Lung cancer is one of the most common and life-threatening cancers in men around the world. Therefore, it is important to pay particular attention to the psychological status of patients with lung cancer due to their greater vulnerability during treatment. This study aimed to evaluate the effectiveness of mindfulness-based stress reduction therapy on the quality of life of patients with lung cancer.
This quasi-experimental study, with a pretest-posttest design and a three-month follow-up, was conducted in the summer of 2019. Thirty patients with lung cancer, who were referred to Masih Daneshvari Hospital in Tehran, Iran, were selected through purposive sampling and randomly assigned to experimental (n=15) and control (n=15) groups. In the pretest stage, the Short-Form Health Survey (SF-36) was completed by both groups. The experimental group received mindfulness-based stress reduction therapy for eight sessions, while the control group did not receive any intervention. In the posttest stage, both groups were examined again, and data were analyzed using SPSS version 21 by repeated measures multivariate analysis of variance (MANOVA).
The findings showed a significant difference between the experimental and control groups after mindfulness-based stress reduction therapy. In other words, the mean score of quality of life increased in the experimental group as compared to the control group (P<0.001).
Based on the results of this study, the effectiveness of mindfulness-based stress reduction therapy in increasing the quality of life of patients with lung cancer was confirmed. Therefore, psychological screening is suggested to improve the quality of life of patients by taking advantage of clinical trials and appropriate intervention models during medical treatment.

Hydatidosis is one of the most important parasitic and zoonotic endemic infections caused by the larvae of cestode Echinococcus granulosus. Co-infection of hydatid cyst with the coronavirus disease 2019 (COVID-19), which is caused by the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), has been previously reported. The mortality rate of hydatidosis is reported to be 2-4% and the liver and lungs are the two most commonly involved organs, respectively. In the present study, we have reported two recovered pulmonary hydatidosis patients who were infected with SARS-CoV-2 after thoracotomy in the hospital. In general, current cases suggest that patients with thoracic surgery are more likely to develop severe infection with severe acute respiratory syndrome coronavirus 2 (SARS-COV-2). The patients presented COVID-19 symptoms shortly after thoracotomy and their viral tests were confirmed with the positive result of SARS-CoV-2 RT-PCR. In conclusion, possible differential diagnoses should be considered in similar cases and adequate attention should be paid to intraoperative and postoperative care.

Diaphragm paralysis may be either idiopathic or associated with several medical conditions including viral and bacterial infection. The association of phrenic nerve palsy with viral infections is rare but well-appreciated in several case reports. Neuropathy, both central and peripheral, is a common neurological consequence of COVID-19. Here, we describe a case of diaphragm paralysis in a woman who was admitted to the hospital because of COVID-19 pneumonia. Post-COVID-19 unilateral paralyzed diaphragm was diagnosed with a chest X-ray for her and the disorder was attributed to COVID-19 because no other etiology was found to be associated. So far, phrenic neuropathy and diaphragmatic paralysis in a COVID-19-affected patient have not been reported from Iran.