 Good evening, everyone. I am Dr. Nikhil. I am from Vardhaman Mahavir Medical College and Sabdajan Hospital. And the topic for my oral paper presentation is assessment of extra pulmonary clinical radiological sequel in COVID-19 recovered individuals. So, the aim of our study was to assess the various extra pulmonary clinical radiological sequelae that the COVID-19 recovered individuals were presenting with. And also, to compare these complications, the incidence of these complications in mild, moderate and severe cases as categorized by Ministry of Health and Family welfare. Coming on to the introduction, COVID-19 or the 2019 coronavirus disease is caused by a group of RNA viruses known as the SARS-CoV-2. On March 11, 2020, the WHO declared COVID-19 to be a global pandemic. And the first laboratory-verified case in India was reported on Jan 30, 2020, in Kerala. The SARS-CoV-2 virus spreads through direct, indirect or close contact with the infected person through the secretions like saliva, respiratory droplets and also fomites. Also, many case reports imply that airborne transmission is also possible and the virus has been proven to persist in aerosols for up to three hours. Coming on to the pathophysiology, direct viral toxicity, endothelial cell destruction, thrombo-inflammation and immunological dysregulation are the main pathways that play a role in multi-organ damage. And for the entrance of the virus to the target cell, this ACE-2 and this transmembrane protein, TMP-RSS-2 must be expressed on the cell surface. COVID-19 is diagnosed primarily based upon the clinical symptoms, laboratory test results and radiological evaluation. We all know that COVID-19 is most recognized for its ability to cause severe respiratory symptoms and only limited data is available on the radiological patterns of extra pulmonary complications. So, our study was aimed to detect these extra pulmonary issues as early as visible using a multi-modality increasing method in order to assess clinicians in planning appropriate care to prevent further progression and irreversible organ damage. We used multi-modality imaging approach based on the clinical presentation of the patient. So, for example, if a COVID-19 recovered individual present to us with flank pain with raised D-dimer levels, so suspecting renal impact, we did renal CT angiography on semen somatom definition flash 256 lice machine. And we used non-ionic iodinated contrast, which was given with an injector pump. And the dosage was approximately 1.5 ml per kg through a flow rate of 5 ml per second. And during the RTL phase, image acquisition was started with a 6 second delay. And after the threshold of 100 hz unit, as the threshold of 100 hz unit reached at the region of interest within the abdominal laorta. And further we used MPR, MIB and VR methods to acquire images in actual coronal and sagittal veins. To detect deep vein thrombosis, USC Doppler was done on GE healthcare USC machine using linear probe and lower limb venous preset in patients who were presenting with pain and swelling of limbs and raised D-dimer levels. Another extra pulmonary complication that we came through was post-COVID nuclear mycoses. So individuals with comorbidities such as diabetes mellitus or other immunocompromised states such as corticosteroid therapy which was given to the patient during active illness or if the patient was presenting with nasal congestion, nasal discharge, facial or orbital swelling. So MRI, PNS with brain screening was done. This scan was done on 3T MRI GE system with the standard head coil and the acquired sequences in routine protocol were T1, T2 with and without fat saturations per even weighted post-contrast images. Also DWI flare was done. Our study showed that the various extra pulmonary sequelae that we assessed. So we assessed 120 patients, 40 each in mild, moderate and severe categories and the results were that the complications were seen more in the patients which had severe illness. Out of the 40 patients, 10 patients with severe COVID presented with deep vein thrombosis whereas in moderate category only 5 patients had DVD and 3 patients in mild category had deep vein thrombosis. Only one patient out of the 40 in severe category presented with renal infarct and none of the patient in mild and moderate category presented with renal infarct. Similarly, 5 patients in severe category presented with post-COVID mucolysmicosis, one in moderate and none of the patient in mild category developed post-COVID mucolysmicosis in our study. Coming on to the representation of the cases, first is renal infarct. This is an actual post-contrast CT abdomen. Angiophase, here we can see the infra-renal abdominal aorta. This is SMA and this is the left kidney which is showing normal cortical enhancement whereas on the right side we can show that there is no enhancement of the anterior part of the cortex as well as of the posterior part of the cortex in upper pole, the anterior part and some part of the posterior cortex at the interval and at the lower pole there is no enhancement of the anterior cortex whereas some mild enhancement is seen on the posterior cortex. However, if we compare it from the normal side the enhancement is less as compared to the normal side. This area in the superior lateral aspect is supplied by the capsular branch. This is the same patient, again axial section, coronal section. The axial section shows that there is non enhancement of the anterior cortex whereas less enhancement as compared to the normal side is seen in the posterior cortex and these posterior segmental branches are also attenuated whereas no anterior segmental branch is seen here. This is the right main renal artery in the coronal plane. This is the capsular branch that was supplying the superior lateral aspect in the last slide. This part here the black arrow is actually the anterior segmental branch which is non-opacified that's why the anterior cortex is not opacified at upper, inter or lower pole. This is the posterior segmental branch. Here in the neck section we can see that the posterior segmental branch is showing a filling defect here so just give off a thrombus and that's the reason why the posterior enhancement in this slide it is present but it is not normal it is less than that of the normal side. So this is because of the thrombus and the partially obstructing thrombus in the right in the posterior segmental branch of the right renal artery. This is again the capsular branch. The second extra pulmonary complication that we came across was post COVID mycosis a few cases of that this is a MRI PNS with the brain screening of a patient who had uncontrolled diabetes. This is a post contrast T1 scan axial and the coronal plane here in the first image we can see that there is the prominence of the retro bulbour segment of right optic nerve we can compare it with the left side which is normal. There is no enhancement of the optic sheath the nerve is smooth the margins are regular whereas on the right side we can see that there is the thickening of the optic sheath and there is some enhancement of the optic sheath. In the second image we can also see that this there is some enhancing soft tissue thickening seen in the medial aspect of the right orbit which is also extending through the ithmoid air cells. This soft tissue thickening is also involving the medial rectus muscle which is being showed by the green arrow the muscle is also appearing to be bulky and in the third image we can see that the soft tissue enhancement is also seen along the right cavernous sinus this green arrow and it is increasing the cavernous part of the right ICL however we can see that the flow void is maintained. This is another patient with history of uncontrolled diabetes mellitus showing black turbinate sign so this black turbinate sign is basically seen in the angioinvasive fungal infections like mucomycosis or aspergillosis basically these angioinvasive fungal infection what they do is they involve the mucosa of the nasal mucosa or the sinus mucosa and they lead to infarction of the mucosa so what happened the mucosa does not enhance due to the infarction caused by the fungus so in the first image these all are the coronal planes in the first image we can see that there is non-enhancing of the superior turbinate and the superior aspect of the middle turbinate also there is non-enhancing mucosa or non-enhancing soft tissue component seen in the left maxillary sinus this is a post amphotericin B therapy scan which was done after two months here we can see that this black turbinate sign is not seen here and the sinuses and the turbinate show normal enhancement also there is no enhancing soft tissue density seen in the left maxillary sinus so basically this black turbinate sign is not specific for mucomicosis only it can be seen in any angioinvasive infection such as aspergillosis as well coming on to the third extraordinary post COVID complication that came across that was lower limb dvd so in in these images first is the grayscale image of right common femoral vein this is the right common femoral vein this is the common femoral artery the superficial one this is the common femoral vein and we can see some eccentric ecogenic contents with it this green arrow some eccentric ecogenic contents are seen within the right common femoral vein the artery shows the normal human on putting color Doppler the artery shows normal flow here we can see and the vein there is in the vein there is the some patchy flow which is suggestive of recanelization and follow up scan in the same patient after anticoagulant therapy shows normal wall-to-wall color flow in the right common femoral vein also a normal wall-to-wall compressibility and augmentation on distal compression was also seen after the course of anticoagulant therapy so these were the cases these were some of the cases that we came across reviewing the previous literature about the renal complications it was found that ak has been found to be an uncommon complication in patients with COVID-19 and only a few cases of renal abnormalities in COVID-19 individuals have been published earlier and in a previous case report the patient had mild form of disease and renal findings were detected incidentally on CT representing acute renal infarct however in our study only we came across with only one patient that too in the severe category who had renal infarct about mucomycosis it is a fungal illness as we all know caused by a group of molds known as mucomycetes it is an uncommon but severe fungal infection it is a potentially fatal illness that mostly affects immunocompromised patients such as those with diabetes hematological malignancies or with the history of hematopoietic stem cell transplantation and the issue of solid organ transplantation again these patients are also on corticosteroid therapy which make them my immunocompromised and in an Indian study which was conducted by Joshi Ayer et al which comprise comprising of 25 patients 22 patients had diabetes and two had HIV infection injectable corticosteroids were given to all the patients and in their study a T2 hyper intense sinus content with increased mucosal thickness enhancing soft tissue these are all the signs that were seen also the black turbinate sign was also demonstrated in their study COVID-19 necessitated coagulopathy as in our case was seen in form of lower dvd it is linked with the hyper inflammatory and hyper coagulable state endothelial injury complement activation platelet activation platelet leukocyte interactions neutrophil extracellular traps these are all the mechanisms which lead to release of pro inflammatory cytokines and the disruption of normal coagulant pathways and are all the mechanisms of thrombo inflammation a single center study of 163 patients have has been done with without post discharge thrombo profile exists and they found that 2.5 percent incidence of thrombosis after 30 days of discharge so our study was a prospective observation study which was performed in a sample size of 120 patients including 40 patients in each mild moderate and severe categories which underwent various imaging investigation according to the presenting complaints renal angiography was performed in patients who had flank pain and elevated edema levels individual with the comorbidities such as diabetes or other immunocompromised states like corticosteroid medication they underwent MRI BNS with brain screening and individuals experiencing pain and swelling in their limbs as well as the elevated edema levels underwent UC Doppler various extra pulmonary clinical radiological sequel as we discussed they were assessed and the incidence of the sequel in patients recovered with mild moderate and severe disease was evaluated and as we found out that the incidence of these extra pulmonary complications was highest in the severe category patients thank you