• Users Online: 34
  • Print this page
  • Email this page


 
 
Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 19  |  Issue : 1  |  Page : 1-5

Spectrum of chest computerized tomographic findings in novel coronavirus disease-19


Department of Radiodiagnosis, GMC, Srinagar, Jammu and Kashmir, India

Date of Submission26-Apr-2020
Date of Decision03-May-2020
Date of Acceptance13-May-2020
Date of Web Publication20-Aug-2020

Correspondence Address:
Dr. Musaib Ahmad Dar
Department of Radiodiagnosis, GMC, Srinagar, Jammu and Kashmir
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/MJ.MJ_13_20

Get Permissions

  Abstract 


Background: Coronavirus disease-19 (COVID-19) is a zoonotic viral disease caused by nonsegmented, enveloped, positive-sense, single-strand ribonucleic acid coronavirus. Recent outbreak started in Wuhan, China, where a new type of coronavirus was isolated from respiratory samples such as bronchoalveolar lavage and sputum of patients developing respiratory symptoms. The World Health Organization declared COVID-19 a pandemic on January 20, 2020. On April 6, 1,288,080 were infected with this virus with 70,567 deaths. Computerized tomography (CT) is the investigation of choice for diagnosing, managing, and accessing temporal changes in COVID-19. Objective: The objective of this study is to describe the chest CT findings in documented nCovid-19-positive patients. Methodology: This was a retrospective observational study done in Government Medical College, Chest Disease Hospital from February 20 to April 25, 2020. Forty-eight patients with COVID-19 reverse transcriptase-polymerase chain reaction-positive test were scanned on 64 slice Somatom CT scanner and findings analyzed. All patients with previously underlying chest disease were excluded. Results: The various chest findings in the nCovid-19-positive patients include ground glassing, (81.25%), consolidation (56.25%), nodules (43.75%), halo sign (31.25%), crazy paving pattern (50%), air bronchogram (12.5%), air bubble sign (6.25%), vascular enlargement (25%), reversed halo sign or atoll sign (18.75%), bronchial wall thickening (6.25%), and mosaic attenuation (6.25%). None of the patients had pleural effusion. Conclusion: Characteristic CT findings of COVID-19 can help radiologists in the early diagnosis of symptomatic patients in whom testing is awaited. Bilateral peripheral ground-glass opacities with consolidation in dependent parts of the lung along with the absence of pleural effusion were the most common abnormality.

Keywords: Coronavirus, mosaic attenuation, reverse transcriptase-polymerase chain reaction


How to cite this article:
Rafiq S, Dar MA, Elahi I, Din IM. Spectrum of chest computerized tomographic findings in novel coronavirus disease-19. Mustansiriya Med J 2020;19:1-5

How to cite this URL:
Rafiq S, Dar MA, Elahi I, Din IM. Spectrum of chest computerized tomographic findings in novel coronavirus disease-19. Mustansiriya Med J [serial online] 2020 [cited 2020 Nov 25];19:1-5. Available from: https://www.mmjonweb.org/text.asp?2020/19/1/1/292710




  Introduction Top


Coronavirus disease-19 (COVID-19) is a zoonotic viral disease caused by nonsegmented, enveloped, positive-sense, single-strand ribonucleic acid coronavirus.[1] Recent outbreak started in Wuhan, China, where a new type of coronavirus was isolated from the respiratory samples such as bronchoalveolar lavage, sputum of patients developing respiratory symptoms. Major symptoms of Covid-19 are fever, cough, breathlessness, and fatigue. The mean incubation period is 5.2 days, with high human-to-human transmission.[2] Before nCovid-19, coronavirus has been associated with middle east respiratory syndrome (MERS), severe acute respiratory syndrome (SARS) coronavirus, and other milder respiratory symptoms. SARS was transmitted through large droplets and direct inoculation.[3] MERS coronavirus is transmitted mainly through nonhuman, zoonotic sources such as bats and camels.[4],[5] The World Health Organization declared COVID-19 a pandemic on January 20, 2020.[6] On April 6, 1,288,080 were infected with this virus with 70,567 deaths.

Computerized tomography (CT) is the investigation of choice for diagnosing, managing, and accessing temporal changes in COVID-19.[7] Virus binds to angiotensin-converting enzyme-2 (ACE2) receptor starting with pulmonary interstitial changes followed by parenchymal changes.[8] Bilateral peripherally distributed ground-glass opacities (GGO) with or without consolidation in posterior aspect of lungs has been characteristic imaging finding on CT.[9],[10]

Objective

The objective of this study is to describe the chest CT findings in documented nCovid-19-positive patients.


  Methodology Top


This was a retrospective observational study done in Government Medical College, Chest Disease Hospital from February 20 to April 25, 2020. Forty-eight patients with COVID-19 reverse transcriptase-polymerase chain reaction (RT-PCR) positive test was scanned on 64 slice Somatom CT scanner. All patients with previously underlying chest disease were excluded. We describe chest CT Imaging findings in these cases. Chest CT findings vary with time course and severity of disease.[11],[12] Categorical values were presented with absolute and relative frequencies (%).


  Results Top


Most of our patients were in the age group of more than 60 years with predominance of male patients [Table 1] and [Table 2]. The various findings found in our study patients are summarized in [Table 3].
Table 1: Age distribution of patients

Click here to view
Table 2: Gender distribution of patients

Click here to view
Table 3: Frequency of findings in Covid positive patients

Click here to view



  Discussion Top


Ground glassing

Ground glassing is defined as the areas of increased pulmonary attenuation without obscuration of lung markings caused by partial replacement of air in air spaces by fluid, cells, etc.[13] In patients with COVID-19 peripheral, subpleural areas of ground glassing with unilateral or bilateral distribution are most commonly seen.[14],[15],[16] GGO as the most common imaging found in 98% cases.[17] In our study, ground glassing [Figure 1], [Figure 2], [Figure 3], [Figure 4] was found in 39 out of 48 patients (81.25%).
Figure 1: Axial computerized tomography image of lung showing evidence of ground glassing along with crazy paving in posterior segments of bilateral lungs

Click here to view
Figure 2: Axial computerized tomography image shows evidence of ground glassing in superior segments of bilateral lower lobes along with Halo sign surrounding nodule in anterior segment of right upper lobe (arrow)

Click here to view
Figure 3: Axial computerized tomography image shows evidence of ground glassing, consolidation along with air bubble sign (pink arrow)

Click here to view
Figure 4: Axial computerized tomography showing evidence of bilateral peripheral ground glassing areas with vascular enlargement (pink arrow)

Click here to view


Consolidation

Consolidation is defined as the areas of increased pulmonary parenchymal attenuation that obscures the margins of underlying vessels and airway walls.[13] Multiple peripheral focal or segmental consolidations in peri-brochovascular distribution with occurrence rate of 2%–64% are seen in Covid patients.[17],[18],[19] In our study, multiple consolidations [Figure 5], [Figure 6], [Figure 7] was found 56.25% of the total number of patients (27 out of 48 patients).
Figure 5: Coronal computerized tomography image revealing the evidence of multiple consolidations in bilateral lung with air bronchogram sign (pink arrow)

Click here to view
Figure 6: Axial computerized tomography image revealing bilateral peripheral-dependent consolidations

Click here to view
Figure 7: Axial computerized tomography image revealing evidence of bilateral multiple consolidation, interlobular septal thickening, ground glassing with peribronchial thickening (pink arrow) associated with right-sided consolidation

Click here to view


Nodules

A nodule is defined as rounded or irregular opacity with well- or poorly defined margins with size <3 cm in diameter.[13] Multiple solid irregular nodules or nodule with surrounding halo have been found in 3%–13% of COVID-19 patients.[14],[20] In our study, 43.75% of the patients were found to have nodules [Figure 2].

Halo sign

Halo sign is defined as the area of ground glassing surrounding nodule or mass.[13] Li et al.[21] reported a case of halo sign in a 27-year-old female COVID-19 patient. In our study, 15 out of 48 patients had Halo sign [Figure 2] (31.25%).

Crazy-paving pattern

Crazy-paving pattern is defined as areas of inter/intralobular septal thickening with superimposed ground glassing.[13] Crazing paving is seen in 5%–36% COVID-19 patients.[16],[18] In our study, 50% of the patients were found to have crazy paving patterns [Figure 1].

Air bronchogram

Air-filled bronchi seen within opaque (high attenuation) airless lung/Consolidation has been documented in CT of Covid patients.[15],[22] In our study, we found 6 out of 48 patients had air bronchogram sign within consolidations [Figure 5] (12.5%).

Air bubble sign

Air bubble sign refers to a small air-containing space in consolidation or ground glassing. Shi et al. termed this sign as round cystic change in their study,[11] whereas Kong et al. reported it as cavity sign.[23] In our study, only 3 out of 48 patients were found to have air bubble sign [Figure 3].

Vascular enlargement

The presence of dilated pulmonary vessels around and within the lesions on CT images was found in RT-PCR-negative COVID-19 patient who was admitted to a hospital 6 days after the symptom onset.[24] In our study, we found 25% of the total number of patients having vascular enlargement [Figure 4].

Reversed halo sign or atoll sign

Atoll sign is defined as the area of ground glassing surrounded by a more or less complete ring-like consolidation.[13] It has been seen in several COVID-19 cases representing disease progression or lesion absorption.[18],[22],[25],[26] In our study, 9 out of 48 patients were found to have reverse Halo sign [Figure 8] which accounted for 18.75% of the total number of patients.
Figure 8: Axial computerized tomography image revealing evidence of areas of ground glassing, consolidations, and nodules. Note reverse halo sign on the right side (arrow)

Click here to view


Bronchial wall thickening

About 10%–20% COVID-19 patients have inflammatory thickening of bronchial wall.[17],[19] The incidence of bronchial wall thickening is more common in severe/critical patients than ordinary patients.[17] In our study, 6.25% (3 out of 48) of the total number of patients had bronchial wall thickening [Figure 7].

Mosaic attenuation

Although mosaic attenuation has not been previously documented in Covid-19 but 3 of our patient had mosaic attenuation [Figure 9], accounting for 6.25%s of the total number of patients.
Figure 9: Axial computerized tomography image revealing evidence of mosaic attenuation in right lung (areas of subtle ground glassing with increased lucency)

Click here to view


Absence of pleural effusion

None of the patients had pleural effusion.


  Summary and Conclusion Top


Characteristic CT findings of COVID-19 can help radiologists in the early diagnosis of symptomatic patients in whom testing is awaited. Bilateral peripheral ground-glass opacities with consolidation in dependent parts of lung along with the absence of pleural effusion were the most common abnormality. Majority of the patients had combination of above described findings. Other common CT features include crazy paving, nodules, and halo sign. Less common signs include vascular enlargement, Atoll sign, bronchial wall thickening, air bronchogram, and air bubble sign. However, these findings are nonspecific can be seen in different viral pneumonias. Follow-up CT is not recommended in case of cure from disease.

Teaching point

Findings of Covid-19 are similar to cryptogenic organizing pneumonia, but they occur in acute settings following a viral prodrome of fever, cough, fatigability, etc.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Weiss SR, Leibowitz JL. Coronavirus pathogenesis. Adv Virus Res 2011;81:85-164.  Back to cited text no. 1
    
2.
Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med 2020;382:1199-207.  Back to cited text no. 2
    
3.
Chan-Yeung M, Xu RH. SARS: Epidemiology. Respirology 2003;8 Suppl:S9-14.  Back to cited text no. 3
    
4.
Mobaraki K, Ahmadzadeh J. Current epidemiological status of Middle East respiratory syndrome coronavirus in the world from 1.1.2017 to 17.1.2018: A cross-sectional study. BMC Infect Dis 2019;19:351.  Back to cited text no. 4
    
5.
MacIntyre CR. The discrepant epidemiology of Middle East respiratory syndrome coronavirus (MERS-CoV). Environ Syst Decis 2014;34:383-90.  Back to cited text no. 5
    
6.
Mahase E. China coronavirus: WHO declares international emergency as death toll exceeds 200. BMJ 2020;368:m408.  Back to cited text no. 6
    
7.
National Health Commission of the People's Republic of China. The Guidlines for the Diagnosis and Treatment of 2019-nCoV Pneumonia (the 5th edition). Available from: http://www.nhc.gov.cn/yzygj/s7653p/202002/d4b895337e19445f8d728fcaf1e3e13a/files/ab6bec7f93e64e7f998d802991203cd6.pdf. [Last accessed on 2020 Mar 08].  Back to cited text no. 7
    
8.
Xu X, Chen P, Wang J, Feng J, Zhou H, Li X, et al. Evolution of the novel coronavirus from the ongoing Wuhan outbreak and modeling of its spike protein for risk of human transmission. Sci China Life Sci 2020;63:457-60.  Back to cited text no. 8
    
9.
Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020;323:1061-9.  Back to cited text no. 9
    
10.
Chung M, Bernheim A, Mei X, Zhang N, Huang M, Zeng X, et al. CT imaging features of 2019 novel coronavirus (2019-nCoV). Radiology 2020;295:202-7.  Back to cited text no. 10
    
11.
Shi H, Han X, Jiang N, Cao Y, Alwalid O, Gu J, et al. Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: A descriptive study. Lancet Infect Dis 2020;20:425-34  Back to cited text no. 11
    
12.
Pan F, Ye T, Sun P, Gui S, Liang B, Li L, et al. Time course of lung changes on chest CT during recovery from 2019 novel coronavirus (COVID-19) pneumonia. Radiology Feb 2020;295:3.  Back to cited text no. 12
    
13.
Hansell DM, Bankier AA, MacMahon H, McLoud TC, Muller NL, Remy J. Fleischner Society: Glossary of terms for thoracic imaging. Radiology 2008;246:697-722.  Back to cited text no. 13
    
14.
Pan Y, Guan H, Zhou S, Wang Y, Li Q, Zhu T, et al. Initial CT findings and temporal changes in patients with the novel coronavirus pneumonia (2019-nCoV): A study of 63 patients in Wuhan, China. Eur Radiol 2020;30:3306-9.  Back to cited text no. 14
    
15.
Song F, Shi N, Shan F, Zhang Z, Shen J, Lu H, et al. Emerging coronavirus 2019- nCoV pneumonia. Radiology 2020;295:210-7.  Back to cited text no. 15
    
16.
Ng MY, Lee EY, Yang J, Yang F, Li X, Wang H, et al. Imaging profile of the COVID-19 infection: Radiologic findings and literature review. Radiology: Cardiothoracic Imaging 2020;2(1).  Back to cited text no. 16
    
17.
Li JW, Wu F, Guo D, Chen L, Zheng F, Li C. The clinical and chest CT features associated with severe and critical COVID-19 pneumonia. Invest Radiol 2020;55:327-31.  Back to cited text no. 17
    
18.
Bernheim A, Mei X, Huang M, Yang Y, Fayad ZA, Zhang N, et al. Chest CT findings in coronavirus disease-19 (COVID-19): Relationship to duration of infection. Radiology 2020;295(3).  Back to cited text no. 18
    
19.
Wu J, Wu X, Zeng W, Guo D, Fang Z, Chen L, et al. Chest CT findings in patients with corona virus disease 2019 and its relationship with clinical features. Invest Radiol 2020;55:257-61.  Back to cited text no. 19
    
20.
Ai T, Yang Z, Hou H, Zhan C, Chen C, Lv W, et al. Correlation of chest CT and RTPCR testing in coronavirus disease 2019 (COVID-19) in China: A report of 1014 cases. Radiology Feb 2020;  Back to cited text no. 20
    
21.
Li X, Zeng X, Liu B, Yu Y. COVID-19 infection presenting with CT halo sign. Radiology: Cardiothoracic Imaging 2020;2:1.  Back to cited text no. 21
    
22.
Yoon S, Lee K, Kim J, Lee YK, Ko H, Kim KH, et al. Chest radiographic and CT findings of the 2019 novel coronavirus disease (COVID-19): Analysis of nine patients treated in Korea. Korean J Radiol 2020;21:494-500.   Back to cited text no. 22
    
23.
Kong W, Agarwal PP. Chest Imaging Appearance of COVID-19 Infection. Radiology: Cardiothoracic Imaging 2020;2(1).  Back to cited text no. 23
    
24.
Xie X, Zhong Z, ZhaoW, Zheng C, Wang F, Liu J. Chest CT for typical 2019-nCoV pneumonia: Relationship to negative RTPCR testing. Radiology 2020.  Back to cited text no. 24
    
25.
Huang P, Liu T, Huang L, Liu H, Lei M, Xu W, et al. Use of chest CT in combination with negative RT-PCR assay for the 2019 novel coronavirus but high clinical suspicion. Radiology 2020;295:22-3.  Back to cited text no. 25
    
26.
Xu R, Du M, Li L, Zhen Z, Wang H, Hu X. CT imaging of one extended family cluster of corona virus disease 2019 (COVID-19) including adolescent patients and “silent infection”. Quant Imaging Med Surg 2020;10:800-4.  Back to cited text no. 26
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Methodology
Results
Discussion
Summary and Conc...
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed458    
    Printed32    
    Emailed0    
    PDF Downloaded81    
    Comments [Add]    

Recommend this journal