CASE 16660 Published on 20.03.2020

0

Teaching Case

Section

Chest imaging

Case Type

Clinical Cases

Authors

Edgar Lorente Martínez

Hospital Universitario Doctor Peset, Valencia, Spain

Patient

72 years, female

Categories

No Area of Interest ; Imaging Technique Conventional radiography ;

No Procedure ; Special Focus Infection ;

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Clinical History

A 72-year-old woman admitted with acute respiratory failure, fever (38ºC) and dyspnoea.

She was tachypneic (30bpm), with lymphopenia and low oxygen saturation (SpO2 85%, PAFI<250).

Patient presented to the emergency department two days earlier with fever (up to 38.6ºC), dry cough, odynophagia and general malaise. She was discharged from hospital because she did not present alarm criteria at that time.

The patient required mechanical ventilation and was admitted to intensive care.

During her stay in ICU, poor evolution to respiratory distress syndrome and to multi-organic failure.

The patient passed away 24 hours later.

Differential Diagnosis List

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Coronavirus disease-19 (COVID-19)

Multifocal bacterial pneumonia

Pulmonary oedema

Acute respiratory distress syndrome (ARDS)

Hypersensitivity pneumonitis

Imaging Findings

Figure 1 (at admission). Ill-defined bilateral alveolar consolidation with peripheral distribution.

Figure 2 (4 hours later). Radiological worsening, with affectation of lower lobes. Endotracheal tube and central venous line were required.

Figure 3 (Day 1). Bilateral alveolar consolidation.

Figure 4 (Day 2). Radiological worsening. Bilateral alveolar consolidation with panlobar affectation.

Figure 5 (Day 3). Bilateral alveolar consolidation with panlobar affectation, with typical radiological findings of ARDS. 24 hours later the patient passed away.

Discussion

Background
Coronavirus disease-19 (COVID-19) is a novel viral pandemic with increasing incidence and a wide spectrum of disease severity [1]. Many countries are currently experiencing community spread to persons without known infectious contacts. In Spain, the guidelines to determine who to test for COVID-19 microbiology are changing. This implies the risk that some patients discharged from the hospital at that moment, may develop days later an ARDS.

Clinical Perspective
Common presenting findings include fever, cough, myalgia, and lymphopenia [2]. In some cases gastrointestinal symptoms are reported [3,4]. The evolution to ARDS secondary to COVID-19 infection is a several and life-threatening complication [5].

Imaging Perspective

COVID-19 infection can lead to rapidly progressive ARDS as we show in this case. The prognosis is poor and radiologic findings can go from ill-defined alveolar consolidations to bilateral consolidations with panlobar affection as seen in ARDS.
Radiographic and computed tomography (CT) imaging early in the disease course may be normal; chest CT has been described as more sensitive than chest X-ray for the detection of characteristic bilateral, peripherally-predominant ground-glass opacities [6–10].

Outcome
COVID-19 RT-PCR returned positive. The patient developed hypoxic respiratory failure and new onset haemoptysis on day two of admission and was intubated and transferred to the intensive care unit.
Teaching Points

Chest imaging findings in COVID-19 infection are not specific and may overlap with other viral pneumonias, including influenza. Chest CT is more sensitive than chest X-ray for detection of ground glass opacities [11-13]; however, is not always available. ARDS is a complication of COVID-19 infection, leading to rapidly progressive organic failure in some cases.

Written patient consent for this case was waived by the Editorial Board. Patient data may have been modified to ensure patient anonymity.

References

[1] Wu Z, McGoogan JM (2020) Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention. JAMA 2019:3–6. (PMID: 32091533)

[2] Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, Zhang L, Fan G, Xu J, Gu X, Cheng Z, Yu T, Xia J, Wei Y, Wu W, Xie X, Yin W, Li H, Liu M, Xiao Y, Gao H, Guo L, Xie J, Wang G, Jiang R, Gao Z, Jin Q, Wang J, Cao B (2020) Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 395:497–506. (PMID: 31986264)

[3] Xiao F, Tang M, Zheng X, Liu Y, Li X, Shan H (2020) Evidence for gastrointestinal infection of SARS-CoV-2. Gastroenterology. doi: 10.1053/j.gastro.2020.02.055 (PMID: 32142773)

[4] Gu J, Han B, Wang J (2020) COVID-19: Gastrointestinal manifestations and potential fecal-oral transmission. Gastroenterology (PMID: 32142785)

[5] Wu C, Chen X, Cai Y, et al. Risk Factors Associated With Acute Respiratory Distress Syndrome and Death in Patients With Coronavirus Disease 2019 Pneumonia in Wuhan, China. JAMA Intern Med. Published online March 13, 2020. doi:10.1001/jamainternmed.2020.0994

[6] Lin C, Ding Y, Xie B, Sun Z, Li X, Chen Z, Niu M (2020) Asymptomatic novel coronavirus pneumonia patient outside Wuhan: The value of CT images in the course of the disease. Clin Imaging 63:7–9. (PMID: 32120312)

[7] Wei J, Xu H, Xiong J, Shen Q, Fan B, Ye C, Dong W, Hu F (2020) 2019 Novel Coronavirus (COVID-19) Pneumonia: Serial Computed Tomography Findings. Korean J. Radiol. (PMID: 32100486)

[8] Bernheim A, Mei X, Huang M, Yang Y, Fayad ZA, Zhang N, Diao K, Lin B, Zhu X, Li K, Li S, Shan H, Jacobi A, Chung M (2020) Chest CT Findings in Coronavirus Disease-19 (COVID-19): Relationship to Duration of Infection. Radiology 19:200463. (PMID: 32077789)

[9] Kong W, Agarwal PP (2020) Chest Imaging Appearance of COVID-19 Infection. Radiol Cardiothorac Imaging 2:e200028.

[10] Zu ZY, Jiang M Di, Xu PP, Chen W, Ni QQ, Lu GM, Zhang LJ (2020) Coronavirus Disease 2019 (COVID-19): A Perspective from China. Radiology 2019:200490. (PMID: 32083985)

[11] Xie X, Zhong Z, Zhao W, Zheng C, Wang F, Liu J (2020) Chest CT for Typical 2019-nCoV Pneumonia: Relationship to Negative RT-PCR Testing. Radiology 200343. (PMID: 32049601)

[12] Fang Y, Zhang H, Xie J, Lin M, Ying L, Pang P, Ji W (2020) Sensitivity of Chest CT for COVID-19: Comparison to RT-PCR. Radiology 2013:200432.

[13] Ai T, Yang Z, Hou H, Zhan C, Chen C, Lv W, Tao Q, Sun Z, Xia L (2020) Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 Cases. Radiology 2019:200642. (PMID: 32101510)

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