Unusual appearance of COVID-19 pneumonia

A 61-year-old male patient presented with three days fever and mild sore throat. Past history of diabetes mellitus and arterial hypertension. Blood analysis showed mild elevation of C-reactive protein level (11,26 mg/l ), normal LDH level, normal WBC count with neutrophylia (80,4%) and hyperglycaemia (151 mg/dl).

Chest X-ray (antero-posterior view): consolidations in right upper lobe sharply defined at the fissure, and in lower zone of the left-lung.

Chest CT was requested in order to exclude associated pathologies and for treatment decisions; it was performed using a 16-row multidetector CT without contrast agent with volumetric acquisition (0,75 mm collimation and 1 mm reconstructed slices). Bilateral finding of multiple consolidations at random segmental distribution, the major one in the dorsal segment of right upper lobe, with evidence of air bronchogram, and extensive peripheral ground-glass opacities. Spaired lung areas show no interstitial abnormalities.  Aspecific mediastinal lymphoadenomegalies. No pleural effusion.

Since December 2019, 41 cases of pneumonia of unknown aetiology have been confirmed in Wuhan city, Hubei Province, China.  Dr Jianguo Xu, an academician of the Chinese Academy of Engineering who led a scientific team, announced that a new‐type coronavirus, tentatively named by World Health Organization as the 2019‐new coronavirus (2019‐nCoV), had caused this outbreak. [1]

In Italy, the first outbreak of the disease was detected on 21st february 2020 with 16 patients in Lombardia [2], and as to 29 March the total number of affected patients has increased to 97.689 [3].

Those infected with the virus may be asymptomatic or develop flu-like symptoms, including fever, cough and dyspnoea [4].  In more severe cases, the disease may progress to pneumonia, multi-organ failure, and exitus [5].

Chest X-ray imaging is mostly negative, especially in early stages of disease [6], or it can show diffuse interstitial abnormalities and/or multifocal consolidations until white lungs in late stages.

CT scan is perfomed in clinical-radiological discrepancy and to help differential diagnosis. The most common findings are diffuse ground-glass opacities, especially in the first stages, with or without interlobular septa thickening (’crazy paving’-pattern),  while in more severe cases coalescent consolidations, usually subpleural, are present, with air bronchogram. Pleural effusion is usually absent. [7].

Chest X-ray is the first examination to be performed, characterised by low sensibility and specificity; CT reaches a 97% sensibility, but only a 25% specificity for COVID-19 alterations [8], so the gold standard for diagnosis remains the RT-PCR, preferably from material collected from lower respiratory tract, if not available from nasopharyngeal swab.

The present case showed unusual findings both on the X-Ray and on the CT scan, not unequivocable, but a following nasopharyngeal swab which was positive for COVID-19.

Teaching point: Numerous cases of confirmed COVID-19 patients have come to our attention, with heterogeneous patterns. Isolated multiple lung consolidations with air bronchogram, associated with peripheral ground-glass opacities, in immunocompetent patients without any other comorbidities, must be suspected for SARS-CoV-2 pneumonia in this pandemic state.

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