CASE 16708 Published on 21.04.2020

COVID-19 patient with probably nosocomial infection

Section

Chest imaging

Case Type

Clinical Cases

Authors

Lesly Yanory Ortega Molina, Beatriz Elduayen Aldaz

Department of Radiology, Complejo Hospitalario de Navarra, Pamplona, Spain.

Patient

74 years, woman

Categories
Area of Interest Emergency, Thorax ; Imaging Technique Conventional radiography, CT
Clinical History

A 74-year-old woman with history of hypertension and heart disease, who had been discharged 10 days before knee prosthetic surgery, was admitted with 4-day history of fever, dry cough and dyspnoea. She had not left home since discharge and no family member was affected. Analysis revealed lymphopenia, elevation of C-reactive protein and a positive RT-PCR. The patient was admitted to the intensive care unit, with a favourable course.

Imaging Findings

Chest X-ray at admission showed diffuse reticular pattern with small opacities in both basal regions (Figure 1). Axial CT performed on first day showed diffuse ground glass opacity predominantly in the lower lobes with small peripheral consolidations in a posterior distribution (figures 2 and 3). Chest X-ray on the second day showed disease progression with diffuse reticular pattern and increased density in both lungs (figure 4) Chest x-ray on the eighth day showed improvement with decreased of high density and reticular pattern, more evident in the upper left lobe (figure 5).

Discussion

Background The outbreak of severe acute respiratory syndrome coronavirus 2 (SARS- CoV-2) disease in China at the end of 2019 (COVID 19) is a novel viral pandemic, that today affect to 693,282 and have caused death to 33,106 people around the world [1]. Studies suggest zoonotic origin of the infection with subsequent human-human spread through droplets or direct contact [2-4]. Infection has mean incubation period of 6.4 days with a range of 0-24 days, and hospital-related transmission and asymptomatic carriers have been described [4-6]. The mean age of people affected in China was 47-49 years, 12-15% was elderly patients and male sex comprised more than half of the cases [6]. Clinical Perspective Fever is the most common symptom described in many studies followed by dry cough and dyspnoea [4,6,7]. Most patients had a normal white blood cell count, but more than 50% had leukopenia [4,7,8] According to a summary report of many cases, 14% were severe (dyspneoa, tachypnea and blood oxygen saturation<93%) and 5% were critical (respiratory failure and shock septic) [2]. These groups were more likely to have comorbidities (at least 20%), being hypertension the most common [6]. The overall case-fatality rate was 2.3% and in elderly patients was 8-15%. [2] Imaging Perspective Chest radiographs are of little diagnostic value in early stages, whereas CT findings may be present even before symptom onset [8] and almost all patients with COVID 19 had characteristic CT features in disease process [14]. More than half of patients presented bilateral multilobar ground-glass opacification (GGO) with a peripheral distribution [8,10] sometimes with a rounded morphology [ 11, 12]. CT in the intermediate stage shows and increase in the number and size of GGOs and transformation of GGO into multifocal consolidative opacities, septal thickening and development of a crazy paving pattern [9]. Bronchiectasis, pleural thickening, subpleural involvement, pleural effusion, pericardial effusion, lymphadenopathy, cavitation, CT halo sign and pneumothorax are uncommon but Main Document 2 may be seen with disease progression [9]. Pleural effusion and lymphadenopathy was considered of poor prognosis [13]. Imaging patters corresponding to clinical improvement usually occur after week 2 of the disease [9]. Outcome The reference standard in COVID-19 diagnosis is real-time reverse transcription polymerase chain reaction (RT-PCR) of viral nucleic acid that has low sensitivity, however, chest CT has high sensitivity for diagnosis in patients with initial false negative RT-PCR results [14,15, 16], so it can be considered a useful diagnostic tool and radiologists must know the typical findings of this disease. Teaching Points The presence of ground glass opacity and peripheral consolidations of bilateral distribution in the current clinical and epidemiological context is diagnosis of COVID-19.

Differential Diagnosis List
Severe pneumonia with acute respiratory distress syndrome and septic shock secondary to COVID 19.
Pulmonary oedema
Other viral pneumonias
Multifocal bacterial pneumonia
Hypersensitivity pneumonitis
Final Diagnosis
Severe pneumonia with acute respiratory distress syndrome and septic shock secondary to COVID 19.
Case information
URL: https://www.eurorad.org/case/16708
ISSN: 1563-4086