Chest imagingCase Type
Christina Aslanidi1, Sofia Athanasiou1, Eleni Lazaridou1, Anastasia Kotanidou2, Demetrios Exarhos1Patient
58 years, male
A 58-year old male non-smoking patient presented to our Emergency Department with progressive dyspnoea. Five days earlier, he complained of fever, sore throat and dry cough with positive RT-PCR test for COVID-19. Medical history included chronic sinusitis without any known pathogen exposure. After 48 hours, due to worsening hypoxemia and deterioration of mental status, he was intubated on the 7th day after the initiation of symptoms.
The chest radiography that was performed at the ED on the day of admission revealed bilateral diffuse alveolar pulmonary consolidations, especially in the right upper and middle zones (Fig. 1). Due to deterioration of his dyspnoea, a non-contrast chest CT was performed later that day using a 16-row multidetector CT to rule out life-threatening complications. CT scan revealed bilateral multifocal ground-glass opacities (GGO) in the upper lobes (Fig. 2a). Mixed GGO along with thickened interlobular septa (crazy-paving pattern) and consolidation lesions with air bronchograms especially in the upper lobes with a slight peripheral preponderance were present as well (Fig. 2b). Moreover, a lesion with reverse halo sign in the right lower lobe was also identified (Fig. 2c). Mediastinal lymphadenopathy was present (Fig. 2d), whereas there were no signs of pleural or pericardial effusion.
Coronavirus disease 2019 (COVID-19) outbreak, first reported in Wuhan, China, has been declared a global health emergency . The vast majority of infected patients present with fever, dry cough and respiratory distress. In COVID-19 diagnosis, real-time reverse transcription-polymerase chain reaction (RT-PCR) of viral nucleic acid is considered as the test of choice [2, 3]. However, since the respiratory system is the predominantly affected system, chest radiography and CT scan is highly recommended in the investigation of suspected or known COVID-19 patients. Due to the shortage and the high false-negative rate of RT-PCR many patients may not be diagnosed on time. CT may be a reliable tool in screening out patients highly suspected for COVID-19 and setting an early diagnosis [2, 4]. Recognition of the diagnostic imaging hallmarks, as well as atypical features, is crucial for efficient patient management and treatment .
When compared to chest radiography, CT demonstrates better the extent and distribution of COVID-19 pulmonary involvement while also detecting findings even before symptoms onset . A wide variety of CT manifestations in COVID-19 have been reported in several studies. The earliest and the most common radiographically visible CT finding is GGO, mainly with bilateral involvement and peripheral distribution [2, 5]. Moreover, GGO is often associated with other features or patterns, such as interlobular septal thickening (crazy-paving pattern), air bronchogram or consolidation, which is indicative of disease progression, as in the present case.  Other CT findings, more common in the later stages of the disease, include bronchiectasis, bronchial wall thickening and pleural changes (mainly pleural thickening), with various rates across the studies . Furthermore, subpleural curvilinear lines can be present, which could be associated with pulmonary oedema or fibrosis due to COVID-19. Dilatation of pulmonary vessels around and within the lesions is often described in infected patients, which has been attributed to the damage and swelling of the capillary wall that is caused by the virus. The presence of nodules with halo or reverse halo sign, as in our case, constitutes another uncommon CT finding. Mediastinal lymphadenopathy, cavitation, pneumothorax and pericardial effusion are atypical CT findings and considered as significant risk factors of severe/critical COVID-19 pneumonia . Performing a follow-up CT scan may also be helpful for the evaluation of prognosis of the patients as well as detection of possible complications, including Acute Respiratory Distress Syndrome (ARDS) and acute pulmonary embolism [8, 9].
In conclusion, bilateral GGO and consolidation with air bronchograms opacities and crazy paving lesions with reverse halo sign are reported as the predominant imaging characteristics in the present case. CT manifestations may be correlated with the progression of COVID-19. As seen in the bibliography, radiological aggravation of the initial image is usually observed on day 7 after the onset of symptoms which is in accordance with our case . It is noteworthy to mention that even middle-aged patients without any comorbidities or a significant past medical history can develop rapid progression of the disease and have a poor prognosis.
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