CASE 16841 Published on 01.07.2020
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COVID-19 pneumonia and CT signs of peripheral lung microinfarctions: a possible correlation? Two clinical cases

Section

Chest imaging

Case Type

Clinical Cases

Authors

Davide Stoppa [1], Federico Paltenghi [1], Giorgia Bestagno [2], Alessandro Baletti [2], Elena Belloni [1]

[1] Department of Radiology, Civili Hospital, Corso Milano, 19, 27029 Vigevano (PV), Italy

[2] Department of Radiology, Hospital of Sanremo (IM) Via Giovanni Borea, 56, 18038, Italy

Connected authors
Patient

25 years, male, 58 years, male

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

Case 1: a 25 years old male nurse referred to Vigevano emergency department with fever and cough. No laboratory tests available.

Case 2: a 58 years old male, husband of a nurse, presented to Sanremo emergency department with fever and cough. Laboratory tests: neutrophilia and lymphopenia, increase of LDH levels.

Imaging Findings

Case 1

29/03/2020 Chest radiography AP view:
Two ill-defined parenchymal opacities in the left medium-lower lung. No pleural effusion.
29/03/2020 Chest CT
Further evaluation of the left lung findings is obtained with an unenhanced chest CT.
In both lungs are noticeable several subpleural consolidations and ground glass opacities (GGO), mainly with rounded shape and some with triangular shape or with Hampton hump sign, most of which show bubbly appeareance. No pleural effusion.

Case 2

27/03/2020 non-contrast Chest CT: multiple ground glass opacities, some of which surrounded with denser consolidations (reverse halo sign), in relationship with centrolobular structures, mainly peripheral, mostly with rounded or elongated shape. No pleural effusion. Dilatation of main pulmonary artery (41 mm).

Due to clinical worsening, an X-ray was performed before intensive care admission

30/03/2020 Chest radiography AP view: bilateral consolidations, mainly peripheral and in lower lung zones, also in right perihilar zone. No pleural effusion. Further X-rays performed in the following days showed progressive improvement of lung transparency, with only remaining of thin atelectatic streaks in the left basal zone.

Discussion

On 11th march 2020 the World Health Organization declared a pandemic state for COVID-19 that caused, as to 19 april 2020, 152,551 deaths in 2,241,359 confirmed cases worldwide [1]. Symptoms are aspecific, mostly flu-like, but in some more severe cases the disease may be fatal [2, 3].
Since the earliest autopsies, it was reported that exitus was caused by multiorgan failure, with predominant lung involvement characterized by infarctions and haemorrhages in peripheral small vessels [4 - 6].
 
To confirm the importance of coagulation alterations in patients with COVID-19 it has been shown that the outcome is directly related to the values of D-Dimer [7] and the use of anticoagulant therapy is important in the management of patients [8 - 10]


Because of the low sensitivity of X-ray examinations [11], CT scans are increasingly requested to better evaluate critical patients and to help differential diagnosis,  with heterogeneous findings [12, 13]

Although cases of pulmonary thromboembolism in COVID-19 patients have been described in literature [14], chest CT is usually performed without contrast medium if there are no specific clinical suspicions, in concerning to organizational / management problems and because of the main peripheral involvement of the alterations.

 

 Rounded lung opacities in COVID-19 is a known expression of the disease both in pure GGO presentation [15]    and in partially-solid or solid consolidations [16],  but its real prevalence has not yet been proven.

.
In both our cases Real-Time – Polymerase Chain Reaction (RT-PCR) obtained from oropharyngeal swab specimens was performed, resulting positive for COVID-19. Both their CT scans showed peripheral GGO and consolidations, associated with some signs usually found in pulmonary peripheral infarction [17 - 20]: reverse halo sign, subpleural triangular shape consolidations, Hampton hump, bubbly consolidations; this evidence seem to validate the histopathological findings seen about peripheral thromboembolic disease.


Take-Home Message: also without contrast medium, numerous signs in non-contrast chest CT of COVID-19 pneumonia suggest  a correlation between pulmonary changes highlighted in histopathological tests and characterized by infarctions and haemorrhages in small peripheral vessels.

 Further studies should be needed to confirm the correlation between COVID-19 pneumonia and CT signs of pulmonary infarctions, especially to better understand the patients’ outcome.

 

Written informed consent for publication has been obtained for both patients.

Differential Diagnosis List
COVID-19 Pneumonia
Other viral pneumonia with peripheral pulmonary infarction
Tromboembolic pulmonary infarction
Aspergillosis
Septic embolism
Malignancy
Final Diagnosis
COVID-19 Pneumonia
Case information
URL: https://www.eurorad.org/case/16841
DOI: 10.35100/eurorad/case.16841
ISSN: 1563-4086
License

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

Figure 1

Case 1 – Chest X-Ray: two ill-defined parenchymal opacities in the left medium-lower lung. No pleural effusion.
Case 1 – Chest X-Ray: two ill-defined parenchymal opacities in the left medium-lower lung. No pleural effusion.
Figure 2

Case 1 – Chest CT, axial plane: triangular shape peripheral consolidation in the left lower lung lobe.
Case 1 – Chest CT, axial plane: triangular shape peripheral consolidation in the left lower lung lobe.
Figure 3

Case 1 – Chest CT, axial plane: consolidation in the right lower lung lobe with Humpton hump sign.
Case 1 – Chest CT, axial plane: consolidation in the right lower lung lobe with Humpton hump sign.
Figure 4

Case 1 – Chest CT, axial plane: bilateral peripheral consolidations with bubbly appearance.
Case 1 – Chest CT, axial plane: bilateral peripheral consolidations with bubbly appearance.
Figure 5

Case 1 – Chest CT, coronal reconstruction: peripheral posterior consolidations.
Case 1 – Chest CT, coronal reconstruction: peripheral posterior consolidations.
Figure 6

Case 1 – Chest CT, sagittal reconstruction: consolidation in the posterior segment of the right lung.
Case 1 – Chest CT, sagittal reconstruction: consolidation in the posterior segment of the right lung.
Figure 7

Case 1 – Chest CT, sagittal reconstruction: multiple consolidations in the left lung
Case 1 – Chest CT, sagittal reconstruction: multiple consolidations in the left lung
Figure 8

Case 2 – Chest CT, axial plane: multiple bilateral ground glass opacities.
Case 2 – Chest CT, axial plane: multiple bilateral ground glass opacities.
Figure 9

Case 2 – Chest CT, axial plane: peripheral bilateral ground glass opacities, also with reverse halo sign.
Case 2 – Chest CT, axial plane: peripheral bilateral ground glass opacities, also with reverse halo sign.
Figure 10

Case 2 – Chest CT, axial plane (mediastinum window): dilatation of main pulmonary artery up to 41 mm.
Case 2 – Chest CT, axial plane (mediastinum window): dilatation of main pulmonary artery up to 41 mm.
Figure 11

Case 2 – Chest CT, coronal reconstruction: peripheral bilateral ground glass opacities, also with reverse halo sign.
Case 2 – Chest CT, coronal reconstruction: peripheral bilateral ground glass opacities, also with reverse halo sign.
Figure 12

Case 2 – Chest CT, sagittal reconstruction: multiple ground glass opacities in the right lung, the one in the superior segment of the lower lobe with reverse halo sign.
Case 2 – Chest CT, sagittal reconstruction: multiple ground glass opacities in the right lung, the one in the superior segment of the lower lobe with reverse halo sign.
Figure 13

Case 2 – Chest X-Ray before intensive care admission: bilateral consolidations, mainly peripheral and in lower lung zones, also in right perihilar zone. No pleural effusion.
Case 2 – Chest X-Ray before intensive care admission: bilateral consolidations, mainly peripheral and in lower lung zones, also in right perihilar zone. No pleural effusion.
Figure 14

Case 2 – Chest X-Ray during hospitalization: improvement of lung transparency
Case 2 – Chest X-Ray during hospitalization: improvement of lung transparency
Figure 15

Case 2 – Chest X-Ray before hospital discharge: remaining of thin atelectatic streaks in the left basal zone.
Case 2 – Chest X-Ray before hospital discharge: remaining of thin atelectatic streaks in the left basal zone.