Chest imagingCase Type
Joseph Carbone, MS3; Eric Han, MS1; Paul A. Kohanteb, MS4; Justin Glavis-Bloom, MD; Roozbeh Houshyar, MD; Maryam Golshan-Momeni, MDPatient
47 years, male
A previously healthy 47-year-old male presented with a 1-week history of fever, vomiting, nausea, and epigastric pain. Laboratory studies were notable for lymphopenia (0.8×103/µL, normal range 0.9×103/µL – 3.3×103/µL). Vitals signs were remarkable only for low-grade fever (37.9°C). He reported no respiratory complaints or known sick contacts.
CT of the abdomen and pelvis was performed with intravenous contrast and demonstrated patchy, peripheral-predominant ground glass opacities at the bilateral lung bases. A subsequent AP chest x-ray demonstrated diffuse peri-bronchial thickening and faint nodular opacities without focal consolidation.
Coronavirus disease-19 (COVID-19) is a novel viral pandemic that primarily affects the respiratory tract and classically produces symptoms of fever, dry cough, and shortness of breath . The virus invades cells by binding to the angiotensin-converting enzyme 2 (ACE2) receptor [2, 3]. High expression of this receptor is found in the lungs, heart, and intestines, which may facilitate the entry of the virus into these areas and multisystem symptoms [4 – 6].
Patients with COVID-19 typically present with fever, dry cough, and dyspnea. There is increased recognition that gastrointestinal symptoms, including nausea, vomiting, and abdominal pain, maybe presenting features [7, 8]. In some cases, gastrointestinal symptoms may appear without respiratory symptoms during initial stages of infection [9 – 11]. It is important that clinicians maintain a high index of suspicion for COVID-19 when encountering patients with gastrointestinal symptoms.
Chest radiographs may be normal in the early stages of COVID-19 infection, and CT may be positive even prior to symptom development . Common CT findings include bilateral, peripheral-predominant ground-glass opacities and interlobar septal thickening . CT imaging may detect a “crazy paving” pattern later in the disease course, which has been reported in patients presenting with atypical symptoms [14, 15]. Clinicians and radiologists must maintain a low threshold of suspicion to detect atypical presentations of COVID-19.
Based on imaging findings, a test for COVID-19 nucleic acid from nasopharyngeal swab was ordered and returned positive. The patient remained stable in the emergency department and was discharged with instructions to self-quarantine and strict return precautions.
Take-Home Message / Teaching Points
Radiologists and other providers should be aware of both classic and atypical imaging characteristics of COVID-19 infection, including peripheral ground-glass opacities, crazy paving, and interlobular septal thickening. Gastrointestinal symptoms may be isolated, early, or predominant manifestation of COVID-19 infection. A high clinical suspicion for COVID-19 infection is required to accurately diagnose atypical COVID-19 presentations.
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