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.
 Lake MA (2020) What we know so far: COVID-19 current clinical knowledge and research. Clinical Medicine (London) 20(2):124–127 (PMID: 32139372)
 Letko M, Marzi A, Munster V (2020) Functional assessment of cell entry and receptor usage for SARS-CoV-2 and other lineage B betacoronaviruses. Nat Microbiol 5(4):562–569 (PMID: 2094589)
 Chen Y, Guo Y, Pan Y, Zhao ZJ (2020) Structure analysis of the receptor binding of 2019-nCoV. Biochem Biophys Res Commun 525(1):135–140 (PMID: 32081428)
 Zou X, Chen K, Zou J, Han P, Hao J, Han Z (2020) Single-cell RNA-seq data analysis on the receptor ACE2 expression reveals the potential risk of different human organs vulnerable to 2019-nCoV infection. Frontiers of medicine 14(2):185–192. (PMID: 32170560)
 Li Y, Zhou W, Yang L, You R (2020) Physiological and pathological regulation of ACE2, the SARS-CoV-2 receptor. Pharmacol Res 157:104833 (PMID: 32302706)  Musa S (2020) Hepatic and gastrointestinal involvement in coronavirus disease 2019 (COVID-19): What do we know till now? Arab J Gastroenterol 21(1):3–8. (PMID: 32253172)
 Patel K, Patel P, Vunnam R (2020) Gastrointestinal, hepatobiliary, and pancreatic manifestations of COVID-19. J Clin Virol 128:104386 (PMID: 32388469)
 Mao R, Qiu Y, He J (2020) Manifestations and prognosis of gastrointestinal and liver involvement in patients with COVID-19: a systematic review and meta-analysis. Lancet Gastroenterol Hepatol (PMID: 32405603)
 Lee I, Huo T, Huang Y (2020) Gastrointestinal and Liver Manifestations in Patients with COVID-19. J Chin Med Assoc (PMID: 32243269)
 Cipriano M, Ruberti E, Giacalone A (2020) Gastrointestinal Infection Could Be New Focus for Coronavirus Diagnosis. Cureus 12(3):e7422 (PMID: 32351807)
 Hajifathalian K, Mahadev S, Schwartz R (2020) SARS-COV-2 infection (coronavirus disease 2019) for the gastrointestinal consultant. World J Gastroenterol 26(14):1546–1553 (PMID: 32327904)
 Tao AI, Zhenlu Yang, Hongyan Hou, Chenao Zhan, Chong Chen, Wenzhi Lv, Qian Tao, Ziyong Sun, Liming Xia. Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 Cases. Radiology, published online Feb 26, 2020. (PMID: 32101510)
 Chung M, Bernheim A., Mei X, et al. (2020): CT Imaging Features of 2019 Novel Cornavirus (2019- nCoV). Radiology 0(0): p.200230
 [Dig X, Xu J, Zhou J, Long Q (2020) Chest CT findings of COVID-19 pneumonia by duration of symptoms. Eur J Radiol. 127:109009 (PMID: 32325282)
 Bernheim A, Mei X, Huang M, Yang Y, Fayad ZA, Zhang N, Diao K, Lin B, Zhu X, Li K, Li S, Shan H, Jacobi A, Chung M (2020) Chest CT Findings in Coronavirus Disease-19 (COVID-19): Relationship to Duration of Infection. Radiology (PMID: 32077789).