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Clinical Infection & Immunity

Case Report

Volume 5, Number 3, September 2020, pages 71-76

Computed Tomography Imaging Abnormalities in COVID-19 Mortality Patients

In December 2019, a novel coronavirus was identified in Wuhan, China to be the cause of a pneumonia outbreak. The disease that was thought to have started from a zoonotic transmission later spread through person-to-person transmission to cause a pandemic. On January 30, 2020, the World Health Organization (WHO) held an emergency meeting and declared the global coronavirus disease 2019 (COVID-19) outbreak a public health emergency of international concern. In February 2020, the WHO named it COVID-19 [1]. The clinical spectrum of COVID-19 is wide and it ranges from asymptomatic infection and mild upper respiratory tract illness to severe viral pneumonia with respiratory failure and death [2].

The gold standard diagnostic testing for COVID-19 is nucleic acid testing (NAT) using reverse transcriptase polymerase chain reaction (RT-PCR). The assay, however, has high specificity and low sensitivity [3]. Due to the scarcity of testing resources, as well as its low sensitivity, computed tomography (CT) scans have become critical in diagnosing COVID-19. In a recent study, it was observed that the sensitivity of CT (98%) was significantly higher than that of RT-PCR (71%) [4].

In another retrospective study observing 132 COVID-19 patients, it was shown that 98.5% (130/132) had CT abnormalities on admission. Of 10 exacerbating patients, seven had a second CT scan showing worsening of the disease. All of the deceased patients had repeated CT scans showing worsening of the disease [5]. Due to the novelty of the disease, further data and evidence of the manifestations of COVID-19 on CT scans are important for establishing it as a more sensitive diagnostic tool for the disease.

An increasing evidence describing the importance of radiological imaging studies in the diagnosis of COVID-19 has been noted in literature. CT scans are particularly widely available and provide high-resolution imaging studies of the lung parenchyma; hence they can lead to early diagnosis, assessment of disease severity and better patient management [6]. The most common radiological presentation described in COVID-19 is patchy ground-glass opacities (GGOs) [7, 8]. This is a case series of 10 COVID-19-positive patients who were admitted to the Brooklyn Hospital Center who had poor prognosis and were deceased after admission.

A case series of 10 mortality patients who were admitted to the Brooklyn Hospital Center and tested positive for COVID-19 was constructed. Workup included routine blood work, inflammatory markers and chest CT scans without contrast. Electronic Medical Records (EMR) was used to extract demographic information. Inclusion criteria consisted of adult mortality patients over the age of 50 who were admitted to the inpatient floors or intensive care unit (ICU) for respiratory distress, tested positive for COVID-19 and had CT scans done to monitor prognosis. It included seven males and three females, aged between 60 and 95 years. The average age was 75.8 years. Six patients were African American, two Hispanics, one Asian and one Caucasian with varying range of comorbidities (Table 1). Seven patients were from home, while three resided in nursing homes. Levels of inflammatory markers were recorded, including ferritin (normal range 22 - 275 mg/mL), lactate dehydrogenase (LDH) (normal range (125 - 220 U/L) and C-reactive protein (CRP) (normal range < 5.00 mg/L).

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Table 1. Basic Characteristics of the Patients

Axial chest CT scans without contrast were performed on all patients. The chest CT of each patient was reviewed by a radiologist at the Brooklyn Hospital Center. The images were analyzed for the presence of GGOs that are defined by an increase in lung density that does not compromise the visualization of the pulmonary blood vessels; the presence of lung consolidation that is defined by higher density than GGOs and blurred margins of bronchial tubules and blood vessels; the presence of interlobular and intralobular septal thickening, also known as “crazy paving”, as well as pleural effusion, pleural thickening or hydrothorax (Figs. 1-10).

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Figure 1. Axial computed tomography scan image of patient 1 showing peripheral ground-glass opacities mostly involving the right lung (red arrows). There is no consolidation or pleural effusion.

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Figure 2. Axial computed tomography scan image of patient 2 showing patchy ground-glass opacity involving right lung most prominent within the anterior aspect of the right upper lobe (red arrows). Left lung is clear. There is no evidence of effusion.

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Figure 3. Axial computed tomography scan image of patient 3 showing diffuse scattered bilateral confluent extensive ground-glass (solid red arrows) and consolidative opacities (dotted red arrows), both central and peripheral. No emphysema or bronchiectasis. Trachea and central bronchi are patent. Trace bilateral dependent small pleural effusions. No evidence of pneumothorax.

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Figure 4. Axial computed tomography scan image of patient 4 showing scattered ground-glass opacities throughout the lungs (red arrows). Some of the opacities are more confluent in the lower lobes.

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Figure 5. Axial computed tomography scan image of patient 5 showing extensive ground-glass opacities (red arrows) involving all lobes of both lungs with “crazy paving” (red circles).

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Figure 6. Axial computed tomography scan image of patient 6 showing diffuse extensive bilateral ground-glass (solid red arrows) and consolidative opacities with bilateral lower lobe and peripheral predominance (dotted red arrows).

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Figure 7. Axial computed tomography scan image of patient 7 showing diffuse area of ground-glass opacities (red arrows) with crazy paving (red circles) involving all lobes of both lungs but predominantly the lower lobes.

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Figure 8. Axial computed tomography scan image of patient 8 showing extensive ground-glass opacities (red arrows) seen in all lobes of both lungs with “crazy paving” (red circles).

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Figure 9. Axial computed tomography scan image of patient 9 showing multifocal areas of ground-glass opacity throughout the lungs with both a central and peripheral distribution. Some of these focal opacities both centrally as well as peripherally are rounded (solid red arrows). An area of crazy paving is seen in the left upper lobe and left lower lobe (red circles). There is consolidation in the left lower lobe (dotted red arrow).Figure 10. Axial computed tomography scan image of patient 10 showing extensive bilateral ground-glass opacities with predominantly upper lobe distribution (red arrows).

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Figure 10. Axial computed tomography scan image of patient 10 showing extensive bilateral ground-glass opacities with predominantly upper lobe distribution (red arrows).

All 10 patients were admitted for severe shortness of breath, fever and cough, and all tested positive for COVID-19 using RT-PCR. The length of stay was less than 7 days for six patients, 8 - 14 days for three patients and > 21 days for one patient, during which, six patients were intubated. All 10 patients had elevated inflammatory markers including ferritin, LDH and CRP (Table 1). All 10 patients had positive chest CT findings. Bilateral involvement was identified in eight patients; 10 patients had GGOs; two with patchy consolidations; four with interlobular and intralobular septal thickening, also known as “crazy paving pattern”; and one patient had pleural effusion. Strictly peripheral distribution of lesions was identified in two patients, peripheral and central lesions were identified in two patients, while six had diffuse distribution (Table 2).

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Table 2. Chest Computed Tomography Scan Manifestations

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a single-stranded RNA virus that has human-to-human transmission ability through respiratory droplets and contact, similar to the transmission of severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) [9, 10]. Clinical symptoms of those 10 patients included fever, cough and shortness of breath, all of which are consistent with reported signs and symptoms of COVID-19.

The most common chest CT findings in COVID-19 include GGOs and patchy consolidations. Severe cases often show mixed lesions of both GGOs and consolidations with diffuse distribution of lesions [11]. Chest CT scan showed eight patients with bilateral lung lesions involving multiple lobes simultaneously, with six patients having diffuse distribution, two patients having peripheral distribution, also known as the “reversed halo sign” and two others having peripheral and central distribution of lesions. This is not a specific imaging characteristic of COVID-19, as many other respiratory diseases can cause similar “reverse halo sign” such as bacterial pneumonia, tuberculosis and cryptococcosis [12]. The small size of the virus could contribute to its ability to deposit in the periphery of the lung, affecting the alveolar epithelium of multiple lobes simultaneously [13].

Despite vigorous medical management, these 10 patients had poor prognosis that ultimately led to cessation of life. The risk factors for disease progression include age over 50, smoking status, existing lung disease such as chronic obstructive pulmonary disease, asthma and other comorbidities such as hypertension, diabetes mellitus, coronary artery disease, hyperlipidemia, obesity and any condition or medication that leads to an immunocompromised state. All those 10 cases had multiple risk factors that could have contributed to their poor prognosis. There have also been recent reports of low lymphocyte count being a predictor of poor prognosis [14, 15]. Among the 10 patients, nine had low absolute lymphocyte count. This could be an indication to the virus’ effect on the immune system or that the multiple risk factors combined with positive disease status affects the immune system negatively.

Limitations of our case series study include being retrospective, which limits the study by the accuracy and availability of the data records. The 10 cases were chosen because chest CT is not a protocol diagnostic tool for COVID-19, and these were among the cases that had chest CT documented. Consequently, a case series is subject to bias because of self-selection of cases for the reasons stated above. In addition, being mortality cases with eight patients having multiple comorbidities could have influenced the course of the disease and exacerbated respiratory distress manifested on chest CT. Lastly, a case series does not have a control group so it is not possible to compare CT imaging to COVID-19-negative patients. These sources of bias hinder the ability to generalize conclusions to a larger population, and a large-scale study that addresses these limitations is required to confirm these results.

This case series concurs previous evidence that chest CT imaging has been shown to be one of the most clinical diagnostic tools for COVID-19. Chest CT manifestations of COVID-19 include patchy or diffuse GGOs and consolidations. Early detection of lung changes can help create early and more intense treatment plan even when the gold standard diagnostic test has not detected the disease due to its relatively low sensitivity.

Acknowledgments

We thank the clinicians and hospitalists of the Family Medicine Department and the Radiology Department at The Brooklyn Hospital Center for the data provided, and we also thank all healthcare workers at the Brooklyn Hospital Center for their extraordinary and selfless work to support their community during this pandemic.

Financial Disclosure

None to declare.

Conflict of Interest

None to declare.

Informed Consent

The manuscript has been de-identified to protect patients. The patients have since died and are unable to provide informed consent.

Author Contributions

All authors contributed to the editing of the manuscript. Sherly Abraham and Nazik Al-Hashimi wrote the manuscript. Nada Al-Hashimi provided data analysis and made the accompanying tables and figures.

Data Availability

The authors declare that data supporting the findings of this study are available within the article.

Abbreviations

COVID-19: coronavirus disease 2019; SARS: severe acute respiratory syndrome; MERS: Middle East respiratory syndrome; SARS-CoV-2: severe acute respiratory syndrome coronavirus 2; WHO: World Health Organization; NAT: nucleic acid testing; RT-PCR: reverse transcriptase polymerase chain reaction

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Clinical Infection and Immunity is published by Elmer Press Inc.