Radiological approach to COVID-19 pneumonia with an emphasis on chest CT

Sequential radiation exposure: uncovering the potential of low dose ionizing radiation in mitigating high dose effects on immune cells

PURPOSE

The radioadaptive response refers to a phenomenon wherein exposure to a low dose of ionizing radiation (LDIR) can induce a protective response in cells or organisms, reducing the adverse effects of a subsequent higher dose of ionizing radiation (HDIR). However, it is possible to administer the low dose after the challenge dose. This study was conducted to determine the potential mitigating effect of LDIR administered after HDIR on mice immune cells.

MATERIALS AND METHODS

Alongside the conventional adaptive response setting, one group of mice was initially exposed to HDIR and subsequently treated with LDIR. Neutrophil activation was done using DHR-reducing assay and cell proliferation was evaluated through CFSE-dilution assay in helper (CD4+) and cytotoxic (CD8+) T cells. Cytokine production by these T cell subsets was also assessed by intracellular staining using flow cytometry.

RESULTS

The results of this study revealed no change in neutrophil function between any of the mice groups compared to the untreated control group. Although significant changes were not detected in the proliferation of CD4+ T cells, decreased proliferation was observed in stimulated CD8+ T cells in the HDIR group. In contrast to IFN-ɣ, which showed no evident change in either of the T cell subsets after stimulation, IL-4 was rigorously dropped in stimulated CD4+ T cells in the HDIR group.

CONCLUSIONS

In summary, the results of this study indicated that the administration of LDIR to mice before HDIR was not able to reduce the detrimental effects of HDIR in our experimental setting. Instead, we observed a mitigating effect of LDIR when administered after the challenge dose. This suggests that not only the dose and duration but also the order of LDIR relative to HDIR affects its efficacy.

A Review of Crucial Radiological Investigations in the Management of COVID-19 Cases

Chest X-ray, chest CT, and lung ultrasound are the most common radiological interventions used in the diagnosis and management of coronavirus disease 2019 (COVID-19) patients. The purpose of this literature review, which was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, is to determine which radiological investigation is crucial for that purpose. PubMed, Medline, American Journal of Radiology (AJR), Public Library of Science (PLOS), Elsevier, National Center for Biotechnology Information (NCBI), and ScienceDirect were explored. Seventy-two articles were reviewed for potential inclusion, including 50 discussing chest CT, 15 discussing chest X-ray, five discussing lung ultrasound, and two discussing COVID-19 epidemiology. The reported sensitivities and specificities for chest CT ranged from 64 to 98% and 25 to 88%, respectively. The reported sensitivities and specificities for chest X-rays ranged from 33 to 89% and 11.1 to 88.9%, respectively. The reported sensitivities and specificities for lung ultrasound ranged from 93 to 96.8% and 21.3 to 95%, respectively. The most common findings on chest CT include ground glass opacities and consolidation. The most common findings on chest X-rays include opacities, consolidation, and pleural effusion. The data indicate that chest CT is the most effective radiological tool for the diagnosis and management of COVID-19 patients. The authors support the continued use of reverse transcription polymerase chain reaction (RT-PCR), along with physical examination and contact history, for such diagnosis. Chest CT could be more appropriate in emergency situations when quick triage of patients is necessary before RT-PCR results are available. CT can also be used to visualize the progression of COVID-19 pneumonia and to identify potential false positive RT-PCR results. Chest X-ray and lung ultrasound are acceptable in situations where chest CT is unavailable or contraindicated.

Steroid exposure and outcome in COVID-19 pneumonia

Background

Corticosteroids are used to treat COVID-19 pneumonia. However, the optimal dose is unclear. This study describes the association between corticosteroid exposure with disease severity and outcome in COVID-19 pneumonia.

Methods

This is a single-centre retrospective, observational study including adult ICU patients who received systemic corticosteroids for COVID-19 pneumonia between March 2020 and March 2021. We recorded patient characteristics, disease severity, total steroid exposure, respiratory support and gas exchange data, and 90-day mortality.

Results

We included 362 patients. We allocated patients to groups with increasing disease severity according to the highest level of respiratory support that they received: high-flow nasal oxygen or continuous positive airway pressure (HFNO/CPAP) in 12.7%, invasive mechanical ventilation (IMV) in 61.6%, and extracorporeal membrane oxygenation (ECMO) in 25.7%. For these three groups, the median (inter-quartile range [IQR]) age was 61 (54-71) vs 58 (50-66) vs 46 (38-53) yr, respectively (P<0.001); median (IQR) APACHE (Acute Physiology and Chronic Health Evaluation) II scores were 12 (9-15) vs 14 (12-18) vs 15 (12-17), respectively (P=0.006); the median (IQR) lowest P a O 2 /FiO₂ ratio was 15.1 (11.8-21.7) vs 15.1 (10.7-22.2) vs 9.5 (7.9-10.9) kPa, respectively (P<0.001). Ninety-day mortality was 9% vs 27% vs 37% (P=0.002). Median (IQR) dexamethasone-equivalent exposure was 37 (24-62) vs 174 (86-504) vs 535 (257-1213) mg (P<0.001). 'Pulsed' steroids were administered to 26% of the IMV group and 48% of the ECMO group. Patients with higher disease severity who received pulse steroids had a higher 90-day mortality.

Conclusions

Corticosteroid exposure increased with the severity of COVID-19 pneumonia. Pulsed dose steroids were used more frequently in patients receiving greater respiratory support. Future studies should address patient selection and outcomes associated with pulsed dose steroids in patients with severe and deteriorating COVID-19 pneumonia.

Relation between Cytokine Levels and Pulmonary Dysfunction in COVID-19 Patients: A Case-Control Study

Aim: The study aimed to assess the relationships between serum cytokine levels and pulmonary dysfunctions in individuals with COVID-19. These correlations may help to suggest strategies for prevention and therapies of coronavirus disease. Patients and methods: Fifty healthy participants and one hundred COVID-19 patients participated in this study. COVID-19 participants were subdivided into moderate and severe groups based on the severity of their symptoms. In both patients and healthy controls, white blood cells (WBCs) and lymphocytes counts and serum C-reactive protein (CRP), interleukin (IL)-1, IL-4, IL-6, IL-18, and IL-35 levels were estimated. All the patients were examined by chest computed tomography (CT) and the COVID-19 Reporting and Data System (CO-RADS) score was assessed. Results: All COVID-19 patients had increased WBCs count and CRP, IL-1β, IL-4, IL-6, IL-18, and IL-35 serum levels than healthy controls. Whereas WBCs, CRP, and cytokines like IL-6 showed significantly higher levels in the severe group as compared to moderate patients, IL-4, IL-35, and IL-18 showed comparable levels in both disease groups. Lymphocytes count in all patient groups exhibited a significant decrease as compared to the heathy controls and it was significantly lower in severe COVID-19 than moderate. Furthermore, CO-RADS score was positively connected with WBCs count as well as CRP and cytokine (IL-35, IL-18, IL-6, IL-4 and IL-1β) levels in both groups. CO-RADS score, also demonstrated a positive correlation with lymphocytes count in the moderate COVID-19 patients, whereas it demonstrated a negative correlation in the severe patients. The receiver operator characteristic (ROC) curve analysis indicated that IL-1β, IL-4, IL-18, and IL-35 were fair (acceptable) predictors for COVID-19 in moderate cases. Whereas IL-6 was good predictor of COVID-19 in severe cases (AUC > 0.800), IL-18 and IL-35 were fair. Conclusion: Severe COVID-19 patients, compared to individuals with moderate illness and healthy controls, had lower lymphocyte counts and increased CRP with greater WBCs counts. In contrast to moderate COVID-19 patients, severe COVID-19 patients had higher levels of IL-6, but IL-4, IL-18, and IL-35 between both illness categories were at close levels. IL-6 level was the most potent predictor of COVID-19 progress and severity. CO-RADS 5 was the most frequent category in both moderate and severe cases. Patients with a typical CO-RADS involvement had a higher CRP and cytokine (IL-1β, IL-6, IL-4, IL-18, and IL-35) levels and WBCs count with a lower lymphocyte number than the others. Cytokine and CRP levels as well as WBCs and lymphocyte counts were considered surrogate markers of severe lung affection and pneumonia in COVID 19 patients.

Submillisievert CT chest for COVID-19 patients in a rural hospital with limited resources

Background

This is a secondary analysis of prospectively acquired data approved by the hospital institutional board committee. We performed a retrospective chart review of 463 patients who underwent a CT Chest for suspected COVID-19 infection between April 1st, 2020, and March 31st, 2021. Patients were grouped based on the CT chest obtained protocol: ultra-low dose or full dose. The likelihood of suspicion of COVID-19 infection was classified on a Likert scale based on the probability of pulmonary involvement. For each group, the sensitivity and specificity of CT were compared to nasopharyngeal swab as standard of reference. The median dose length product and duration of apnea were compared between both groups using two-tailed Mann–Whitney U test. The aim of this study is to share our experience of reducing radiation dose in COVID-19 patients by using an ultra-low dose CT chest protocol on a 16 row multidetector CT scan in a hospital with limited resources.

Results

Two hundred sixty-nine patients underwent a full dose CT and 194 patients an ultra-low dose CT. In the former group, the median dose length product was 341.11 mGy*cm [Interquartile range (IQR), 239.1–443.2] and the median duration of apnea was 13.29 s [IQR, 10.85–15.73]. In the latter group, the median dose length product was 30.8 mGy*cm [IQR, 28.9–32.7] and median duration of apnea was 8.27 s [IQR, 7.69–8.85]. The sensitivity of the ultra-low dose CT was 91.2% and that of the full dose was 94%.

Conclusion

A 90% reduction in estimated dose and 38% reduction in apnea duration could be achieved using an ultra-low dose CT chest protocol on a 16-row MDCT without significant loss in the sensitivity of CT to detect COVID-related parenchymal involvement.

COVID-19 pneumonia: lessons learned, challenges, and preparing for the future

Coronavirus disease 2019 (COVID-19) is a viral disease that causes life-threatening health problems during acute illness, causing a pandemic and millions of deaths. Although computed tomography (CT) was used as a diagnostic tool for COVID-19 in the early period of the pan demic due to the inaccessibility or long duration of the polymerase chain reaction tests, cur rent studies have revealed that CT scan should not be used to diagnose COVID-19. However, radiologic findings are vital in assessing pneumonia severity and investigating complications in patients with COVID-19. Long-term symptoms, also known as long COVID, in people recovering from COVID-19 affect patients' quality of life and cause global health problems. Herein, we aimed to summarize the lessons learned in COVID-19 pneumonia, the challenges in diagnosing the disease and complications, and the prospects for future studies.

Contribution of Erythrocyte Sedimentation Rate to Predict Disease Severity and Outcome in COVID-19 Patients

Aim

The use of erythrocyte sedimentation rate (ESR) in coronavirus disease 2019 (COVID-19) to determine disease severity and prognosis is limited. This study aimed to interrogate the diagnostic and prognostic role of ESR compared to other acute-phase reactants.

Method

This retrospective cross-sectional study included 493 confirmed and hospitalized adult COVID-19 patients. Pneumonia, radiological severity, oxygen, intensive care requirements, mortality, ESR, and other acute-phase reactant values were recorded. Logistic regression and ROC analysis identified the effect of ESR on mortality and the sensitivity and specificity of the optimal cutoff values of ESR for the prediction of pneumonia, intensive care needs, and mortality and compared these with values for CRP.

Results

Of patients, 346 (70.2%) had pneumonia, 98 (19.9%) required intensive care, 183 (37.1%) required oxygen support, and 62 (12.6%) died. ESR data were obtained for 278 patients. Among patients, 80.2% had ESR above 20 mm/h, with a median value of 53 (interquartile range: 49). ESR was higher among those with pneumonia (p < 0.001), requiring oxygen (p < 0.001), and requiring intensive care (p=0.003) compared to those without these, and in exitus patients (p=0.043) compared to survivors. Logistic regression analysis identified that ESR did not impact mortality. ROC analysis found the AUC, cutoff, sensitivity, and specificity results of ESR for pneumonia were 0.827, 37 mm/h, 77%, and 78%; for intensive care were 0.625, 50 mm/h, 74%, and 52; and for mortality were 0.606, 51 mm/h, 71%, and 49%, respectively. However, ROC analysis values for CRP were superior to ESR for all these categories.

Conclusion

ESR increased in COVID-19 patients in the presence of pneumonia and severe disease; however, it was not prognostic. Sensitivity and specificity values for pneumonia, intensive care requirements, and mortality were lower than those for CRP.

The Use of Chest Radiographs and Machine Learning Model for the Rapid Detection of Pneumonitis in Pediatric

Pneumonia is a common lung disease that is the leading cause of death worldwide. It primarily affects children, accounting for 18% of all deaths in children under the age of five, the elderly, and patients with other diseases. There is a variety of imaging diagnosis techniques available today. While many of them are becoming more accurate, chest radiographs are still the most common method for detecting pulmonary infections due to cost and speed. A convolutional neural network (CNN) model has been developed to classify chest X-rays in JPEG format into normal, bacterial pneumonia, and viral pneumonia. The model was trained using data from an open Kaggle database. The data augmentation technique was used to improve the model's performance. A web application built with NextJS and hosted on AWS has also been designed. The model that was optimized using the data augmentation technique had slightly better precision than the original model. This model was used to create a web application that can process an image and provide a prediction to the user. A classification model was developed that generates a prediction with 78 percent accuracy. The precision of this calculation could be improved by increasing the epoch, among other subjects. With the help of artificial intelligence, this research study was aimed at demonstrating to the general public that deep-learning models can be created to assist health professionals in the early detection of pneumonia.

Fungal colonization and infections in patients with COVID-19 in intensive care units: A real-life experience at a tertiary-care hospital

PURPOSE

To evaluate the management of patients with COVID-19 in the intensive care units (ICUs) with fungal infection/colonization and to highlight diagnostic problems in these patients.

METHODS

We included all patients with a COVID-19 diagnosis who were aged ≥18 years and followed in the ICU for the first 8 months. Patient data were obtained from medical records. We compared the risk factors, laboratory data, and outcomes of patients with fungal infection/colonization.

RESULTS

A total of 118 patients (81 men and 37 women) were included. The mean age was 70.3 ± 14.8 (35-94) years. Of the patients, 79 (66.9%) patients were ≥65 years old. Fungal infection/colonization was detected in 39 (33.1%) patients. Fungi were isolated from 34 (28.8%) patients. Ten fungal species were isolated from 51 samples (the most common being Candida albicans). Three patients (2.5%) had proven candidemia. We observed two (1.7%) possible cases of COVID-19-associated pulmonary aspergillosis (CAPA). Eighteen patients (15.3%) underwent antifungal therapy. The risk of fungal infection/colonization increased as the duration of invasive mechanical ventilation increased. The fatality rate was 61.9% and increased with age and the use of mechanical ventilation. The fatality rate was 4.2-times-higher and the use of mechanical ventilation was 35.9-times-higher in the patients aged ≥65 years than in the patients aged <65 years. No relationship was found between fungal colonization/infection, antifungal treatment, and the fatality rate.

CONCLUSION

During the pandemic, approximately one-third of the patients in ICUs exhibited fungal infection/colonization. Candida albicans was the most common species of fungal infection as in the pre-pandemic area. Because of the cross-contamination risk, we performed diagnostic bronchoscopy and control thorax computed tomography during the ICU stay, and our patients mainly received empirical antifungal therapy.

VECTOR: An algorithm for the detection of COVID-19 pneumonia from velcro-like lung sounds

The coronavirus disease 2019 (COVID-19) has severely stressed the sanitary systems of all countries in the world. One of the main issues that physicians are called to tackle is represented by the monitoring of pauci-symptomatic COVID-19 patients at home and, generally speaking, everyone the access to the hospital might or should be severely reduced. Indeed, the early detection of interstitial pneumonia is particularly relevant for the survival of these patients. Recent studies on rheumatoid arthritis and interstitial lung diseases have shown that pathological pulmonary sounds can be automatically detected by suitably developed algorithms. The scope of this preliminary work consists of proving that the pathological lung sounds evidenced in patients affected by COVID-19 pneumonia can be automatically detected as well by the same class of algorithms. In particular the software VECTOR, suitably devised for interstitial lung diseases, has been employed to process the lung sounds of 28 patient recorded in the emergency room at the university hospital of Modena (Italy) during December 2020. The performance of VECTOR has been compared with diagnostic techniques based on imaging, namely lung ultrasound, chest X-ray and high resolution computed tomography, which have been assumed as ground truth. The results have evidenced a surprising overall diagnostic accuracy of 75% even if the staff of the emergency room has not been suitably trained for lung auscultation and the parameters of the software have not been optimized to detect interstitial pneumonia. These results pave the way to a new approach for monitoring the pulmonary implication in pauci-symptomatic COVID-19 patients.

Serum albumin levels monitoring in ICU in early days and mortality risk association in patients with moderate to severe COVID-19 pneumonia

Objective

To establish correlation between serum albumin during early days of ICU admission and risk of death in COVID-19 pneumonia.

Methods

In this retrospective study, we included 76 patients hospitalized in ICU, who stayed for at least four days with COVID-19 pneumonia, from May 1, 2020 to June 30, 2020 in Lahore Health Care Hospital and Al-Shafi Hospital. Patients were labelled as COVID-19 pneumonia on radiological basis as bilateral 'ground-glass opacity' in lower zones and RT-PCR positive result in nasopharyngeal swab. All patients were oxygen dependent, either on high flow oxygen via non rebreathing mask or invasive positive pressure ventilation support. Serum albumin levels were measured daily from first day to fourth day of ICU admission. The data was analyzed using SPSS version 26 and Microsoft excel 2016.

Results

Out of 76 patients of COVID-19 pneumonia admitted in ICU who stayed for more than four days, 38 patients expired. The mean age of all the patients was 58.9±12.56 years, 38(50%) of the patients were ≥60 years and 49 (62%) of them were male. On day four of ICU admission, mean serum albumin of discharged patients was 3.83±0.22 g/dl while mean serum albumin level of expired patients was 2.96±0.46 g/dl. Strong negative correlation (r = -767) was found between decrease in serum albumin level and increase number of deaths from COVID-19 pneumonia. Weak correlation was observed between increase in serum CRP and increase number of deaths in the same patients.

Conclusion

Daily monitoring of serum albumin level of COVID-19 pneumonia patients can be used as a biological marker for monitoring of cytokine storm and risk of death in COVID-19 pneumonia.

Computed tomography evaluation of pancreatic steatosis: correlation with COVID-19 prognosis

Aim: To investigate the relationship between pancreatic steatosis (PS) assessed on computed tomography (CT) and COVID-19 prognosis. Materials & methods: This retrospective study covers 396 patients with COVID-19 (mean age: 52.50 ± 16.86 years), who underwent unenhanced chest CT. PS was compared with clinical findings, comorbidities, requirements for hospitalization, intubation and intensive care unit (ICU), length of hospitalization and death. Results: PS was found to be strongly correlated with the severity of clinical findings and hospitalization rates (p < 0.001). In hospitalized patients, length of hospitalization (p = 0.002) and rates of ICU requirement (p = 0.003) were higher in patients with PS. Conclusion: PS, correlated with clinical severity and hospitalization requirement, is an independent risk factor for COVID-19.

Fat accumulation in the pancreas that is associated with obesity and metabolic syndrome can be used for estimating the clinical course of patients with COVID-19. Fat accumulation was determined by comparing the pancreas and spleen using computed tomography tools. In our study with 396 COVID-19 patients, the patients with fatty pancreas clearly seemed to have more severe clinical findings. Similarly, the rates of the requirement for hospitalization/intensive care unit and length of hospitalization were higher than in patients without fatty pancreas. The median length of hospitalization was 9 days in patients with fatty pancreas and 6 days in patients without fatty pancreas. However, death rates were only slightly higher in patients with fatty pancreas.

In COVID-19 patients, the patients with fatty pancreas assessed using computed tomography have a more severe clinical course, higher rates of hospitalization/ICU requirement and increased length of hospitalization compared with the patients without fatty pancreas. #COVID-19 #computed tomography #fatty pancreas.

Efficacy of chest X-ray in the diagnosis of COVID-19 pneumonia: comparison with computed tomography through a simplified scoring system designed for triage

Background

There is no consensus on the imaging modality to be used in the diagnosis and management of Coronavirus disease 2019 (COVID-19) pneumonia. The purpose of this study was to make a comparison between computed tomography (CT) and chest X-ray (CXR) through a scoring system that can be beneficial to the clinicians in making the triage of patients diagnosed with COVID-19 pneumonia at their initial presentation to the hospital.

Results

Patients with a negative CXR (30.1%) had significantly lower computed tomography score (CTS) (p < 0.001). Among the lung zones where the only infiltration pattern was ground glass opacity (GGO) on CT images, the ratio of abnormality seen on CXRs was 21.6%. The cut-off value of X-ray score (XRS) to distinguish the patients who needed intensive care at follow-up (n = 12) was 6 (AUC = 0.933, 95% CI = 0.886–0.979, 100% sensitivity, 81% specificity).

Conclusions

Computed tomography is more effective in the diagnosis of COVID-19 pneumonia at the initial presentation due to the ease detection of GGOs. However, a baseline CXR taken after admission to the hospital can be valuable in predicting patients to be monitored in the intensive care units.

COVID-19-Related Lung Involvement at Different Time Intervals: Evaluation of Computed Tomography Images With Semiquantitative Scoring System and COVID-19 Reporting and Data System Scoring

INTRODUCTION

This study aimed to evaluate the frequency of typical and atypical thoracic CT findings in patient groups diagnosed during different periods of the pandemic, examine disease severity using radiological scoring methods, and determine the relationship between atypical CT findings and disease severity.

MATERIALS AND METHODS

One hundred fifty-one patients with positive reverse transcription polymerase chain reaction (RT-PCR) test and thoracic CT scan were included in the study. The patients were divided into two groups as group 1 (March to August 2020) diagnosed in the first six months of the pandemic and group 2 (September 2020 to February 2021) diagnosed in the second six months. CT images of the patients were analyzed for the frequency of typical and atypical findings. Evaluation was made in terms of disease suspicion and severity by scoring methods, and the relationship between atypical findings and disease severity was examined.

RESULTS

There was no statistically significant difference between the frequency and distribution patterns of typical CT findings observed in both groups. The most common atypical finding in both groups was nodular lesions. Central distribution, one of the atypical findings, was not seen in group 1, whereas it was present in nine patients in group 2 (p=0.001). The mean CT severity score was higher in group 2, and there was a statistically significant difference between the mean CT scores of both groups (p<0.001). In addition, six (7.2%) patients in group 1 and 34 (50%) patients in group 2 had CT scores above the cut-off value (p<0.001). There was no statistically significant relationship between atypical findings and severity score.

CONCLUSION

Other diseases and atypical findings that may accompany COVID-19 pneumonia may increase the rate of misdiagnosis. In the diagnosis of the disease, clinical signs and symptoms and radiological findings should be evaluated together, and it should be kept in mind that lung findings in thorax CT change over time.

CXCL10 levels at hospital admission predict COVID-19 outcome: hierarchical assessment of 53 putative inflammatory biomarkers in an observational study

Background

Host inflammation contributes to determine whether SARS-CoV-2 infection causes mild or life-threatening disease. Tools are needed for early risk assessment.

Methods

We studied in 111 COVID-19 patients prospectively followed at a single reference Hospital fifty-three potential biomarkers including alarmins, cytokines, adipocytokines and growth factors, humoral innate immune and neuroendocrine molecules and regulators of iron metabolism. Biomarkers at hospital admission together with age, degree of hypoxia, neutrophil to lymphocyte ratio (NLR), lactate dehydrogenase (LDH), C-reactive protein (CRP) and creatinine were analysed within a data-driven approach to classify patients with respect to survival and ICU outcomes. Classification and regression tree (CART) models were used to identify prognostic biomarkers.

Results

Among the fifty-three potential biomarkers, the classification tree analysis selected CXCL10 at hospital admission, in combination with NLR and time from onset, as the best predictor of ICU transfer (AUC [95% CI] = 0.8374 [0.6233–0.8435]), while it was selected alone to predict death (AUC [95% CI] = 0.7334 [0.7547–0.9201]). CXCL10 concentration abated in COVID-19 survivors after healing and discharge from the hospital.

Conclusions

CXCL10 results from a data-driven analysis, that accounts for presence of confounding factors, as the most robust predictive biomarker of patient outcome in COVID-19.

Graphic abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s10020-021-00390-4.

Imaging approach to COVID-19 associated pulmonary embolism

The novel coronavirus disease-2019 (COVID-19) illness and deaths, caused by the severe acute respiratory syndrome coronavirus-2, continue to increase. Multiple reports highlight the thromboembolic complications, such as pulmonary embolism (PE), in COVID-19. Imaging plays an essential role in the diagnosis and management of COVID-19 patients with PE. There continues to be a rapid evolution of knowledge related to COVID-19 associated PE. This review summarises the current understanding of prevalence, pathophysiology, role of diagnostic imaging modalities, and management, including catheter-directed therapy for COVID-19 associated PE. It also describes infection control considerations for the radiology department while providing care for patients with COVID-19 associated PE.

The Impact of the COVID-19 Pandemic on Dementia Risk: Potential Pathways to Cognitive Decline

BACKGROUND

Coronavirus disease 2019 (COVID-19), the far-reaching pandemic, has infected approximately 185 million of the world's population to date. After infection, certain groups, including older adults, men, and people of color, are more likely to have adverse medical outcomes. COVID-19 can affect multiple organ systems, even among asymptomatic/mild severity individuals, with progressively worse damage for those with higher severity infections.

SUMMARY

The COVID-19 virus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), primarily attaches to cells through the angiotensin-converting enzyme 2 (ACE2) receptor, a universal receptor present in most major organ systems. As SARS-CoV-2 binds to the ACE2 receptor, its bioavailability becomes limited, thus disrupting homeostatic organ function and inducing an injury cascade. Organ damage can then arise from multiple sources including direct cellular infection, overactive detrimental systemic immune response, and ischemia/hypoxia through thromboembolisms or disruption of perfusion. In the brain, SARS-CoV-2 has neuroinvasive and neurotropic characteristics with acute and chronic neurovirulent potential. In the cardiovascular system, COVID-19 can induce myocardial and systemic vascular damage along with thrombosis. Other organ systems such as the lungs, kidney, and liver are all at risk for infection damage. Key Messages: Our hypothesis is that each injury consequence has the independent potential to contribute to long-term cognitive deficits with the possibility of progressing to or worsening pre-existing dementia. Already, reports from recovered COVID-19 patients indicate that cognitive alterations and long-term symptoms are prevalent. This critical review highlights the injury pathways possible through SARS-CoV-2 infection that have the potential to increase and contribute to cognitive impairment and dementia.

Endovascular Aortic Aneurysm Repair during the Early Days of the COVID-19 Outbreak

Introduction: We report the results of endovascular aortic repair (EVAR) in three patients during the COVID-19 pandemic. Materials and Methods: Three patients were diagnosed with abdominal aortic aneurysm. All three patients were male and aged 68 years. The diameter of the aneurysm was larger than 65 mm and was considered suitable for EVAR. Thorax tomography was performed to exclude SARS-CoV-2 infection before the procedure. Results: We performed EVAR under general anesthesia. “Priority Level” was based on the guideline of the American College of Surgeons. The procedure was conducted in the angiography laboratory by taking advanced precautions. Intensive care admission was avoided. The postoperative period was uneventful, and all patients were discharged without any condition associated with COVID-19. There were no mortality, rupture, secondary intervention, major adverse event, limb occlusion, and 60-day read-mission. Conclusions: During the pandemic, EVAR can be performed for symptomatic abdominal aortic aneurysm with a diameter of more than 65 mm. Thorax tomography is safe to exclude SARS-CoV-2 infection. However, tomographic angiography to monitor patients may be difficult during the pandemic.

Factors Predicting Outcome in Intensive Care Unit-Admitted COVID-19 Patients: Using Clinical, Laboratory, and Radiologic Characteristics

PURPOSE

To investigate the factors contributing to mortality in coronavirus disease 2019 (COVID-19) patients admitted in the intensive care unit (ICU) and design a model to predict the mortality rate.

METHOD

We retrospectively evaluated the medical records and CT images of the ICU-admitted COVID-19 patients who had an on-admission chest CT scan. We analyzed the patients' demographic, clinical, laboratory, and radiologic findings and compared them between survivors and nonsurvivors.

RESULTS

Among the 121 enrolled patients (mean age, 62.2 ± 14.0 years; male, 82 (67.8%)), 41 (33.9%) survived, and the rest succumbed to death. The most frequent radiologic findings were ground-glass opacity (GGO) (71.9%) with peripheral (38.8%) and bilateral (98.3%) involvement, with lower lobes (94.2%) predominancy. The most common additional findings were cardiomegaly (63.6%), parenchymal band (47.9%), and crazy-paving pattern (44.4%). Univariable analysis of radiologic findings showed that cardiomegaly (p : 0.04), pleural effusion (p : 0.02), and pericardial effusion (p : 0.03) were significantly more prevalent in nonsurvivors. However, the extension of pulmonary involvement was not significantly different between the two subgroups (11.4 ± 4.1 in survivors vs. 11.9 ± 5.1 in nonsurvivors, p : 0.59). Among nonradiologic factors, advanced age (p : 0.002), lower O2 saturation (p : 0.01), diastolic blood pressure (p : 0.02), and hypertension (p : 0.03) were more commonly found in nonsurvivors. There was no significant difference between survivors and nonsurvivors in terms of laboratory findings. Three following factors remained significant in the backward logistic regression model: O2 saturation (OR: 0.91 (95% CI: 0.84-0.97), p : 0.006), pericardial effusion (6.56 (0.17-59.3), p : 0.09), and hypertension (4.11 (1.39-12.2), p : 0.01). This model had 78.7% sensitivity, 61.1% specificity, 90.0% positive predictive value, and 75.5% accuracy in predicting in-ICU mortality.

CONCLUSION

A combination of underlying diseases, vital signs, and radiologic factors might have prognostic value for mortality rate prediction in ICU-admitted COVID-19 patients.

Diagnostic Performance of COVID-19 Reporting and Data System Classification Across Residents and Radiologists: A Retrospective Study

OBJECTIVE

The aim of the study was to evaluate the interobserver agreement and diagnostic accuracy of COVID-19 Reporting and Data System (CO-RADS), in patients suspected COVID-19 pneumonia.

METHODS

Two hundred nine nonenhanced chest computed tomography images of patients with clinically suspected COVID-19 pneumonia were included. The images were evaluated by 2 groups of observers, consisting of 2 residents-radiologists, using CO-RADS. Reverse transcriptase-polymerase chain reaction (PCR) was used as a reference standard for diagnosis in this study. Sensitivity, specificity, area under receiver operating characteristic curve (AUC), and intraobserver/interobserver agreement were calculated.

RESULTS

COVID-19 Reporting and Data System was able to distinguish patients with positive PCR results from those with negative PCR results with AUC of 0.796 in the group of residents and AUC of 0.810 in the group of radiologists. There was moderate interobserver agreement between residents and radiologist with κ values of 0.54 and 0.57.

CONCLUSIONS

The diagnostic performance of CO-RADS for predicting COVID-19 pneumonia showed moderate interobserver agreement between residents and radiologists.

Atypical chest CT findings of COVID-19 pneumonia: a pictorial review

Coronavirus disease 2019 (COVID-19) first emerged in China and rapidly spread in the world causing a pandemic. Chest computed tomography (CT) continues to play an important role in the diagnosis and follow-up of the disease due to shortcomings of the real-time reverse transcription-polymerase chain reaction test, which is the gold standard in the diagnosis of this disease. Typical chest CT findings of COVID-19 pneumonia have been widely reported in the literature. However, atypical findings such as central involvement, peribronchovascular involvement, isolated upper lobe involvement, nodular involvement, lobar consolidation, solitary involvement, pleural and pericardial fluid, and subpleural sparing can also be seen. Knowing these atypical findings is important to avoid misdiagnosis. This review summarizes the atypical findings that can be seen in the course of the disease and may be confused with other diseases.

A comparison of clinical, laboratory and chest CT findings of laboratory-confirmed and clinically diagnosed COVID-19 patients at first admission

PURPOSE

This study aims to identify chest computed tomography (CT) characteristics of coronavirus disease 2019 (COVID-19), investigate the association between CT findings and laboratory or demographic findings, and compare the accuracy of chest CT with reverse transcription-polymerase chain reaction (RT-PCR).

METHODS

Overall, 120 of 159 consecutive cases isolated due to suspected COVID-19 at our hospital between 17 and 25 March 2020 were included in this retrospective study. All patients underwent both chest CT and RT-PCR at first admission. The patients were divided into two groups: laboratory-confirmed COVID-19 and clinically diagnosed COVID-19. Clinical findings, laboratory findings, radiologic features and CT severity index (CT-SI) of the patients were noted. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of chest CT were calculated for the diagnosis of COVID-19, using RT-PCR as reference.

RESULTS

The laboratory-confirmed and clinically diagnosed COVID-19 groups consisted of 69 (M/F 43/26, mean age 50.9±14.0 years) and 51 patients (M/F 24/27, mean age 50.9±18.8 years), respectively. Dry cough (62.3% vs. 52.9%), fever (30.4% vs. 25.5%) and dyspnea (23.2% vs. 27.5%) were the most common admission symptoms in the laboratory-confirmed and clinically diagnosed COVID-19 groups, respectively. Bilateral multilobe involvement (83.1% vs. 57.5%), peripheral distribution (96.9% vs. 97.5%), patchy shape (75.4% vs. 70.0%), ground-glass opacities (GGO) (96.9% vs. 100.0%), vascular enlargement (56.9% vs. 50.0%), intralobular reticular density (40.0% vs. 40.0%) and bronchial wall thickening (27.7% vs. 45.0%) were the most common CT findings in the laboratory-confirmed and clinically diagnosed COVID-19 subgroups, respectively. Except for the bilateral involvement and white blood cell (WBC) count, no difference was found between the clinical, laboratory, and parenchymal findings of the two groups. Positive correlation was found between CT-SI and, lactate dehydrogenase (LDH) and C-reactive protein (CRP) values in the laboratory-confirmed COVID-19 subgroup. Chest CT and RT-PCR positivity rates among patients with suspected COVID-19 were 87.5% (105/120) and 57.5% (69/120), respectively. The sensitivity, specificity, PPV, NPV and accuracy rates of chest CT were determined as 94.2% (95% confidence interval [CI], 85.8-98.4), 21.57% (95% CI, 11.3-35.3), 61.90% (95% CI, 58.2-65.5), 73.3% (95% CI, 48.2-89.1) and 63.3% (95% CI, 54.1-71.9), respectively.

CONCLUSION

Chest CT has high sensitivity and low specificity in the diagnosis of COVID-19. The clinical, laboratory, and CT findings of laboratory-confirmed and clinically diagnosed COVID-19 patients are similar.

An Illustrated Guide to the Imaging Evolution of COVID in Non-Epidemic Areas of Southeast China

Purpose: By analyzing the CT manifestations and evolution of COVID in non-epidemic areas of southeast China, analyzing the developmental abnormalities and accompanying signs in the early and late stages of the disease, providing imaging evidence for clinical diagnosis and identification, and assisting in judging disease progression and monitoring prognosis. Methods: This retrospective and multicenter study included 1,648 chest CT examinations from 693 patients with laboratory-confirmed COVID-19 infection from 16 hospitals of southeast China between January 19 and March 27, 2020. Six trained radiologists analyzed and recorded the distribution and location of the lesions in the CT images of these patients. The accompanying signs include crazy-paving sign, bronchial wall thickening, microvascular thickening, bronchogram sign, fibrous lesions, halo and reverse-halo signs, nodules, atelectasis, and pleural effusion, and at the same time, they analyze the evolution of the abovementioned manifestations over time. Result: There were 1,500 positive findings in 1,648 CT examinations of 693 patients; the average age of the patients was 46 years, including 13 children; the proportion of women was 49%. Early CT manifestations are single or multiple nodular, patchy, or flaky ground-glass-like density shadows. The frequency of occurrence of ground-glass shadows (47.27%), fibrous lesions (42.60%), and microvascular thickening (40.60%) was significantly higher than that of other signs. Ground-glass shadows increase and expand 3-7 days after the onset of symptoms. The distribution and location of lesions were not significantly related to the appearance time. Ground-glass shadow is the most common lesion, with an average absorption time of 6.2 days, followed by consolidation, with an absorption time of about 6.3 days. It takes about 8 days for pure ground-glass lesions to absorb. Consolidation change into ground glass or pure ground glass takes 10-14 days. For ground-glass opacity to evolve into pure ground-glass lesions, it takes an average of 17 days. For ground-glass lesions to evolve into consolidation, it takes 7 days, pure ground-glass lesions need 8 days to evolve into ground-glass lesions. The average time for CT signs to improve is 10-15 days, and the first to improve is the crazy-paving sign and nodules; while the progression of the disease is 6-12 days, the earliest signs of progression are air bronchogram signs, bronchial wall thickening, and bronchiectasis. There is no severe patient in this study. Conclusion: This study depicts the CT manifestation and evolution of COVID in non-epidemic origin areas, and provides valuable first-hand information for clinical diagnosis and judgment of patient's disease evolution and prediction.

Highlighting COVID-19: What the imaging exams show about the disease

Coronavirus disease 2019 (COVID-19), a global emergency, is caused by severe acute respiratory syndrome coronavirus 2. The gold standard for its diagnosis is the reverse transcription polymerase chain reaction, but considering the high number of infected people, the low availability of this diagnostic tool in some contexts, and the limitations of the test, other tools that aid in the identification of the disease are necessary. In this scenario, imaging exams such as chest X-ray (CXR) and computed tomography (CT) have played important roles. CXR is useful for assessing disease progression because it allows the detection of extensive consolidations, besides being a fast and cheap method. On the other hand, CT is more sensitive for detecting lung changes in the early stages of the disease and is also useful for assessing disease progression. Of note, ground-glass opacities are the main COVID-19-related CT findings. Positron emission tomography combined with CT can be used to evaluate chronic and substantial damage to the lungs and other organs; however, it is an expensive test. Lung ultrasound (LUS) has been shown to be a promising technique in that context as well, being useful in the screening and monitoring of patients, disease classification, and management related to mechanical ventilation. Moreover, LUS is an inexpensive alternative available at the bedside. Finally, magnetic resonance imaging, although not usually requested, allows the detection of pulmonary, cardiovascular, and neurological abnormalities associated with COVID-19. Furthermore, it is important to consider the challenges faced in the radiology field in the adoption of control measures to prevent infection and in the follow-up of post-COVID-19 patients.

A simplified alternative diagnostic algorithm for SARS-CoV-2 suspected symptomatic patients and confirmed close contacts (asymptomatic): A consensus of Latin American experts

INTRODUCTION

Latin America accounts for one-quarter of global COVID-19 cases and one-third of deaths. Inequalities in the region lead to barriers regarding the best use of diagnostic tests during the pandemic. There is a need for a simplified guideline, considering the region's health resources' low availability, international guidelines, medical literature, and local expertise.

METHODS

Nine experts from Latin American countries developed a simplified algorithm for COVID-19 diagnosis, using a modified Delphi method. Twenty-four questions related to diagnostic settings were proposed, followed by discussion of the literature and experts' experience.

RESULTS

The algorithm considers three timeframes (≤7 days, 8-13 days, and ≥ 14 days) and discusses diagnostic options for each one. SARS-CoV-2 rRT-PCR is the test of choice from day 1 to day 14 after symptom onset or close contact, although antigen testing may be used in particular situations, from days 5 to 7. Antibody assays may be used for confirmation, mainly after day 14. If the clinical suspicion is very high, but other tests are negative, these assays may be used as an adjunct to decision-making from day 8 to day 13.

CONCLUSION

The proposed algorithm aims to support COVID-19 diagnosis decision-making in Latin America.

Diagnostic performance of Radiological Society of North America structured reporting language for chest computed tomography findings in patients with COVID-19

PURPOSE

To evaluate the diagnostic performance of the RSNA structured reporting language for chest CT findings in patients with COVID-19.

MATERIAL AND METHODS

Patients with suspected COVID-19 who underwent chest CT and RT-PCR tests were enrolled consecutively in this retrospective study, regardless of symptoms. Imaging findings were categorized as "typical", "indeterminate", "atypical", or "negative" according to RSNA reporting language and compared to RT-PCR. "Single, round GGO" and "single, peripheral GGO," do not fit the reporting language, were also analyzed as "indeterminate" patterns.

RESULTS

Of the 1186 patients included in the analysis, the diagnosis of COVID-19 was confirmed in 388 patients. Of the 388 patients, CT findings were categorized as "typical" in 248, "indeterminate" in 77, and "negative" in 63. The sensitivity, specificity, and accuracy of "typical" findings were 63.9, 99.0, and 87.5% for COVID-19, respectively. In addition to the "typical" findings, the highest diagnostic accuracy of 92.2% was achieved when the "single, peripheral GGO" and "single, round GGO" were considered to be CT-positive.

CONCLUSION

The RSNA reporting language has significant diagnostic performance for identifying COVID-19 pneumonia. CT findings that do not exactly fit the RSNA reporting language, such as "single, round GGO" and "single, peripheral GGO" improve diagnostic performance.

Corticosteroids in COVID-19: one size does not fit all

Edalatifardet al. [1], in a single-blind randomised controlled clinical trial, showed that methylprednisolone pulse administration (250 mg per day intravenously for 3 days) to hospitalised, not intubated patients with severe coronavirus disease 2019 (COVID-19), significantly improved survival and duration of recovery compared to standard care; the effect was more prominent in patients receiving noninvasive ventilation and reservoir mask support.

Organising pneumonia and acute fibrinous and organising pneumonia have been reported as the predominant patterns in pathological samples from COVID-19 patients. Critically ill COVID-19 patients may benefit even more from higher corticosteroid doses.https://bit.ly/3timqPM

Clinical characteristics of outpatients and inpatients with COVID-19 in Bushehr: a report from the south of Iran

Aim: To investigate clinical, laboratory and imaging features of COVID-19 patients in Bushehr, a southern province of Iran. Materials & methods: A total of 148 COVID-19 patients were enrolled. The patients were categorized into four groups including inpatients, outpatients, elderly and nonelderly. Clinical, laboratory and computed tomography characteristics were analyzed and compared. Results: Levels of erythrocyte sedimentation rate, CRP, lactate dehydrogenase and aspartate aminotransferas among inpatients were higher than outpatients. There were significant differences in the levels of creatinine and blood urine nitrogen between elderly and nonelderly patients. The incidence of ground-glass opacities in inpatients was significantly higher than in outpatients. Conclusion: COVID-19 is associated with more severe renal failure in elderly patients. Elderly patients with underlying conditions are at increased risk of severe progression of COVID-19.

Dandelion and focal crazy paving signs: the lung CT based predictors for evaluation of the severity of coronavirus disease

PURPOSE

To describe the radiological features of coronavirus disease 19 (COVID-19) and to explore the significant signs that indicate severity of disease.

MATERIALS AND METHODS

We collected data retrospectively of 180 cases of COVID-19, from 15 January 2020 to 31 March 2020, from both the Wuhan Zhongnan and Beijing Ditan Hospitals, including 103 cases of mild and 77 cases of severe pneumonia. All patients had their first chest computed tomography scan within five days of symptom onset. The dandelion sign was defined by a focal ground glass opacity (GGO) with a central thickening of the airway wall, and the focal crazy paving sign was defined by a focal GGO with thickening of the interlobular septa.

RESULTS

Consolidation presented in only 4.9% (5/103) of the mild pneumonia cases, which was significantly lower than that in severe pneumonia cases (70.1% 54/77), p < .001). Multifocal distribution and pure GGOs were observed more frequently in severe cases of pneumonia (p < .05). The dandelion sign was present in 86.4% (89/103) of the mild pneumonia cases, significantly more frequent than those with severe pneumonia (13.0% [10/77], p < .001). The focal crazy paving sign presented in 65.0% (67/103) of the mild pneumonia cases and was significantly more frequent than in severe cases (23.4% [18/77], p < .001). The hospital stay duration of the mild pneumonia group (13.6 ± 7.2 days) was significantly shorter than the severe pneumonia group (26.6 ± 11.7 days, p < .001).

CONCLUSIONS

Consolidation, pure GGO and multifocal distribution on a CT scan were associated with severe COVID-19. The dandelion and focal crazy paving signs indicate mild COVID-19.

The clinical findings and outcomes of symptomatic pregnant women diagnosed with or suspected of having coronavirus disease 2019 in a tertiary pandemic hospital in Istanbul, Turkey

AIM

To observe the clinical course of symptomatic pregnant women diagnosed with or suspected of having COVID-19.

METHODS

This study analyzed the clinical and laboratory results of 27 patients with real-time polymerase chain reaction (RT-PCR)-confirmed COVID-19 and 25 patients with a suspected COVID-19 diagnosis based on their symptoms and chest computed tomography (CT) findings. The patients' coagulation parameters and acute-phase reactants were evaluated both before and after treatment. The maternal and neonatal outcomes were also reviewed.

RESULTS

The mean duration of hospitalization was 6.1 ± 3 days. The gestational age of the patients ranged from 6w2d to 40w2d. Thirty-five patients' CT scan findings suggested viral pneumonia. Four patients delivered vaginally, and 10 patients underwent a cesarean section during the study period. Four of the cesarean deliveries were indicated due to COVID-19 hypoxemia-related fetal distress. Four patients were admitted to the intensive care unit (ICU) after the cesarean section.

CONCLUSION

Early hospitalization and medical treatment can alleviate symptoms, improve the clinical course and reduce the need for ICU in symptomatic pregnant patients with suspected or confirmed COVID-19. Chest CT scans are a suitable option for suspected but unconfirmed COVID-19 infection.

CT findings of 795 COVID-19 positive cases: a multicenter study in Egypt

Background

Corona Virus Disease 2019 (COVID-19) outbreak was officially announced as a global pandemic by the WHO on March 11th 2020. Thorough understanding of CT imaging features of COVID-19 is essential for effective patient management; rationalizing the need for relevant research. The aim of this study was to analyze the chest CT findings of patients with real-time polymerase chain reaction (RT-PCR) proved COVID-19 admitted to four Egyptian hospitals. The recently published RSNA expert consensus statement on reporting COVID-19 chest CT findings was taken into consideration.

Results

Normal CT “negative for COVID-19” was reported in 26.1% of our RT-PCR proved COVID-19 cases. In descending order of prevalence, imaging findings of the positive CT studies (73.9%) included GGO (69%), consolidation (49.7%), crazy paving (15.4%), and peri-lobular fibrosis (40.6%). These showed a dominantly bilateral (68.2%), peripheral (72.4%), and patchy (64.7%) distribution. Remarkably, thymic hyperplasia was identified in 14.3% of studies. According to the RSNA consensus, CT findings were classified as typical in 68.9%, indeterminate in 3.6%, and atypical in 1.4% of the evaluated CT studies.

Conclusion

Although COVID-19 cannot be entirely excluded by chest CT, it can be distinguished in more than two-thirds of cases; making CT a widely available, non-invasive, and rapid diagnostic tool.

CT chest findings in patients infected with COVID-19: review of literature

Background

Coronavirus disease 2019 (COVID-19) is a highly infectious disease causing severe respiratory distress syndrome that was first discovered by the end of 2019 in Wuhan, China.

Main text

A wide variety of CT findings in COVID-19 have been reported in different studies, and the CT findings differ according to the stage of the disease and disease severity and associated co-morbidities. We will discuss each sign separately and its importance in diagnosis and prognosis.

Conclusion

CT plays a pivotal role in the diagnosis and management of COVID-19 pneumonia. The typical appearance of COVID-19 pneumonia is bilateral patchy areas of ground glass infiltration, more in the lower lobes. The appearance of other signs like consolidation, air bronchogram, crazy pavement appearance, and air bubble signs appear during the course of the disease. In the context of pandemic, the CT chest can be used as a screening tool in symptomatic patients as it is cheaper, available, and time saving.

Clinical and radiological diagnosis of non-SARS-CoV-2 viruses in the era of COVID-19 pandemic

Following the announcement of the first coronavirus disease 2019 (COVID-19) case on 11 March 2020 in Turkey, we aimed to report the coinfection rates, and the clinical, laboratory, radiological distinctive features of viral pneumonia caused by viruses other than severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A cross-sectional study was conducted between 18 and 31 March 2020. COVID-19 suspected cases admitted to pandemic policlinic, who had nasopharyngeal swab specimens tested for both SARS-CoV-2 and other respiratory viral pathogens, were included. Among 112 patients, SARS-CoV-2 was detected in 34 patients (30%). Among the non-SARS-CoV-2 viruses (n = 25, 22%), metapneumovirus (n = 10) was the most frequent agent. There were two coinfections with SARS-CoV-2. Sputum was less in the SARS-CoV-2 group (P = .003). The leukocyte, lymphocyte, and thrombocyte count and C-reactive protein levels were the lowest in the SARS-CoV-2 group (P < .001, P = .04, P < .001, P = .007, respectively). Peripheral involvement (80% vs 20%; P ≤ .001), pure ground-glass opacity (65% vs 33%; P = .04), apicobasal gradient (60% vs 40%; P = .08), involvement of greater than or equal to three lobes (80% vs 40%; odds ratio: 6.0; 95% confidence interval: 1.33-27.05; P = .02), and consolidation with accompanying ground-glass opacity (4% vs 33%; P = .031) were more common in SARS-CoV-2 group. Some clinical, laboratory, and radiological findings may help in the differential diagnosis of non-SARS-CoV-2 viruses from COVID-19. However, coinfections may occur, and a non-SARS-CoV-2 pathogen positivity does not exclude accompanying COVID-19.

Paraspinal Myositis in Patients with COVID-19 Infection

Myalgia is a previously reported symptom in patients with COVID-19 infection; however, the presence of paraspinal myositis has not been previously reported. We report MR imaging findings of the spine obtained in a cohort of 9 patients with COVID-19 infection who presented to our hospital between March 3, 2020 and May 6, 2020. We found that 7 of 9 COVID-19 patients (78%) who underwent MR imaging of the spine had MR imaging evidence of paraspinal myositis, characterized by intramuscular edema and/or enhancement. Five of these 7 patients had a prolonged hospital course (greater than 25 days). Our knowledge of the imaging manifestations of COVID-19 infection is expanding. It is important for clinicians>a to be aware of the relatively high frequency of paraspinal myositis in this small cohort of patients with COVID-19 infection.

A Telemedicine Approach to Covid-19 Assessment and Triage

Covid-19 is a new highly contagious RNA viral disease that has caused a global pandemic. Human-to-human transmission occurs primarily through oral and nasal droplets and possibly through the airborne route. The disease may be asymptomatic or the course may be mild with upper respiratory symptoms, moderate with non-life-threatening pneumonia, or severe with pneumonia and acute respiratory distress syndrome. The severe form is associated with significant morbidity and mortality. While patients who are unstable and in acute distress need immediate in-person attention, many patients can be evaluated at home by telemedicine or videoconferencing. The more benign manifestations of Covid-19 may be managed from home to maintain quarantine, thus avoiding spread to other patients and health care workers. This document provides an overview of the clinical presentation of Covid-19, emphasizing telemedicine strategies for assessment and triage of patients. Advantages of the virtual visit during this time of social distancing are highlighted.

Imaging of COVID-19 pneumonia in children

OBJECTIVE

Literature related to the imaging of COVID-19 pneumonia, its findings and contribution to diagnosis and its differences from adults are limited in pediatric patients. The aim of this study was to evaluate chest X-ray and chest CT findings in children with COVID-19 pneumonia.

METHODS

Chest X-ray findings of 59 pediatric patients and chest CT findings of 22 patients with a confirmed diagnosis of COVID-19 pneumonia were evaluated retrospectively.

RESULTS

COVID-19 pneumonia was most commonly observed unilaterally and in lower zones of lungs in chest X-ray examinations. Bilateral and multifocal involvement (55%) was the most observed involvement in the CT examinations, as well as, single lesion and single lobe (27%) involvement were also detected. Pure ground-glass appearance was observed in 41%, ground-glass appearance and consolidation together was in 36%. While peripheral and central co-distribution of the lesions (55%) were frequently observed, the involvement of the lower lobes (69%) was significant. In four cases,the coexistence of multiple rounded multifocal ground-glass appearance and rounded consolidation were observed.

CONCLUSION

COVID-19 pneumonia imaging findings may differ in the pediatric population from adults. In diagnosis, chest X-ray should be preferred, CT should be requested if there is a pathologic finding on radiography that merits further evaluation and if clinically indicated.

ADVANCES IN KNOWLEDGE

Radiological findings of COVID-19 observed in children may differ from adults. Chest X-ray should often be sufficient in children avoiding additional irradiation, chest CT needs only be done in cases of clinical necessity.

Diagnosing COVID-19 in the Emergency Department: A Scoping Review of Clinical Examinations, Laboratory Tests, Imaging Accuracy, and Biases

OBJECTIVE

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged as a global pandemic in early 2020 with rapidly evolving approaches to diagnosing the clinical illness called coronavirus disease (COVID-19). The primary objective of this scoping review is to synthesize current research of the diagnostic accuracy of history, physical examination, routine laboratory tests, real-time reverse transcription-polymerase chain reaction (rRT-PCR), immunology tests, and computed tomography (CT) for the emergency department (ED) diagnosis of COVID-19. Secondary objectives included a synopsis of diagnostic biases likely with current COVID-19 research as well as corresponding implications of false-negative and false-positive results for clinicians and investigators.

METHODS

A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Scoping Review (PRISMA-ScR)-adherent synthesis of COVID-19 diagnostic accuracy through May 5, 2020, was conducted. The search strategy was designed by a medical librarian and included studies indexed by PubMed and Embase since January 2020.

RESULTS

A total of 1,907 citations were screened for relevance. Patients without COVID-19 are rarely reported, so specificity and likelihood ratios were generally unavailable. Fever is the most common finding, while hyposmia and hypogeusia appear useful to rule in COVID-19. Cough is not consistently present. Lymphopenia is the mostly commonly reported laboratory abnormality and occurs in over 50% of COVID-19 patients. rRT-PCR is currently considered the COVID-19 criterion standard for most diagnostic studies, but a single test sensitivity ranges from 60% to 78%. Multiple reasons for false-negatives rRT-PCR exist, including sample site tested and disease stage during which sample was obtained. CT may increase COVID-19 sensitivity in conjunction with rRT-PCR, but guidelines for imaging patients most likely to benefit are emerging. IgM and IgG serology levels are undetectable in the first week of COVID-19, but sensitivity (range = 82% to 100%) and specificity (range = 87% to 100%) are promising. Whether detectable COVID-19 antibodies correspond to immunity remains unanswered. Current studies do not adhere to accepted diagnostic accuracy reporting standards and likely report significantly biased results if the same tests were to be applied to general ED populations with suspected COVID-19.

CONCLUSIONS

With the exception of fever and disorders of smell/taste, history and physical examination findings are unhelpful to distinguish COVID-19 from other infectious conditions that mimic SARS-CoV-2 like influenza. Routine laboratory tests are also nondiagnostic, although lymphopenia is a common finding and other abnormalities may predict severe disease. Although rRT-PCR is the current criterion standard, more inclusive consensus-based criteria will likely emerge because of the high false-negative rate of PCR tests. The role of serology and CT in ED assessments remains undefined.

Optical theranostics and treatment dosimetry for COVID-19 lung complications: Towards increasing the survival rate of vulnerable populations

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The progression of the COVID-19 pandemic was slowed by implemented social isolation measures and adaptation of the healthcare system.

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Still, no effective treatments for severe lung complications are available for the most susceptible populations.

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Optical theranostics methods can identify COVID-19 pulmonary manifestations and provide automated and real-time control of the treatment dosimetry.

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Optical methods are flexible for combination with existing medical devices and drug repurposing protocols.

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Implementation of reliable and safe theranostics methods requires strong collaboration among researchers, industry and medical institutions.