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      Chest CT Findings in 2019 Novel Coronavirus (2019-nCoV) Infections from Wuhan, China: Key Points for the Radiologist

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      , MD
      Radiology
      Radiological Society of North America

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          Abstract

          A cluster of patients with an acute severe lower respiratory tract illness linked to a seafood and live animal market was reported by public health officials in Wuhan, Hubei Province, China, in December 2019 (1). Shortly thereafter, the Chinese Center for Disease Control and Prevention commenced an investigation into the outbreak. A previously unknown coronavirus (2019 novel coronavirus [2019-nCoV]) was isolated from respiratory epithelial cells in these patients (2). Initially confined to Wuhan, the infection has spread elsewhere, with 9720 confirmed cases in China and 106 confirmed cases in other countries—including six in the United States as of January 31, 2020 (3,4). Seven coronaviruses are known to cause disease in humans (2,5,6). Two strains, severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV), have zoonotic origins and have been linked to outbreaks of severe respiratory illnesses in humans (6). Although 2019-nCoV, too, is believed to have a zoonotic origin, person-to-person transmission has been documented (7). Most patients with 2019-nCoV infection present with fever (98%), cough (76%), and myalgia or fatigue (44%). Dyspnea has been reported in 55% of patients, developing in a median of 8 days after onset of initial symptoms. Six of 41 patients (15%) in the largest published cohort to date (8) died from their illness, and there are now 80 confirmed deaths (4). Limited information exists regarding chest imaging findings of 2019-nCoV lung infection (Table). One initial report included chest radiographs of a single patient. A bedside chest radiograph obtained 8 days after symptom onset showed bilateral lung consolidation with relative peripheral sparing. A radiograph obtained 3 days later showed more extensive, basal predominant lung consolidation with possible small pleural effusions corresponding to clinical worsening (2). A second report showed CT images from a single patient who had peripheral, bilateral ground-glass opacity (9). A different report of six family members with 2019-nCoV lung infection mentions lung opacities present on chest CT scans but lacks details on pattern or distribution aside from ground-glass opacities in an asymptomatic 10-year-old boy (7). A recent cohort study of 41 patients with confirmed 2019-nCoV infection included limited analysis of chest imaging studies. All but one patient was reported to have bilateral lung involvement on chest radiographs (8). Patients admitted to the intensive care unit were more likely to have larger areas of bilateral consolidation on CT scans, whereas patients not requiring admission to the intensive care unit with milder illness were more likely to have ground-glass opacity and small areas of consolidation, the latter description suggesting an organizing pneumonia pattern of lung injury. A study of CT scans of 21 patients with 2019-nCoV infection (10) showed three (21%) with normal CT scans, 12 (57%) with ground-glass opacity only, and six (29%) with ground-glass opacity and consolidation at presentation. Fifteen patients (71%) had two or more lobes involved, and 16 (76%) had bilateral disease. Interestingly, three patients (14%) had normal scans at diagnosis. One of those patients still had a normal scan at short-term follow-up. Seven other patients underwent follow-up CT (range, 1–4 days; mean, 2.5 days); five (63%) had mild progression, and two (25%) had moderate progression. Reported Chest CT Findings in 2019 Novel Coronavirus Infections Overall, the imaging findings reported for 2019-nCoV are similar to those reported for SARS-CoV (11–13) and MERS-CoV (14,15), not surprising as the responsible viruses are also coronaviruses. Given that up to 30% of patients with 2019-nCoV infection develop acute respiratory distress syndrome (8), chest imaging studies showing extensive consolidation and ground-glass opacity, typical of acute lung injury, are not unexpected (16,17). The long-term imaging features of 2019-nCoV are not yet known but presumably will resemble those of other causes of acute lung injury. As the number of reported cases of 2019-nCoV infection continue to increase, radiologists may encounter patients with this infection. A high index of suspicion and detailed exposure and travel history are critical to considering this diagnosis. In the correct clinical setting, bilateral ground-glass opacities or consolidation at chest imaging should prompt the radiologist to suggest 2019-nCoV as a possible diagnosis. Furthermore, a normal chest CT scan does not exclude the diagnosis of 2019-nCoV infection.

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          Most cited references5

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          CT Imaging of the 2019 Novel Coronavirus (2019-nCoV) Pneumonia

          A 33-year-old woman presented to the hospital with a 5-day history of fever and cough of unknown cause. She indicated that she worked in Wuhan, China (the center of novel coronavirus outbreak) but had traveled to Lanzhou, China, 6 days before presentation to the hospital. At admission, her body temperature was elevated to 39.0°C (102.2°F) and coarse breath sounds of both lungs were heard at auscultation. Laboratory studies showed leucopenia (white blood cell count: 2.91 × 109/L). The white blood cell differential count showed 70.0% neutrophils and 0.1% eosinophils. There were elevated blood levels for C-reactive protein (16.16 mg/L; normal range, 0–10 mg/L), erythrocyte sedimentation rate (29 mm/h; normal range, <20 mm/h), and D-dimer (580 ng/mL; normal range, 500 ng/mL). Unenhanced chest CT showed multiple peripheral ground-glass opacities in both lungs (Figure, A ) that did not spare the subpleural regions. Real-time fluorescence polymerase chain reaction of the patient’s sputum was positive for the 2019 novel coronavirus (2019-nCoV) nucleic acid. On the basis of epidemiologic characteristics, clinical manifestations, chest images, and laboratory findings, the diagnosis of 2019-nCoV pneumonia was made. After receiving 3 days of treatment, combined with interferon inhalation, the patient was clinically worse with progressive pulmonary opacities found at repeat chest CT (Figure, B ). Unenhanced CT images in a 33-year-old woman. A, Image shows multiple ground-glass opacities in bilateral lungs. Ground-glass opacities are seen in the posterior segment of right upper lobe and apical posterior segment of left superior lobe. B, Image obtained 3 days after follow-up shows progressive ground-glass opacities in the posterior segment of right upper lobe and apical posterior segment of left superior lobe. The bilateralism of the peripheral lung opacities, without subpleural sparing, are common CT findings of the 2019 novel coronavirus pneumonia.
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            Acute respiratory distress syndrome: CT abnormalities at long-term follow-up.

            To document abnormalities at computed tomography (CT) in adult survivors of acute respiratory distress syndrome (ARDS), to determine the relationships between CT patients during the acute phase and at follow-up, and to assess the effects of mechanical ventilation on the development of CT abnormalities. Thin-section CT scans were obtained during the acute illness and at follow-up in 27 patients with ARDS. The extent and distribution of individual CT patterns were independently analyzed. At follow-up CT, a reticular pattern was the most prevalent (23 patients [85%]) and extensive CT abnormality, with a striking anterior distribution (more anterior distribution than posterior distribution, P < .001). A reticular pattern at follow-up was inversely correlated with the extent of intense parenchymal opacification on scans obtained during the acute illness (Spearman r = -0.26; P < .001). The extent of a reticular pattern at follow-up CT was independently related to the total duration of mechanical ventilation (P = .02) but was most strongly related to the duration of pressure-controlled inverse-ratio ventilation (P < .001). A reticular pattern, with a striking anterior distribution, is a frequent finding of follow-up CT in ARDS survivors and is most strongly related to the duration of pressure-controlled inverse-ratio ventilation.
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              High-resolution CT findings of severe acute respiratory syndrome at presentation and after admission.

              The aim of this study was to assess the high-resolution CT (HRCT) findings at presentation and after hospital admission in patients with severe acute respiratory syndrome (SARS). We reviewed the HRCT findings at presentation (n = 12) and after hospital admission (n = 25) of 29 patients with SARS and compared the HRCT findings with the radiographic findings. HRCT scans were obtained using 1-mm (n = 28) or 2-mm (n = 1) collimation. The radiographs and HRCT scans were reviewed independently by two observers who reached a decision by consensus. All patients had abnormal findings on HRCT at presentation. Eight of these 12 patients had normal findings on radiographs. The predominant HRCT findings at presentation consisted of unilateral (n = 6) or bilateral (n = 2) ground-glass opacities or focal unilateral (n = 2) or bilateral (n = 2) areas of consolidation. All patients showed progression of disease on follow-up. The predominant HRCT findings on follow-up CT scans consisted of unilateral (n = 2) or bilateral ground-glass opacities (n = 13), unilateral (n = 2) or bilateral consolidation (n = 5), or a mixed bilateral pattern of ground-glass attenuation, consolidation, and reticulation (n = 3). Reticulation with associated architectural distortion and mild traction bronchiectasis was present in eight patients. HRCT can show parenchymal abnormalities in patients with SARS who have normal findings on radiographs at presentation. Follow-up CT scans obtained in hospitalized patients show findings consistent with fibrosis in a small percentage of patients.
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                Author and article information

                Contributors
                Journal
                Radiology
                Radiology
                Radiology
                Radiology
                Radiological Society of North America
                0033-8419
                1527-1315
                4 February 2020
                : 200241
                Affiliations
                [1]From the Department of Radiology, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792.
                Author notes
                Address correspondence to the author ( jkanne@ 123456uwhealth.org ).
                Author information
                https://orcid.org/0000-0002-4224-8536
                Article
                200241
                10.1148/radiol.2020200241
                7233362
                32017662
                6e74575a-bcdb-4041-8eda-d2817fc64bc7
                2020 by the Radiological Society of North America, Inc.

                This article is made available via the PMC Open Access Subset for unrestricted re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the COVID-19 pandemic or until permissions are revoked in writing. Upon expiration of these permissions, PMC is granted a perpetual license to make this article available via PMC and Europe PMC, consistent with existing copyright protections.

                History
                : 29 January 2020
                : 30 January 2020
                : 1 February 2020
                : 3 February 2020
                Categories
                Reviews and Commentary
                Perspectives
                CH, Chest Radiology
                CT, Computed Tomography

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