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      Lung Ultrasound Findings in Patients With Coronavirus Disease (COVID-19)

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          Abstract

          OBJECTIVE. Although chest CT is the standard imaging modality in early diagnosis and management of coronavirus disease (COVID-19), the use of lung ultrasound (US) presents some advantages over the use of chest CT and may play a complementary role in the workup of COVID-19. The objective of our study was to investigate US findings in patients with COVID-19 and the relationship of the US findings with the duration of symptoms and disease severity. MATERIALS AND METHODS. From March 3, 2020, to March 30, 2020, consecutive patients with a positive reverse transcriptase polymerase chain reaction test result for the virus that causes COVID-19 were enrolled in this study. Lung US was performed, and the imaging features were analyzed. The Fisher exact test was used to compare the percentages of patients with each US finding between groups with different symptom durations and disease severity. RESULTS. Our study population comprised 28 patients (14 men and 14 women; mean age ± SD, 59.8 ± 18.3 years; age range, 21-92 years). All 28 patients (100.0%, 28/28) had positive lung US findings. The most common findings were the following: B-lines (100.0%, 28/28), consolidation (67.9%, 19/28), and a thickened pleural line (60.7%, 17/28). A thickened pleural line was observed in a higher percentage of patients with a longer duration of the disease than in those with a shorter duration of the disease, and pulmonary consolidations were more common in severe and critical cases than in moderate cases. CONCLUSION. Typical lung US findings in patients with COVID-19 included B-lines, pulmonary consolidation, and a thickened pleural line. In addition, our results indicate that lung US findings can be be used to reflect both the infection duration and disease severity.

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          Relation Between Chest CT Findings and Clinical Conditions of Coronavirus Disease (COVID-19) Pneumonia: A Multicenter Study

          OBJECTIVE. The increasing number of cases of confirmed coronavirus disease (COVID-19) in China is striking. The purpose of this study was to investigate the relation between chest CT findings and the clinical conditions of COVID-19 pneumonia. MATERIALS AND METHODS. Data on 101 cases of COVID-19 pneumonia were retrospectively collected from four institutions in Hunan, China. Basic clinical characteristics and detailed imaging features were evaluated and compared between two groups on the basis of clinical status: nonemergency (mild or common disease) and emergency (severe or fatal disease). RESULTS. Patients 21-50 years old accounted for most (70.2%) of the cohort, and five (5.0%) patients had disease associated with a family outbreak. Most patients (78.2%) had fever as the onset symptom. Most patients with COVID-19 pneumonia had typical imaging features, such as ground-glass opacities (GGO) (87 [86.1%]) or mixed GGO and consolidation (65 [64.4%]), vascular enlargement in the lesion (72 [71.3%]), and traction bronchiectasis (53 [52.5%]). Lesions present on CT images were more likely to have a peripheral distribution (88 [87.1%]) and bilateral involvement (83 [82.2%]) and be lower lung predominant (55 [54.5%]) and multifocal (55 [54.5%]). Patients in the emergency group were older than those in the non-emergency group. Architectural distortion, traction bronchiectasis, and CT involvement score aided in evaluation of the severity and extent of the disease. CONCLUSION. Patients with confirmed COVID-19 pneumonia have typical imaging features that can be helpful in early screening of highly suspected cases and in evaluation of the severity and extent of disease. Most patients with COVID-19 pneumonia have GGO or mixed GGO and consolidation and vascular enlargement in the lesion. Lesions are more likely to have peripheral distribution and bilateral involvement and be lower lung predominant and multifocal. CT involvement score can help in evaluation of the severity and extent of the disease.
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            Coronavirus Disease 2019 (COVID-19): Role of Chest CT in Diagnosis and Management

            OBJECTIVE. The objective of our study was to determine the misdiagnosis rate of radiologists for coronavirus disease 2019 (COVID-19) and evaluate the performance of chest CT in the diagnosis and management of COVID-19. The CT features of COVID-19 are reported and compared with the CT features of other viruses to familiarize radiologists with possible CT patterns. MATERIALS AND METHODS. This study included the first 51 patients with a diagnosis of COVID-19 infection confirmed by nucleic acid testing (23 women and 28 men; age range, 26-83 years) and two patients with adenovirus (one woman and one man; ages, 58 and 66 years). We reviewed the clinical information, CT images, and corresponding image reports of these 53 patients. The CT images included images from 99 chest CT examinations, including initial and follow-up CT studies. We compared the image reports of the initial CT study with the laboratory test results and identified CT patterns suggestive of viral infection. RESULTS. COVID-19 was misdiagnosed as a common infection at the initial CT study in two inpatients with underlying disease and COVID-19. Viral pneumonia was correctly diagnosed at the initial CT study in the remaining 49 patients with COVID-19 and two patients with adenovirus. These patients were isolated and obtained treatment. Ground-glass opacities (GGOs) and consolidation with or without vascular enlargement, interlobular septal thickening, and air bronchogram sign are common CT features of COVID-19. The The "reversed halo" sign and pulmonary nodules with a halo sign are uncommon CT features. The CT findings of COVID-19 overlap with the CT findings of adenovirus infection. There are differences as well as similarities in the CT features of COVID-19 compared with those of the severe acute respiratory syndrome. CONCLUSION. We found that chest CT had a low rate of missed diagnosis of COVID-19 (3.9%, 2/51) and may be useful as a standard method for the rapid diagnosis of COVID-19 to optimize the management of patients. However, CT is still limited for identifying specific viruses and distinguishing between viruses.
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              Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic

              Dear Editor, Up to 24 February 2020, there have been 77,269 officially reported confirmed cases of 2019 novel corona virus (SARS-CoV-2) infection in China. As lung abnormalities may develop before clinical manifestations and nucleic acid detection, experts have recommended early chest computerized tomography (CT) for screening suspected patients [1]. The high contagiousness of SARS-CoV-2 and the risk of transporting unstable patients with hypoxemia and hemodynamic failure make chest CT a limited option for the patient with suspected or established COVID-19. Lung ultrasonography gives the results that are similar to chest CT and superior to standard chest radiography for evaluation of pneumonia and/or adult respiratory distress syndrome (ARDS) with the added advantage of ease of use at point of care, repeatability, absence of radiation exposure, and low cost [2]. In this report, we summarize our early experience with lung ultrasonography for evaluation of SARS-CoV-2 infection in China with the intent of alerting frontline intensivists to the utility of lung ultrasonography for management of COVID-19. Ultrasonographic features of nCoV pneumonia We performed lung ultrasonography on 20 patients with COVID-19 using a 12-zone method [3]. Characteristic findings included the following: Thickening of the pleural line with pleural line irregularity; B lines in a variety of patterns including focal, multifocal, and confluent; Consolidations in a variety of patterns including multifocal small, non-translobar, and translobar with occasional mobile air bronchograms; Appearance of A lines during recovery phase; Pleural effusions are uncommon. The observed patterns occurred across a continuum from mild alveolar interstitial pattern, to severe bilateral interstitial pattern, to lung consolidation. Table 1 summarizes typical lung ultrasonography finds in patients with COVID-19 respiratory disease in comparison with chest CT findings. Typical lung ultrasonography images are shown in the supplementary material (Supplementary Fig. 1.) Table 1 CT and ultrasonographic features of COVID-19 pneumonia Lung CT Lung ultrasound Thickened pleura Thickened pleural line Ground glass shadow and effusion B lines (multifocal, discrete, or confluent) Pulmonary infiltrating shadow Confluent B lines Subpleural consolidation Small (centomeric) consolidations) Translobar consolidation Both non-translobar and translobar consolidation Pleural effusion is rare. Pleural effusion is rare More than two lobes affected Multilobar distribution of abnormalities Negative or atypical in lung CT images in the super-early stage, then diffuse scattered or ground glass shadow with the progress of the disease, further lung consolidation Focal B lines is the main feature in the early stage and in mild infection; alveolar interstitial syndrome is the main feature in the progressive stage and in critically ill patients; A lines can be found in the convalescence; pleural line thickening with uneven B lines can be seen in patients with pulmonary fibrosis The findings of lung ultrasonography features of SARS-CoV-2 pneumonia/ARDS are related to the stage of disease, the severity of lung injury, and comorbidities. The predominant pattern is of varying degrees of interstitial syndrome and alveolar consolidation, the degree of which is correlated with the severity of the lung injury. A recognized limitation of lung ultrasonography is that it cannot detect lesions that are deep within the lung, as aerated lung blocks transmission of ultrasonography, i.e., the abnormality must extend to the pleural surface to be visible with on ultrasonography examination. Chest CT is required to detect pneumonia that does not extend to the pleural surface. Based upon our experience, we consider that lung ultrasonography has major utility for management of COVID-19 with respiratory involvement due to its safety, repeatability, absence of radiation, low cost and point of care use; chest CT may be reserved for cases where lung ultrasonography is not sufficient to answer the clinical question. We find there is utility of lung ultrasonography for rapid assessment of the severity of SARS-CoV-2 pneumonia/ARDS at presentation, to track the evolution of disease, to monitor lung recruitment maneuvers, to guide response to prone position, the management of extracorporeal membrane therapy, and for making decisions related to weaning the patient form ventilatory support. Electronic supplementary material Supplementary Figure 1: Typical lung ultrasonography images of nCoV pneumonia. B lines; B. confluent B lines; C. small consolidations; D. translobar consolidation. Supplementary Figure 1 Typical lung ultrasonography images of nCoV pneumonia. A. B lines; B. confluent B lines; C. small consolidations; D. translobar consolidation. (TIFF 34299 kb)
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                Author and article information

                Journal
                American Journal of Roentgenology
                American Journal of Roentgenology
                American Roentgen Ray Society
                0361-803X
                1546-3141
                July 22 2020
                : 1-5
                Affiliations
                [1 ]Department of Ultrasound, Beijing Ditan Hospital, Capital Medical University, Beijing, China.
                [2 ]Department of Ultrasound, Peking University Third Hospital, 49 N Garden Rd, Haidian District, Beijing 100191, China.
                [3 ]Department of Radiology, Beijing Ditan Hospital, Capital Medical University, Beijing, China.
                Article
                10.2214/AJR.20.23513
                32755198
                8df58da7-7f7a-48f0-9dcc-ed272c8f7cd4
                © 2020
                History

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