Severe acute respiratory syndrome (SARS): chest radiographic features in children

Abstract

Background: Severe acute respiratory syndrome (SARS) is a recently recognized condition of viral origin associated with substantial morbidity and mortality rates in adults. Little information is available on its radiologic manifestations in children.

Objective: The goal of this study was to characterize the radiographic presentation of children with SARS.

Materials and methods: We abstracted data (n=62) on the radiologic appearance and course of SARS in pediatric patients with suspect (n=25) or probable (n=37) SARS, diagnosed in five hospital sites located in three cities: Toronto, Singapore, and Hong Kong. Available chest radiographs and thoracic CTs were reviewed for the presence of the following radiographic findings: airspace disease, air bronchograms, airways inflammation and peribronchial thickening, interstitial disease, pleural effusion, and hilar adenopathy.

Results: A total of 62 patients (suspect=25, probable=37) were evaluated for SARS. Patient ages ranged from 5.5 months to 17 years and 11.5 months (average, 6 years and 10 months) with a female-to-male ratio of 32:30. Forty-one patients (66.1%) were in close contact with other probable, suspect, or quarantined cases; 10 patients (16.1%) had recently traveled to WHO-designated affected areas within 10 days; and 7 patients (11.2%) were transferred from other hospitals that had SARS patients. Three patients, who did not have close/hospital contact or travel history to affected areas, were classified as SARS cases based on their clinical signs and symptoms and on the fact that they were living in an endemic area. The most prominent clinical presentations were fever, with a temperature over 38 degrees C (100%), cough (62.9%), rhinorrhea (22.6%), myalgia (17.7%), chills (14.5%), and headache (11.3%). Other findings included sore throat (9.7%), gastrointestinal symptoms (9.7%), rigor (8.1%), and lethargy (6.5%). In general, fever and cough were the most common clinical presentations amongst younger pediatric SARS cases (age<10 years), whereas, in addition to these symptoms, headache, myalgia, sore throat, chills, and/or rigor were common in older patients (age>/=10 years). The chest radiographs of 35.5% of patients were normal. The most prominent radiological findings that were observed in the remaining patients were areas of consolidation (45.2%), often peripheral with multifocal lesions in 22.6%. Peribronchial thickening was noted on chest radiographs of 14.5% of patients. Pleural effusion was observed only in one patient (age 17 years and 11.5 months), whereas interstitial disease was not observed in any patient.

Conclusion: In pediatric cases, SARS manifests with nonspecific radiographic features making radiological differentiation difficult, especially from other commonly encountered childhood respiratory viral illnesses causing airspace disease. The radiographic presentation of suspected SARS cases ranged from normal to mild perihilar peribronchial thickening. The radiographic presentations, as expected, were relatively more pronounced in the SARS probable cases.

Fig. 1

A 34-month-old boy with probable SARS from household contact. Clinical presentation included fever (41 °C), cough and rhinorrhea. Initial chest radiograph revealed mild perihilar peribronchial thickening and patchy, multifocal infiltrates at the left lung base

Fig. 2

A 29-month-old boy with probable SARS from household contact presented with fever (38.2 °C) and cough. Initial chest radiograph showed a focal area of airspace opacification in the right lower lobe

Fig. 3

A 16-month-old girl with probable SARS with recent travel history to Guangdong Province, South China, presented with fever and cough. Initial chest radiograph revealed a patchy opacity in right upper lobe and a mild peribronchial thickening extending into the lower lobes. Subsequent radiographs showed decreased opacity within the right upper lobe and an increased density within the right infrahilar region

Fig. 4

A 17-year-old girl with probable SARS exposed through household contact. Signs and symptoms of the patient at admission included fever (40.1 °C), cough, dyspnea, hypoxemia, and bilateral crackles. The initial radiograph revealed dense airspace disease involving the right middle lobe and posterior left lower lobe

Fig. 5

High-resolution CT of a 13-year-old girl who presented with persistent fever for 1 week with chills, rigors, rhinorrhea, and myalgia. There is mixed airspace consolidation and ground-glass opacity in the left lower lobe

Fig. 6a, b

A 16-year-old girl, who presented with fever, chills, rigors, myalgia, and headache for 2 days. She had a history of hospital contact with probable SARS patients. a Chest radiograph on admission is unremarkable with no definite consolidative change. b High-resolution CT on the same day shows a focal consolidation at the right lung base