2019-novel Coronavirus severe adult respiratory distress syndrome in two cases in Italy: An uncommon radiological presentation

Abstract

Introduction: Several recent case reports have described common early chest imaging findings of lung pathology caused by 2019 novel Coronavirus (SARS-COV2) which appear to be similar to those seen previously in SARS-CoV and MERS-CoV infected patients.

Objective: We present some remarkable imaging findings of the first two patients identified in Italy with COVID-19 infection travelling from Wuhan, China. The follow-up with chest X-Rays and CT scans was also included, showing a progressive adult respiratory distress syndrome (ARDS).

Results: Moderate to severe progression of the lung infiltrates, with increasing percentage of high-density infiltrates sustained by a bilateral and multi-segmental extension of lung opacities, were seen. During the follow-up, apart from pleural effusions, a tubular and enlarged appearance of pulmonary vessels with a sudden caliber reduction was seen, mainly found in the dichotomic tracts, where the center of a new insurgent pulmonary lesion was seen. It could be an early alert radiological sign to predict initial lung deterioration. Another uncommon element was the presence of mediastinal lymphadenopathy with short-axis oval nodes.

Conclusions: Although only two patients have been studied, these findings are consistent with the radiological pattern described in literature. Finally, the pulmonary vessels enlargement in areas where new lung infiltrates develop in the follow-up CT scan, could describe an early predictor radiological sign of lung impairment.

Keywords: COVID-19; CT-scan; Crazy-paving; Enlarged pulmonary vessels; Ground glass opacities; SARS-COV2.

Figure 1

a,b,c. (a, b) Lung VCAR imaging displaying baseline CT and follow-up CT with progressive impairment of the lung parenchyma. (c) lung sparing analysis.

Figure 2

a,b. (a) Baseline chest CT images in a 66 years old man displaying multiple patchy ground glass opacities with reticular and interlobular septal thickening: crazy paving. The lesions are mostly distributed in the upper segment of right lower lobe and focal ground glass opacities in the superior segment of left inferior lobe. (b) Mediastinal lymphadenopathies the biggest with short axis of 12 mm.

Figure 3

a,b. (a) Follow-up CT in a 66 years old man after 5 days, shows severe progression of pneumonia with increased of extension of ground glass opacities and consolidation. (b) Appearance of bilateral pleural effusion.

Figure 4

a,b. (a) Baseline CT images in a 65 years old woman shows patchy ground-glass opacities in the posterior segment of upper right lobe, with pleural contact.(b) Mediastinal lymphadenopathy with short axis of 10 mm.

Figure 5

a,b. (a) Follow-up CT after 3 days in a 65 years old woman shows increase size and density of the lesions (b) with bilateral pleural effusion.

Figure 6

a,b. (a) Baseline chest CT shows tubular size increase of segmental vessel with normally ventilated adjacent lung parenchyma, (b) where after 3 days there is a ground-glass opacities.