Incidentally discovered COVID-19 in low-suspicion patients-a threat to front line health care workers

Abstract

Purpose: The COVID-19 pandemic has been responsible for thousands of deaths worldwide. Testing remains at a premium, and criteria for testing remains reserved for those with lower respiratory infection symptoms and/or a known high-risk exposure. The role of imaging in COVID-19 is rapidly evolving; however, few algorithms include imaging criteria, and it is unclear what should be done in low-suspicion patients with positive imaging findings.

Methods: From 03/01/2020-03/20/2020, a retrospective review of all patients with suspected COVID-19 on imaging was performed. Imaging was interpreted by a board-certified, fellowship-trained radiologist. Patients were excluded if COVID-19 infection was suspected at the time of presentation, was the reason for imaging, or if any lower respiratory symptoms were present.

Results: Eight patients with suspected COVID-19 infection on imaging were encountered. Seven patients received testing due to suspicious imaging findings with subsequent lab-confirmed COVID-19. No patients endorsed prior exposure to COVID-19 or recent international travel. COVID-19 was suggested in six patients incidentally on abdominal CT and two on chest radiography. At the time of presentation, no patients were febrile, and seven endorsed gastrointestinal symptoms. Five COVID-19 patients eventually developed respiratory symptoms and required intubation. Two patients expired during the admission.

Conclusions: Patients with imaging findings suspicious for COVID-19 warrant prompt reverse transcription polymerase chain reaction (RT-PCR) testing even in low clinical suspicion cases. The prevalence of disease in the population may be underestimated by the current paradigm of RT-PCR testing with the current clinical criteria of lower respiratory symptoms and exposure risk.

Keywords: COVID-19; Incidental findings.

Fig. 1

Imaging findings of COVID-19 incidentally detected on CT. a A 54-year-old presented to clinic with right lower quadrant pain with concern for appendicitis. A CT of the abdomen and pelvis was obtained revealing rounded, peripheral ground glass opacities (GGO; arrows) with associated areas of vascular engorgement (arrow heads) at the lung bases. b A chest radiograph was obtained for the same patient. Subtle, peripheral ground glass opacities are identified at the lung bases (arrows). c A 56-year-old lady presented with abdominal pain, nausea, and diarrhea. An initial CT of the abdomen revealed findings consistent with COVID-19. A CT chest was obtained, revealing bilateral, diffuse, rounded GGOs in the lungs (arrows)

Fig. 2

a A 62-year-old lady presented with subjective fevers, vomiting, and diarrhea. A chest radiograph was obtained to evaluate for etiology of fever, revealing bilateral, hazy, peripheral patchy grand glass opacities. b Lateral view chest radiograph of the same patient. c Chest radiograph two days after admission demonstrates increasing bilateral airspace opacities, with signs of developing acute respiratory distress syndrome. d Chest radiograph four days after admission demonstrate an intubated patient with progressive lung involvement, bilateral consolidations with septal thickening, and florid ARDS