Adverse Initial CT Findings Associated with Poor Prognosis of Coronavirus Disease

Abstract

Background: The predictors of poor prognosis in patients with coronavirus disease 2019 (COVID-19) using computed tomography (CT) have not been investigated in a large cohort. Therefore, the purpose of this study was to investigate the adverse initial CT features to predict poor prognosis in COVID-19.

Methods: From February to April 2020, 281 COVID-19 patients who underwent CT at the time of admission were included. We divided the patients into the severe and non-severe disease groups. The severe group included patients with severe pneumonia or critical events. Intensive care unit admission or death were the critical events in this study. We compared the clinical and CT findings between the severe and non-severe groups and investigated the prognostic factors and critical events of the severe group using the regression analysis.

Results: Among the 281 patients, 36 (12.8%) patients were in the severe group and 245 (87.2%) patients were in the non-severe group. Critical events occurred in 10 patients (3.6%). In the severe group, patients showed significantly more pneumonia with consolidation, crazy-paving appearance, pleural effusion, and higher CT scores than those in the non-severe group (all, P < 0.05). In the multivariate regression, pleural effusion (odds ratio [OR], 8.96; 95% confidence interval [CI], 1.81-44.42; P = 0.007), CT score > 5 (OR, 3.70; 95% CI, 1.44-9.53; P = 0.007), old age (> 77 years, OR, 9.96; 95% CI, 3.78-26.28; P < 0.001), and elevated C-reactive protein (OR, 4.15; 95% CI, 1.62-10.6; P = 0.003) were significant prognostic factors of severe disease. CT score > 5 (OR, 7.29; 95% CI, 1.37-38.68; P = 0.020), pleural effusion (OR, 5.67; 95% CI, 1.04-30.8; P = 0.045) and old age (OR, 8.6; 95% CI, 1.80-41.0; P = 0.007) were also significant predictors of critical events.

Conclusion: Pleural effusion and the extent of pneumonia on initial CT scans are associated with poor prognosis in patients with COVID-19.

Keywords: COVID-19; Computed Tomography; Coronavirus; Pneumonia.

Fig. 1. Flow chart of the patient population.

COVID-19 = coronavirus disease 2019, CT = computed tomography, ICU = intensive care unit.

Fig. 2. A 54-year-old male patient with non-severe COVID-19 pneumonia. He had a history of hypertension and ischemic heart disease. Initial chest computed tomography taken one day after admission (arrow) shows a focal peripheral consolidation at both lower lobes. Three segments were involved, and the CT score was 5. There is no pleural effusion. During hospitalization, peripheral oxygen saturation was maintained above 95%.

COVID-19 = coronavirus disease 2019, CT = computed tomography.

Fig. 3. An 81-year-old female with COVID-19 in the intensive care unit. She had a history of stroke. Initial chest CT one day after admission (A) shows focal GGO at the superior segment of the left lower lobe and the right lower lobe (black arrows), and a small amount of left pleural effusion (B; white arrow). Two segments were involved, and the CT score was 2. Five days after the initial CT, chest radiograph (C) shows an aggravation of the pneumonia. The peripheral oxygen saturation decreased to 88%, and oxygen supply treatment was started. The patient was admitted to the intensive care unit for close monitoring. Follow-up CT (D, E) after treatment showed multifocal consolidation and GGO in both the lungs, and a small amount of left pleural effusion (white arrow) is observed.

COVID-19 = coronavirus disease 2019, CT = computed tomography, GGO = ground glass opacity.

Fig. 4. A 52-year-old female with severe COVID-19 pneumonia. She had a history of hypertension and dementia. An initial chest CT scan on the day of admission shows focal subpleural consolidation (black arrow) with ground-glass opacity at the right lower lobe superior segment (A). A small amount of right pleural effusion is also noted (B; white arrow). One segment was involved, and the CT score was 1. Pneumonia is seen aggravated on the follow-up chest radiograph nine days after the initial CT (C). Peripheral oxygen saturation decreased to 92%, and 2 L nasal prong oxygen therapy was initiated.

COVID-19 = coronavirus disease 2019, CT = computed tomography.

Fig. 5. Death of a 92-year-old male with COVID-19. He had a history of stroke, diabetes, and situs inversus totalis. Initial chest CT on the day of admission shows bilateral COVID-19 pneumonia (A, B), and a moderate amount of pleural effusion (C) is observed. All 20 segments were involved, and the CT score was 33. On the next day, peripheral oxygen saturation decreased by 90%. The patient refused active treatment or resuscitation, and died after 15 days due to respiratory failure.

COVID-19 = coronavirus disease 2019, CT = computed tomography.