Multisystem Imaging Manifestations of COVID-19, Part 2: From Cardiac Complications to Pediatric Manifestations

Abstract

Infection with severe acute respiratory syndrome coronavirus 2 results in coronavirus disease 2019 (COVID-19), which was declared an official pandemic by the World Health Organization on March 11, 2020. COVID-19 has been reported in most countries, and as of August 15, 2020, there have been over 21 million cases of COVID-19 reported worldwide, with over 800 000 COVID-19-associated deaths. Although COVID-19 predominantly affects the respiratory system, it has become apparent that many other organ systems can also be involved. Imaging plays an essential role in the diagnosis of all manifestations of the disease and its related complications, and proper utilization and interpretation of imaging examinations is crucial. A comprehensive understanding of the diagnostic imaging hallmarks, imaging features, multisystem involvement, and evolution of imaging findings is essential for effective patient management and treatment. In part 1 of this article, the authors described the viral pathogenesis, diagnostic imaging hallmarks, and manifestations of the pulmonary and peripheral and central vascular systems of COVID-19. In part 2 of this article, the authors focus on the key imaging features of the varied pathologic manifestations of COVID-19, involving the cardiac, neurologic, abdominal, dermatologic and ocular, and musculoskeletal systems, as well as the pediatric and pregnancy-related manifestations of the virus. Online supplemental material is available for this article. ^©RSNA, 2020.

Figure 1.

Flow chart shows the suggested patient workup and role of imaging in COVID-19. Alk phos = alkaline phosphatase, c/w = consistent with, CBC diff = complete blood count with differential, CHF =congestive heart failure, Choly = cholecystitis, Cr = creatinine, CT A/P = CT of the abdomen and pelvis, CTA = CT angiography, CXR = chest radiography, dx = diagnosis, ED = emergency department, EKG =electrocardiography, H/N CTA = head and neck CT angiography, ICU = intensive care unit, LFT = liver function tests, MRA = MR angiography, MRV = MR venography, PE = pulmonary embolism, PCR = polymerase chain reaction, POCUS = point-of-care US, PPE = personal protective equipment, RUQ = right upper quadrant, SOB = shortness of breath, (-) = negative, (+) = positive.

Figure 2a.

Pulmonary edema in a 50-year-old woman with a history of end-stage renal disease who underwent hemodialysis and who was admitted to the hospital for hypoxia and pneumonia in the setting of COVID-19. (a) Upright posteroranterior chest radiograph obtained at hospital admission shows a right lower lobe consolidation (circle). (b–d) Chest radiograph (b) and axial contrast material–enhanced chest CT images (c, d) obtained after 1 month for persistent hypoxemia show pulmonary edema (with pulmonary venous congestion [black arrows in b] depicted on the chest radiograph), increasing small bilateral pleural effusions (arrows in c), cardiomegaly (arrowheads in b and c), prominent interlobular septal (arrowheads in d) and peribronchovascular (arrow in d) thickening, and diffuse ground-glass opacities. The findings are indicative of pulmonary edema superimposed on the typical appearance of COVID-19 pneumonia. Note that the right lower lobe pneumonia depicted in a is almost completely resolved in b (white arrow in b).

Figure 2b.

Pulmonary edema in a 50-year-old woman with a history of end-stage renal disease who underwent hemodialysis and who was admitted to the hospital for hypoxia and pneumonia in the setting of COVID-19. (a) Upright posteroranterior chest radiograph obtained at hospital admission shows a right lower lobe consolidation (circle). (b–d) Chest radiograph (b) and axial contrast material–enhanced chest CT images (c, d) obtained after 1 month for persistent hypoxemia show pulmonary edema (with pulmonary venous congestion [black arrows in b] depicted on the chest radiograph), increasing small bilateral pleural effusions (arrows in c), cardiomegaly (arrowheads in b and c), prominent interlobular septal (arrowheads in d) and peribronchovascular (arrow in d) thickening, and diffuse ground-glass opacities. The findings are indicative of pulmonary edema superimposed on the typical appearance of COVID-19 pneumonia. Note that the right lower lobe pneumonia depicted in a is almost completely resolved in b (white arrow in b).

Figure 2c.

Pulmonary edema in a 50-year-old woman with a history of end-stage renal disease who underwent hemodialysis and who was admitted to the hospital for hypoxia and pneumonia in the setting of COVID-19. (a) Upright posteroranterior chest radiograph obtained at hospital admission shows a right lower lobe consolidation (circle). (b–d) Chest radiograph (b) and axial contrast material–enhanced chest CT images (c, d) obtained after 1 month for persistent hypoxemia show pulmonary edema (with pulmonary venous congestion [black arrows in b] depicted on the chest radiograph), increasing small bilateral pleural effusions (arrows in c), cardiomegaly (arrowheads in b and c), prominent interlobular septal (arrowheads in d) and peribronchovascular (arrow in d) thickening, and diffuse ground-glass opacities. The findings are indicative of pulmonary edema superimposed on the typical appearance of COVID-19 pneumonia. Note that the right lower lobe pneumonia depicted in a is almost completely resolved in b (white arrow in b).

Figure 2d.

Pulmonary edema in a 50-year-old woman with a history of end-stage renal disease who underwent hemodialysis and who was admitted to the hospital for hypoxia and pneumonia in the setting of COVID-19. (a) Upright posteroranterior chest radiograph obtained at hospital admission shows a right lower lobe consolidation (circle). (b–d) Chest radiograph (b) and axial contrast material–enhanced chest CT images (c, d) obtained after 1 month for persistent hypoxemia show pulmonary edema (with pulmonary venous congestion [black arrows in b] depicted on the chest radiograph), increasing small bilateral pleural effusions (arrows in c), cardiomegaly (arrowheads in b and c), prominent interlobular septal (arrowheads in d) and peribronchovascular (arrow in d) thickening, and diffuse ground-glass opacities. The findings are indicative of pulmonary edema superimposed on the typical appearance of COVID-19 pneumonia. Note that the right lower lobe pneumonia depicted in a is almost completely resolved in b (white arrow in b).

Figure 3a.

Myocarditis in a 17-year-old adolescent boy who presented to the pediatric emergency room with chest pain and was diagnosed with elevated troponin levels, diffuse ST-segment elevation at electrocardiography, ventricular ectopy, and COVID-19. (a) Cardiac short-axis T2-weighted fat-saturated black-blood MR image shows diffuse increased signal intensity in the subepicardial layer of the septal, lateral, and inferolateral walls in the basal segment (arrows) and subepicardial layer of the lateral and inferolateral walls of the midventricular segments (not shown), consistent with edema. (b) Precontrast T1-weighted short-axis fat-saturated MR image shows normal myocardial thickness and signal intensity (arrows). (c, d) Postcontrast short-axis T1-weighted cardiac MR images obtained at the same level as b show early (c) and delayed (d) subepicardial enhancement of the basal anterior, anterolateral, inferolateral, and inferior segments in a nonischemic pattern (arrows), findings consistent with myocarditis given the clinical context. The enhancement area corresponds to the T2 signal abnormality depicted in a.

Figure 3b.

Myocarditis in a 17-year-old adolescent boy who presented to the pediatric emergency room with chest pain and was diagnosed with elevated troponin levels, diffuse ST-segment elevation at electrocardiography, ventricular ectopy, and COVID-19. (a) Cardiac short-axis T2-weighted fat-saturated black-blood MR image shows diffuse increased signal intensity in the subepicardial layer of the septal, lateral, and inferolateral walls in the basal segment (arrows) and subepicardial layer of the lateral and inferolateral walls of the midventricular segments (not shown), consistent with edema. (b) Precontrast T1-weighted short-axis fat-saturated MR image shows normal myocardial thickness and signal intensity (arrows). (c, d) Postcontrast short-axis T1-weighted cardiac MR images obtained at the same level as b show early (c) and delayed (d) subepicardial enhancement of the basal anterior, anterolateral, inferolateral, and inferior segments in a nonischemic pattern (arrows), findings consistent with myocarditis given the clinical context. The enhancement area corresponds to the T2 signal abnormality depicted in a.

Figure 3c.

Myocarditis in a 17-year-old adolescent boy who presented to the pediatric emergency room with chest pain and was diagnosed with elevated troponin levels, diffuse ST-segment elevation at electrocardiography, ventricular ectopy, and COVID-19. (a) Cardiac short-axis T2-weighted fat-saturated black-blood MR image shows diffuse increased signal intensity in the subepicardial layer of the septal, lateral, and inferolateral walls in the basal segment (arrows) and subepicardial layer of the lateral and inferolateral walls of the midventricular segments (not shown), consistent with edema. (b) Precontrast T1-weighted short-axis fat-saturated MR image shows normal myocardial thickness and signal intensity (arrows). (c, d) Postcontrast short-axis T1-weighted cardiac MR images obtained at the same level as b show early (c) and delayed (d) subepicardial enhancement of the basal anterior, anterolateral, inferolateral, and inferior segments in a nonischemic pattern (arrows), findings consistent with myocarditis given the clinical context. The enhancement area corresponds to the T2 signal abnormality depicted in a.

Figure 3d.

Myocarditis in a 17-year-old adolescent boy who presented to the pediatric emergency room with chest pain and was diagnosed with elevated troponin levels, diffuse ST-segment elevation at electrocardiography, ventricular ectopy, and COVID-19. (a) Cardiac short-axis T2-weighted fat-saturated black-blood MR image shows diffuse increased signal intensity in the subepicardial layer of the septal, lateral, and inferolateral walls in the basal segment (arrows) and subepicardial layer of the lateral and inferolateral walls of the midventricular segments (not shown), consistent with edema. (b) Precontrast T1-weighted short-axis fat-saturated MR image shows normal myocardial thickness and signal intensity (arrows). (c, d) Postcontrast short-axis T1-weighted cardiac MR images obtained at the same level as b show early (c) and delayed (d) subepicardial enhancement of the basal anterior, anterolateral, inferolateral, and inferior segments in a nonischemic pattern (arrows), findings consistent with myocarditis given the clinical context. The enhancement area corresponds to the T2 signal abnormality depicted in a.

Figure 4.

Right ventricular thrombus and COVID-19 pneumonia in a 62-year-old man with hypoxia and markedly elevated d-dimer levels (>50 000 ng/mL). Axial chest CT angiographic image shows a well-circumscribed hypoattenuating filling defect within the lumen of the right ventricle, indicative of a thrombus (solid arrow). Patchy lung opacities (dashed arrows) related to COVID-19 pneumonia are only vaguely depicted, owing to the window settings used.

Figure 5a.

Long segment right internal carotid artery (ICA) occlusion with associated bilateral large middle cerebral artery territory infarcts in a 59-year-old man who underwent intubation due to COVID-19 who presented with sudden onset of confusion. The serum analysis results showed a high d-dimer level of 5.6 mg/mL. (a) Axial nonenhanced head CT image shows large regions of hypoattenuation (arrows) in the bilateral middle cerebral artery territories, reflecting cytotoxic edema secondary to acute bilateral middle cerebral artery territorial infarctions without hemorrhagic transformation. The findings are indicative of cardioembolic phenomena (given various vascular distributions), hypoxic-ischemic injury, or ischemic vasculopathy secondary to COVID-19. (b–d) Sagittal maximum intensity projection (b) and axial head and neck CT angiographic images (c, d) show a long segment filling defect from the proximal cervical segment of the right ICA (arrow in b) to the intracranial ICA, with involvement of the right petrous (not shown) and cavernous ICA segments (arrow in c), indicative of right ICA thrombosis and occlusion. The right carotid terminus (white arrow in d) and right middle cerebral artery are completely occluded, and the M1 segment of the left middle cerebral artery is nearly completely occluded, with only a small sleeve of intravenous contrast material opacifying the artery (black arrow in d). Note that the loss of gray matter–white matter differentiation is more pronounced on the right (arrowheads in d).

Figure 5b.

Long segment right internal carotid artery (ICA) occlusion with associated bilateral large middle cerebral artery territory infarcts in a 59-year-old man who underwent intubation due to COVID-19 who presented with sudden onset of confusion. The serum analysis results showed a high d-dimer level of 5.6 mg/mL. (a) Axial nonenhanced head CT image shows large regions of hypoattenuation (arrows) in the bilateral middle cerebral artery territories, reflecting cytotoxic edema secondary to acute bilateral middle cerebral artery territorial infarctions without hemorrhagic transformation. The findings are indicative of cardioembolic phenomena (given various vascular distributions), hypoxic-ischemic injury, or ischemic vasculopathy secondary to COVID-19. (b–d) Sagittal maximum intensity projection (b) and axial head and neck CT angiographic images (c, d) show a long segment filling defect from the proximal cervical segment of the right ICA (arrow in b) to the intracranial ICA, with involvement of the right petrous (not shown) and cavernous ICA segments (arrow in c), indicative of right ICA thrombosis and occlusion. The right carotid terminus (white arrow in d) and right middle cerebral artery are completely occluded, and the M1 segment of the left middle cerebral artery is nearly completely occluded, with only a small sleeve of intravenous contrast material opacifying the artery (black arrow in d). Note that the loss of gray matter–white matter differentiation is more pronounced on the right (arrowheads in d).

Figure 5c.

Long segment right internal carotid artery (ICA) occlusion with associated bilateral large middle cerebral artery territory infarcts in a 59-year-old man who underwent intubation due to COVID-19 who presented with sudden onset of confusion. The serum analysis results showed a high d-dimer level of 5.6 mg/mL. (a) Axial nonenhanced head CT image shows large regions of hypoattenuation (arrows) in the bilateral middle cerebral artery territories, reflecting cytotoxic edema secondary to acute bilateral middle cerebral artery territorial infarctions without hemorrhagic transformation. The findings are indicative of cardioembolic phenomena (given various vascular distributions), hypoxic-ischemic injury, or ischemic vasculopathy secondary to COVID-19. (b–d) Sagittal maximum intensity projection (b) and axial head and neck CT angiographic images (c, d) show a long segment filling defect from the proximal cervical segment of the right ICA (arrow in b) to the intracranial ICA, with involvement of the right petrous (not shown) and cavernous ICA segments (arrow in c), indicative of right ICA thrombosis and occlusion. The right carotid terminus (white arrow in d) and right middle cerebral artery are completely occluded, and the M1 segment of the left middle cerebral artery is nearly completely occluded, with only a small sleeve of intravenous contrast material opacifying the artery (black arrow in d). Note that the loss of gray matter–white matter differentiation is more pronounced on the right (arrowheads in d).

Figure 5d.

Long segment right internal carotid artery (ICA) occlusion with associated bilateral large middle cerebral artery territory infarcts in a 59-year-old man who underwent intubation due to COVID-19 who presented with sudden onset of confusion. The serum analysis results showed a high d-dimer level of 5.6 mg/mL. (a) Axial nonenhanced head CT image shows large regions of hypoattenuation (arrows) in the bilateral middle cerebral artery territories, reflecting cytotoxic edema secondary to acute bilateral middle cerebral artery territorial infarctions without hemorrhagic transformation. The findings are indicative of cardioembolic phenomena (given various vascular distributions), hypoxic-ischemic injury, or ischemic vasculopathy secondary to COVID-19. (b–d) Sagittal maximum intensity projection (b) and axial head and neck CT angiographic images (c, d) show a long segment filling defect from the proximal cervical segment of the right ICA (arrow in b) to the intracranial ICA, with involvement of the right petrous (not shown) and cavernous ICA segments (arrow in c), indicative of right ICA thrombosis and occlusion. The right carotid terminus (white arrow in d) and right middle cerebral artery are completely occluded, and the M1 segment of the left middle cerebral artery is nearly completely occluded, with only a small sleeve of intravenous contrast material opacifying the artery (black arrow in d). Note that the loss of gray matter–white matter differentiation is more pronounced on the right (arrowheads in d).

Figure 6a.

Multiple brain infarcts in various vascular territories and intraparenchymal hemorrhage after extubation in a 58-year-old woman with a history of diabetes mellitus who was hospitalized with COVID-19. The patient’s hospital stay was complicated by multiorgan failure, line sepsis, and new neurologic deficits. (a) Axial T2-weighted (T2) FLAIR brain MR image shows a focal heterogeneous hyperintensity (arrow) within the right occipital lobe, representing an evolving intraparenchymal hematoma, with surrounding edema and mass effect. (b, c) Axial diffusion-weighted (DWI) and ADC MR images show restricted diffusion in the right frontal lobe, compatible with a small focus of acute infarct (arrow). Additional foci of restricted diffusion were depicted in the left frontal lobe (not shown), consistent with small infarcts in different vascular distributions.

Figure 6b.

Multiple brain infarcts in various vascular territories and intraparenchymal hemorrhage after extubation in a 58-year-old woman with a history of diabetes mellitus who was hospitalized with COVID-19. The patient’s hospital stay was complicated by multiorgan failure, line sepsis, and new neurologic deficits. (a) Axial T2-weighted (T2) FLAIR brain MR image shows a focal heterogeneous hyperintensity (arrow) within the right occipital lobe, representing an evolving intraparenchymal hematoma, with surrounding edema and mass effect. (b, c) Axial diffusion-weighted (DWI) and ADC MR images show restricted diffusion in the right frontal lobe, compatible with a small focus of acute infarct (arrow). Additional foci of restricted diffusion were depicted in the left frontal lobe (not shown), consistent with small infarcts in different vascular distributions.

Figure 6c.

Multiple brain infarcts in various vascular territories and intraparenchymal hemorrhage after extubation in a 58-year-old woman with a history of diabetes mellitus who was hospitalized with COVID-19. The patient’s hospital stay was complicated by multiorgan failure, line sepsis, and new neurologic deficits. (a) Axial T2-weighted (T2) FLAIR brain MR image shows a focal heterogeneous hyperintensity (arrow) within the right occipital lobe, representing an evolving intraparenchymal hematoma, with surrounding edema and mass effect. (b, c) Axial diffusion-weighted (DWI) and ADC MR images show restricted diffusion in the right frontal lobe, compatible with a small focus of acute infarct (arrow). Additional foci of restricted diffusion were depicted in the left frontal lobe (not shown), consistent with small infarcts in different vascular distributions.

Figure 7a.

Watershed infarcts and cardioembolic infarcts in a 55-year-old woman with COVID-19 who presented with left gaze deviation. (a) Initial axial T2-weighted (T2) FLAIR brain MR image shows hyperintense signal abnormality (arrows), predominantly within the high frontal and parietal subcortical white matter bilaterally. (b) Repeat axial T2-weighted (T2) FLAIR MR image obtained 3 days later shows interval development of a linearly oriented pattern of signal abnormality (arrows) within the centrum semiovale bilaterally, greater on the left than on the right. (c, d) Axial diffusion-weighted (DWI) (c) and ADC (d) brain MR images show restricted diffusion in the corresponding areas of abnormality (arrows), indicative of watershed infarcts. (e, f) Axial diffusion-weighted (DWI) (e) and ADC (f) brain MR images show restricted diffusion involving the bilateral occipital lobes (arrows), indicative of additional foci of acute infarct.

Figure 7b.

Watershed infarcts and cardioembolic infarcts in a 55-year-old woman with COVID-19 who presented with left gaze deviation. (a) Initial axial T2-weighted (T2) FLAIR brain MR image shows hyperintense signal abnormality (arrows), predominantly within the high frontal and parietal subcortical white matter bilaterally. (b) Repeat axial T2-weighted (T2) FLAIR MR image obtained 3 days later shows interval development of a linearly oriented pattern of signal abnormality (arrows) within the centrum semiovale bilaterally, greater on the left than on the right. (c, d) Axial diffusion-weighted (DWI) (c) and ADC (d) brain MR images show restricted diffusion in the corresponding areas of abnormality (arrows), indicative of watershed infarcts. (e, f) Axial diffusion-weighted (DWI) (e) and ADC (f) brain MR images show restricted diffusion involving the bilateral occipital lobes (arrows), indicative of additional foci of acute infarct.

Figure 7c.

Watershed infarcts and cardioembolic infarcts in a 55-year-old woman with COVID-19 who presented with left gaze deviation. (a) Initial axial T2-weighted (T2) FLAIR brain MR image shows hyperintense signal abnormality (arrows), predominantly within the high frontal and parietal subcortical white matter bilaterally. (b) Repeat axial T2-weighted (T2) FLAIR MR image obtained 3 days later shows interval development of a linearly oriented pattern of signal abnormality (arrows) within the centrum semiovale bilaterally, greater on the left than on the right. (c, d) Axial diffusion-weighted (DWI) (c) and ADC (d) brain MR images show restricted diffusion in the corresponding areas of abnormality (arrows), indicative of watershed infarcts. (e, f) Axial diffusion-weighted (DWI) (e) and ADC (f) brain MR images show restricted diffusion involving the bilateral occipital lobes (arrows), indicative of additional foci of acute infarct.

Figure 7d.

Watershed infarcts and cardioembolic infarcts in a 55-year-old woman with COVID-19 who presented with left gaze deviation. (a) Initial axial T2-weighted (T2) FLAIR brain MR image shows hyperintense signal abnormality (arrows), predominantly within the high frontal and parietal subcortical white matter bilaterally. (b) Repeat axial T2-weighted (T2) FLAIR MR image obtained 3 days later shows interval development of a linearly oriented pattern of signal abnormality (arrows) within the centrum semiovale bilaterally, greater on the left than on the right. (c, d) Axial diffusion-weighted (DWI) (c) and ADC (d) brain MR images show restricted diffusion in the corresponding areas of abnormality (arrows), indicative of watershed infarcts. (e, f) Axial diffusion-weighted (DWI) (e) and ADC (f) brain MR images show restricted diffusion involving the bilateral occipital lobes (arrows), indicative of additional foci of acute infarct.

Figure 7e.

Watershed infarcts and cardioembolic infarcts in a 55-year-old woman with COVID-19 who presented with left gaze deviation. (a) Initial axial T2-weighted (T2) FLAIR brain MR image shows hyperintense signal abnormality (arrows), predominantly within the high frontal and parietal subcortical white matter bilaterally. (b) Repeat axial T2-weighted (T2) FLAIR MR image obtained 3 days later shows interval development of a linearly oriented pattern of signal abnormality (arrows) within the centrum semiovale bilaterally, greater on the left than on the right. (c, d) Axial diffusion-weighted (DWI) (c) and ADC (d) brain MR images show restricted diffusion in the corresponding areas of abnormality (arrows), indicative of watershed infarcts. (e, f) Axial diffusion-weighted (DWI) (e) and ADC (f) brain MR images show restricted diffusion involving the bilateral occipital lobes (arrows), indicative of additional foci of acute infarct.

Figure 7f.

Watershed infarcts and cardioembolic infarcts in a 55-year-old woman with COVID-19 who presented with left gaze deviation. (a) Initial axial T2-weighted (T2) FLAIR brain MR image shows hyperintense signal abnormality (arrows), predominantly within the high frontal and parietal subcortical white matter bilaterally. (b) Repeat axial T2-weighted (T2) FLAIR MR image obtained 3 days later shows interval development of a linearly oriented pattern of signal abnormality (arrows) within the centrum semiovale bilaterally, greater on the left than on the right. (c, d) Axial diffusion-weighted (DWI) (c) and ADC (d) brain MR images show restricted diffusion in the corresponding areas of abnormality (arrows), indicative of watershed infarcts. (e, f) Axial diffusion-weighted (DWI) (e) and ADC (f) brain MR images show restricted diffusion involving the bilateral occipital lobes (arrows), indicative of additional foci of acute infarct.

Figure 8a.

Hemorrhagic venous infarct related to venous thrombosis in a 29-year-old woman who had two seizures after having 1 week of cough and fever and who received positive test results for COVID-19 in the emergency department. (a) Axial nonenhanced head CT image shows a left temporoparietal hemorrhagic venous infarct (arrows), with adjacent edema, mass effect, and minimal rightward midline shift. (b) Axial CT venogram shows absence of contrast material in the left sigmoid sinus (arrows), indicative of venous sinus thrombosis. (c) Three-dimensional maximum intensity projection image from MR venography shows thrombosis of the left transverse and sigmoid sinuses (solid arrows). Note that the right transverse sinus appears patent (dashed arrow).

Figure 8b.

Hemorrhagic venous infarct related to venous thrombosis in a 29-year-old woman who had two seizures after having 1 week of cough and fever and who received positive test results for COVID-19 in the emergency department. (a) Axial nonenhanced head CT image shows a left temporoparietal hemorrhagic venous infarct (arrows), with adjacent edema, mass effect, and minimal rightward midline shift. (b) Axial CT venogram shows absence of contrast material in the left sigmoid sinus (arrows), indicative of venous sinus thrombosis. (c) Three-dimensional maximum intensity projection image from MR venography shows thrombosis of the left transverse and sigmoid sinuses (solid arrows). Note that the right transverse sinus appears patent (dashed arrow).

Figure 8c.

Hemorrhagic venous infarct related to venous thrombosis in a 29-year-old woman who had two seizures after having 1 week of cough and fever and who received positive test results for COVID-19 in the emergency department. (a) Axial nonenhanced head CT image shows a left temporoparietal hemorrhagic venous infarct (arrows), with adjacent edema, mass effect, and minimal rightward midline shift. (b) Axial CT venogram shows absence of contrast material in the left sigmoid sinus (arrows), indicative of venous sinus thrombosis. (c) Three-dimensional maximum intensity projection image from MR venography shows thrombosis of the left transverse and sigmoid sinuses (solid arrows). Note that the right transverse sinus appears patent (dashed arrow).

Figure 9a.

Viral encephalitis in a 57-year-old man with a history of hypoxemic respiratory failure who required intubation in the setting of COVID-19 pneumonia. The hospital stay was complicated by hypercoagulability in the setting of COVID-19. (a, b) Axial (a) and coronal (b) T2-weighted (T2) FLAIR MR images show an infiltrative pattern of heterogeneous signal abnormality (arrows) throughout the left cerebral hemisphere involving the frontal, temporal, and occipital lobes, as well as the basal ganglia and thalamus. (c) Axial susceptibility-weighted image (SWI) shows multiple nodular and curvilinear foci of abnormal magnetic susceptibility (arrows), consistent with foci of parenchymal and subarachnoid hemorrhage. (d) Axial postcontrast T1-weighted MR image shows an amorphous curvilinear pattern of avid contrast enhancement (arrows).

Figure 9b.

Viral encephalitis in a 57-year-old man with a history of hypoxemic respiratory failure who required intubation in the setting of COVID-19 pneumonia. The hospital stay was complicated by hypercoagulability in the setting of COVID-19. (a, b) Axial (a) and coronal (b) T2-weighted (T2) FLAIR MR images show an infiltrative pattern of heterogeneous signal abnormality (arrows) throughout the left cerebral hemisphere involving the frontal, temporal, and occipital lobes, as well as the basal ganglia and thalamus. (c) Axial susceptibility-weighted image (SWI) shows multiple nodular and curvilinear foci of abnormal magnetic susceptibility (arrows), consistent with foci of parenchymal and subarachnoid hemorrhage. (d) Axial postcontrast T1-weighted MR image shows an amorphous curvilinear pattern of avid contrast enhancement (arrows).

Figure 9c.

Viral encephalitis in a 57-year-old man with a history of hypoxemic respiratory failure who required intubation in the setting of COVID-19 pneumonia. The hospital stay was complicated by hypercoagulability in the setting of COVID-19. (a, b) Axial (a) and coronal (b) T2-weighted (T2) FLAIR MR images show an infiltrative pattern of heterogeneous signal abnormality (arrows) throughout the left cerebral hemisphere involving the frontal, temporal, and occipital lobes, as well as the basal ganglia and thalamus. (c) Axial susceptibility-weighted image (SWI) shows multiple nodular and curvilinear foci of abnormal magnetic susceptibility (arrows), consistent with foci of parenchymal and subarachnoid hemorrhage. (d) Axial postcontrast T1-weighted MR image shows an amorphous curvilinear pattern of avid contrast enhancement (arrows).

Figure 9d.

Viral encephalitis in a 57-year-old man with a history of hypoxemic respiratory failure who required intubation in the setting of COVID-19 pneumonia. The hospital stay was complicated by hypercoagulability in the setting of COVID-19. (a, b) Axial (a) and coronal (b) T2-weighted (T2) FLAIR MR images show an infiltrative pattern of heterogeneous signal abnormality (arrows) throughout the left cerebral hemisphere involving the frontal, temporal, and occipital lobes, as well as the basal ganglia and thalamus. (c) Axial susceptibility-weighted image (SWI) shows multiple nodular and curvilinear foci of abnormal magnetic susceptibility (arrows), consistent with foci of parenchymal and subarachnoid hemorrhage. (d) Axial postcontrast T1-weighted MR image shows an amorphous curvilinear pattern of avid contrast enhancement (arrows).

Figure 10a.

Hemorrhagic diffuse leukoencephalopathy in a 43-year-old woman with COVID-19. The hospital stay was complicated by inability to follow commands and persistently depressed status after extubation. The laboratory test results showed markedly elevated d-dimer levels (>7.6 mg/mL), international normalized ratio level (1.4), and platelet count (290). (a) Axial T2-weighted MR image shows confluent bilateral signal hyperintensities (arrows) in the white matter of both parietal lobes. No associated diffusion restriction was depicted on diffusion-weighted or ADC images (not shown). (b) Axial gradient-echo MR image shows punctate microhemorrhages (arrow) in the subcortical white matter of the left occipital lobe. Multiple microhemorrhages were scattered throughout the cerebral hemispheres bilaterally and in the splenium of the corpus callosum (not shown).

Figure 10b.

Hemorrhagic diffuse leukoencephalopathy in a 43-year-old woman with COVID-19. The hospital stay was complicated by inability to follow commands and persistently depressed status after extubation. The laboratory test results showed markedly elevated d-dimer levels (>7.6 mg/mL), international normalized ratio level (1.4), and platelet count (290). (a) Axial T2-weighted MR image shows confluent bilateral signal hyperintensities (arrows) in the white matter of both parietal lobes. No associated diffusion restriction was depicted on diffusion-weighted or ADC images (not shown). (b) Axial gradient-echo MR image shows punctate microhemorrhages (arrow) in the subcortical white matter of the left occipital lobe. Multiple microhemorrhages were scattered throughout the cerebral hemispheres bilaterally and in the splenium of the corpus callosum (not shown).

Figure 11.

Intraventricular hemorrhage in a 65-year-old man receiving anticoagulation therapy in the intensive care unit as treatment for severe COVID-19 pneumonia. Axial nonenhanced CT image of the head shows a small amount of layering hyperattenuating fluid in the bilateral atria of the lateral ventricles, compatible with either spontaneous or traumatic acute intraventricular hemorrhage.

Figure 12a.

Gastritis and colitis in two patients who each presented with epigastric and abdominal pain and received positive test results for COVID-19 in the emergency department. Coronal contrast-enhanced CT images of the abdomen and pelvis show thickening of the gastric wall and associated mucosal hyperenhancement (arrows in a) and thickening of the ascending and descending colon with mucosal enhancement (arrows in b), findings that are indicative of gastritis (a) and colitis (b), respectively. Note the hepatic steatosis in a.

Figure 12b.

Gastritis and colitis in two patients who each presented with epigastric and abdominal pain and received positive test results for COVID-19 in the emergency department. Coronal contrast-enhanced CT images of the abdomen and pelvis show thickening of the gastric wall and associated mucosal hyperenhancement (arrows in a) and thickening of the ascending and descending colon with mucosal enhancement (arrows in b), findings that are indicative of gastritis (a) and colitis (b), respectively. Note the hepatic steatosis in a.

Figure 13a.

Proctocolitis in a 72-year-old man who presented to the emergency department with abdominal pain and fever and was diagnosed with COVID-19. Sagittal (a) and axial (b) contrast-enhanced CT images of the abdomen and pelvis show marked edema of the distended rectal wall (white arrows), with hyperenhancing mucosa (black arrow) and significant inflammatory changes in the surrounding perirectal fat (*). Note that the remaining large bowel wall is normal (arrowhead in a), and no significant amount of stool is depicted in the rectum. On the day of hospital admission, CT images of the abdomen and pelvis obtained through the lung bases depicted bilateral peripheral airspace opacities, ground-glass opacities, and areas of consolidations (not shown), findings typical of COVID-19 pneumonia.

Figure 13b.

Proctocolitis in a 72-year-old man who presented to the emergency department with abdominal pain and fever and was diagnosed with COVID-19. Sagittal (a) and axial (b) contrast-enhanced CT images of the abdomen and pelvis show marked edema of the distended rectal wall (white arrows), with hyperenhancing mucosa (black arrow) and significant inflammatory changes in the surrounding perirectal fat (*). Note that the remaining large bowel wall is normal (arrowhead in a), and no significant amount of stool is depicted in the rectum. On the day of hospital admission, CT images of the abdomen and pelvis obtained through the lung bases depicted bilateral peripheral airspace opacities, ground-glass opacities, and areas of consolidations (not shown), findings typical of COVID-19 pneumonia.

Figure 14a.

Superior mesenteric artery thrombosis complicated by bowel ischemia and perforation in a 54-year-old man who presented to the emergency department with abdominal pain and was diagnosed with COVID-19. (a–c) Coronal (a) and axial (b, c) contrast-enhanced CT images of the abdomen and pelvis show mucosal hyperenhancement involving the small bowel (F in a, white arrow in c), with associated mild wall thickening. There is a long segment of bowel wall hypoenhancement in the distal ileum, with a large focal wall defect (solid white arrows in a). Note the extension of intraluminal bowel contents, fluid, and air through the defect into the peritoneum (dashed arrow in a). The findings are indicative of bowel ischemia with distal ileal bowel wall perforation. There are multiple fluid-filled dilated loops of small bowel proximal to this region, suggestive of an ileus. There are associated thrombi within the proximal superior mesenteric artery (black arrow in a, arrow in b) and in the distal ileal branches (not shown). Mesenteric congestion and trace ascites are noted (* in a and c). However, no organized fluid collection is depicted. Note the enlarged nonenhancing left external iliac vein, compatible with deep vein thrombosis (black arrow in c). (d) Gray-scale (left) and power Doppler (right) US images of the left upper extremity, obtained owing to arm swelling, show a near-occlusive thrombus extending from the forearm to the upper humeral segment of the cephalic vein (Ceph V) (arrows in d).

Figure 14b.

Superior mesenteric artery thrombosis complicated by bowel ischemia and perforation in a 54-year-old man who presented to the emergency department with abdominal pain and was diagnosed with COVID-19. (a–c) Coronal (a) and axial (b, c) contrast-enhanced CT images of the abdomen and pelvis show mucosal hyperenhancement involving the small bowel (F in a, white arrow in c), with associated mild wall thickening. There is a long segment of bowel wall hypoenhancement in the distal ileum, with a large focal wall defect (solid white arrows in a). Note the extension of intraluminal bowel contents, fluid, and air through the defect into the peritoneum (dashed arrow in a). The findings are indicative of bowel ischemia with distal ileal bowel wall perforation. There are multiple fluid-filled dilated loops of small bowel proximal to this region, suggestive of an ileus. There are associated thrombi within the proximal superior mesenteric artery (black arrow in a, arrow in b) and in the distal ileal branches (not shown). Mesenteric congestion and trace ascites are noted (* in a and c). However, no organized fluid collection is depicted. Note the enlarged nonenhancing left external iliac vein, compatible with deep vein thrombosis (black arrow in c). (d) Gray-scale (left) and power Doppler (right) US images of the left upper extremity, obtained owing to arm swelling, show a near-occlusive thrombus extending from the forearm to the upper humeral segment of the cephalic vein (Ceph V) (arrows in d).

Figure 14c.

Superior mesenteric artery thrombosis complicated by bowel ischemia and perforation in a 54-year-old man who presented to the emergency department with abdominal pain and was diagnosed with COVID-19. (a–c) Coronal (a) and axial (b, c) contrast-enhanced CT images of the abdomen and pelvis show mucosal hyperenhancement involving the small bowel (F in a, white arrow in c), with associated mild wall thickening. There is a long segment of bowel wall hypoenhancement in the distal ileum, with a large focal wall defect (solid white arrows in a). Note the extension of intraluminal bowel contents, fluid, and air through the defect into the peritoneum (dashed arrow in a). The findings are indicative of bowel ischemia with distal ileal bowel wall perforation. There are multiple fluid-filled dilated loops of small bowel proximal to this region, suggestive of an ileus. There are associated thrombi within the proximal superior mesenteric artery (black arrow in a, arrow in b) and in the distal ileal branches (not shown). Mesenteric congestion and trace ascites are noted (* in a and c). However, no organized fluid collection is depicted. Note the enlarged nonenhancing left external iliac vein, compatible with deep vein thrombosis (black arrow in c). (d) Gray-scale (left) and power Doppler (right) US images of the left upper extremity, obtained owing to arm swelling, show a near-occlusive thrombus extending from the forearm to the upper humeral segment of the cephalic vein (Ceph V) (arrows in d).

Figure 14d.

Superior mesenteric artery thrombosis complicated by bowel ischemia and perforation in a 54-year-old man who presented to the emergency department with abdominal pain and was diagnosed with COVID-19. (a–c) Coronal (a) and axial (b, c) contrast-enhanced CT images of the abdomen and pelvis show mucosal hyperenhancement involving the small bowel (F in a, white arrow in c), with associated mild wall thickening. There is a long segment of bowel wall hypoenhancement in the distal ileum, with a large focal wall defect (solid white arrows in a). Note the extension of intraluminal bowel contents, fluid, and air through the defect into the peritoneum (dashed arrow in a). The findings are indicative of bowel ischemia with distal ileal bowel wall perforation. There are multiple fluid-filled dilated loops of small bowel proximal to this region, suggestive of an ileus. There are associated thrombi within the proximal superior mesenteric artery (black arrow in a, arrow in b) and in the distal ileal branches (not shown). Mesenteric congestion and trace ascites are noted (* in a and c). However, no organized fluid collection is depicted. Note the enlarged nonenhancing left external iliac vein, compatible with deep vein thrombosis (black arrow in c). (d) Gray-scale (left) and power Doppler (right) US images of the left upper extremity, obtained owing to arm swelling, show a near-occlusive thrombus extending from the forearm to the upper humeral segment of the cephalic vein (Ceph V) (arrows in d).

Figure 15a.

Bowel ischemia and perforation as a complication of COVID-19 in a 65-year-old man with a history of asthma, hypertension, and hyperlipidemia. (a–c) Axial (a, c) and coronal (b, d) intravenous contrast material–enhanced CT images of the abdomen and pelvis show significant pneumatosis of the cecum and right ascending colon (dashed arrows in a and d), with associated perforation of the ascending colon (AC and dashed arrows in b) and a large complex fluid collection with an enhancing rim, indicative of an abscess (solid arrows in b). The abscess is filled with extravasated fecal material. Note the mesenteric venous gas (solid arrows in a), associated with pneumatosis. Note also the small amount of ascites and mesenteric congestion (* in a and d). Portal venous gas is present (solid arrows in c and d). Peripheral airspace disease (black arrow in d) in the right lower lobe is also depicted.

Figure 15b.

Bowel ischemia and perforation as a complication of COVID-19 in a 65-year-old man with a history of asthma, hypertension, and hyperlipidemia. (a–c) Axial (a, c) and coronal (b, d) intravenous contrast material–enhanced CT images of the abdomen and pelvis show significant pneumatosis of the cecum and right ascending colon (dashed arrows in a and d), with associated perforation of the ascending colon (AC and dashed arrows in b) and a large complex fluid collection with an enhancing rim, indicative of an abscess (solid arrows in b). The abscess is filled with extravasated fecal material. Note the mesenteric venous gas (solid arrows in a), associated with pneumatosis. Note also the small amount of ascites and mesenteric congestion (* in a and d). Portal venous gas is present (solid arrows in c and d). Peripheral airspace disease (black arrow in d) in the right lower lobe is also depicted.

Figure 15c.

Bowel ischemia and perforation as a complication of COVID-19 in a 65-year-old man with a history of asthma, hypertension, and hyperlipidemia. (a–c) Axial (a, c) and coronal (b, d) intravenous contrast material–enhanced CT images of the abdomen and pelvis show significant pneumatosis of the cecum and right ascending colon (dashed arrows in a and d), with associated perforation of the ascending colon (AC and dashed arrows in b) and a large complex fluid collection with an enhancing rim, indicative of an abscess (solid arrows in b). The abscess is filled with extravasated fecal material. Note the mesenteric venous gas (solid arrows in a), associated with pneumatosis. Note also the small amount of ascites and mesenteric congestion (* in a and d). Portal venous gas is present (solid arrows in c and d). Peripheral airspace disease (black arrow in d) in the right lower lobe is also depicted.

Figure 15d.

Bowel ischemia and perforation as a complication of COVID-19 in a 65-year-old man with a history of asthma, hypertension, and hyperlipidemia. (a–c) Axial (a, c) and coronal (b, d) intravenous contrast material–enhanced CT images of the abdomen and pelvis show significant pneumatosis of the cecum and right ascending colon (dashed arrows in a and d), with associated perforation of the ascending colon (AC and dashed arrows in b) and a large complex fluid collection with an enhancing rim, indicative of an abscess (solid arrows in b). The abscess is filled with extravasated fecal material. Note the mesenteric venous gas (solid arrows in a), associated with pneumatosis. Note also the small amount of ascites and mesenteric congestion (* in a and d). Portal venous gas is present (solid arrows in c and d). Peripheral airspace disease (black arrow in d) in the right lower lobe is also depicted.

Figure 16a.

Ischemic enterocolitis, periportal edema, mesenteric congestion, ascites, and multifocal bilateral native and renal transplant infarcts in a severely ill 75-year-old man with COVID-19 pneumonia, elevated liver function test results, and oliguria. (a, b) Coronal (a) and axial (b) contrast-enhanced images of the abdomen and pelvis show marked pericholecystic and periportal edema (white arrows) and thickened small and large bowel (black arrows). Note that the colon is fluid filled. Multifocal wedge-shaped areas of hypoattenuation are depicted in the renal cortex of the transplant kidney allograft and native kidneys (arrowheads), compatible with multifocal native renal and renal transplant infarcts. Note the marked heterogeneity of the liver parenchyma that could be attributable to hepatitis (* in a). The main mesenteric vasculature was patent. Mesenteric congestion and ascites were also present, implying the manifestation of mesenteric ischemia, likely as a result of microthrombosis. (c) Endoscopic image of the left colon shows denudation of the colonic epithelium, compatible with ischemic colitis. (Case courtesy of Christine [Cooky] Menias, MD, Mayo Clinic, Phoenix, Ariz.)

Figure 16b.

Ischemic enterocolitis, periportal edema, mesenteric congestion, ascites, and multifocal bilateral native and renal transplant infarcts in a severely ill 75-year-old man with COVID-19 pneumonia, elevated liver function test results, and oliguria. (a, b) Coronal (a) and axial (b) contrast-enhanced images of the abdomen and pelvis show marked pericholecystic and periportal edema (white arrows) and thickened small and large bowel (black arrows). Note that the colon is fluid filled. Multifocal wedge-shaped areas of hypoattenuation are depicted in the renal cortex of the transplant kidney allograft and native kidneys (arrowheads), compatible with multifocal native renal and renal transplant infarcts. Note the marked heterogeneity of the liver parenchyma that could be attributable to hepatitis (* in a). The main mesenteric vasculature was patent. Mesenteric congestion and ascites were also present, implying the manifestation of mesenteric ischemia, likely as a result of microthrombosis. (c) Endoscopic image of the left colon shows denudation of the colonic epithelium, compatible with ischemic colitis. (Case courtesy of Christine [Cooky] Menias, MD, Mayo Clinic, Phoenix, Ariz.)

Figure 16c.

Ischemic enterocolitis, periportal edema, mesenteric congestion, ascites, and multifocal bilateral native and renal transplant infarcts in a severely ill 75-year-old man with COVID-19 pneumonia, elevated liver function test results, and oliguria. (a, b) Coronal (a) and axial (b) contrast-enhanced images of the abdomen and pelvis show marked pericholecystic and periportal edema (white arrows) and thickened small and large bowel (black arrows). Note that the colon is fluid filled. Multifocal wedge-shaped areas of hypoattenuation are depicted in the renal cortex of the transplant kidney allograft and native kidneys (arrowheads), compatible with multifocal native renal and renal transplant infarcts. Note the marked heterogeneity of the liver parenchyma that could be attributable to hepatitis (* in a). The main mesenteric vasculature was patent. Mesenteric congestion and ascites were also present, implying the manifestation of mesenteric ischemia, likely as a result of microthrombosis. (c) Endoscopic image of the left colon shows denudation of the colonic epithelium, compatible with ischemic colitis. (Case courtesy of Christine [Cooky] Menias, MD, Mayo Clinic, Phoenix, Ariz.)

Figure 17a.

Pneumopericardium with air dissecting into the peritoneum, mimicking bowel perforation, in a 64-year-old man who underwent intubation for COVID-19 pneumonia. (a) Axial nonenhanced chest CT image shows pneumopericardium (black arrows) and bibasilar airspace consolidations (white arrows), compatible with COVID-19 pneumonia. (b) Axial nonenhanced CT image of the abdomen and pelvis shows pneumopericardium and free air under the diaphragm, anterior to the liver (black arrows), without findings of bowel wall ischemia to suggest a perforation (not shown). Note the bibasilar consolidations (white arrows).

Figure 17b.

Pneumopericardium with air dissecting into the peritoneum, mimicking bowel perforation, in a 64-year-old man who underwent intubation for COVID-19 pneumonia. (a) Axial nonenhanced chest CT image shows pneumopericardium (black arrows) and bibasilar airspace consolidations (white arrows), compatible with COVID-19 pneumonia. (b) Axial nonenhanced CT image of the abdomen and pelvis shows pneumopericardium and free air under the diaphragm, anterior to the liver (black arrows), without findings of bowel wall ischemia to suggest a perforation (not shown). Note the bibasilar consolidations (white arrows).

Figure 18a.

Heterogeneous liver enhancement and biliary stasis in an 84-year-old woman with a history of hypertension and asthma who was admitted to the intensive care unit for hypoxic respiratory failure secondary to COVID-19 pneumonia and septic shock. The results of a laboratory test also confirmed elevated transaminase levels (aspartate transaminase, 1085 U/L; alanine transaminase, 741 U/L). The patient died 3 days later despite cholecystostomy placement. Axial (a) and coronal (b) CT angiographic images of the abdomen and pelvis show marked heterogeneous enhancement within the liver, with multiple areas of hypoenhancement along the biliary distribution (arrows in a). The gallbladder (GB) is distended, and there is a marked dilatation of the extrahepatic biliary duct (black arrow in b), with gradual tapering of the common bile duct within its distal segment (white arrow in b). No radiopaque obstructive stones or sludge were visualized. The findings are indicative of biliary stasis and an infectious or inflammatory process of the gallbladder. Note that the sensitivity of gallstone evaluation at CT is variable based on the composition of the stones.

Figure 18b.

Heterogeneous liver enhancement and biliary stasis in an 84-year-old woman with a history of hypertension and asthma who was admitted to the intensive care unit for hypoxic respiratory failure secondary to COVID-19 pneumonia and septic shock. The results of a laboratory test also confirmed elevated transaminase levels (aspartate transaminase, 1085 U/L; alanine transaminase, 741 U/L). The patient died 3 days later despite cholecystostomy placement. Axial (a) and coronal (b) CT angiographic images of the abdomen and pelvis show marked heterogeneous enhancement within the liver, with multiple areas of hypoenhancement along the biliary distribution (arrows in a). The gallbladder (GB) is distended, and there is a marked dilatation of the extrahepatic biliary duct (black arrow in b), with gradual tapering of the common bile duct within its distal segment (white arrow in b). No radiopaque obstructive stones or sludge were visualized. The findings are indicative of biliary stasis and an infectious or inflammatory process of the gallbladder. Note that the sensitivity of gallstone evaluation at CT is variable based on the composition of the stones.

Figure 19a.

Acute cholecystitis in a critically ill 64-year-old man with COVID-19 and sepsis. Gray-scale (a) and color Doppler (b) US images show a dilated gallbladder (GB) with sludge (* in b). Significant wall edema (dashed arrow) and hyperemia (solid arrows in b) are also present. The US Murphy sign was not assessed owing to the patient’s altered mental status. The findings are indicative of bile stasis and acute cholecystitis. Sterile green thick dark bile was visualized during cholecystostomy placement.

Figure 19b.

Acute cholecystitis in a critically ill 64-year-old man with COVID-19 and sepsis. Gray-scale (a) and color Doppler (b) US images show a dilated gallbladder (GB) with sludge (* in b). Significant wall edema (dashed arrow) and hyperemia (solid arrows in b) are also present. The US Murphy sign was not assessed owing to the patient’s altered mental status. The findings are indicative of bile stasis and acute cholecystitis. Sterile green thick dark bile was visualized during cholecystostomy placement.

Figure 20.

Ovarian vein thrombosis in a 27-year-old woman who presented to the emergency department with right flank pain. Reverse transcription–polymerase chain reaction test results confirmed COVID-19. Coronal contrast-enhanced CT image of the abdomen and pelvis shows a long segment filling defect (arrows) in the left ovarian vein, indicative of gonadal vein thrombosis. Given the positive COVID-19 results, it is uncertain if the viral infection was the cause of the thrombosis, as no other preexisting conditions or risk factors were identified.

Figure 21.

Renal infarcts in a 57-year-old man with COVID-19, diagnosed after presenting to the emergency department with abdominal pain. Coronal contrast-enhanced CT image of the abdomen and pelvis shows multiple linear hypoattenuating areas, extending from the left renal sinus to the surface of the cortex (white arrows). Note the occlusive thrombus (black arrow) in the segmental left renal artery. The findings are indicative of an infarct of the left kidney. Small wedge-shaped regions of hypoattenuation were also present in the right kidney, indicative of an infarct (not shown). Note the small amount of perihepatic free fluid (FF).

Figure 22.

Renal infarct in a critically ill 52-year-old man who underwent intubation for COVID-19 and who presented with oliguria and was diagnosed with elevated creatinine levels. Sagittal color Doppler US image shows a focal area of hypoperfusion (solid arrows) in the upper pole of the left kidney, compatible with an infarct. Normal perfusion (dashed arrows) is seen in the lower pole of the kidney. Bilateral patchy ground-glass opacities, a typical finding of COVID-19 pneumonia, were depicted at chest radiography (not shown).

Figure 23a.

Splenic infarcts and cystitis in an 84-year-old man with a history of newly diagnosed lung cancer who presented to the emergency department with left upper quadrant pain and urinary frequency. The test results confirmed COVID-19. (a, b) Coronal (a) and axial (b) contrast-enhanced CT images of the abdomen and pelvis show multiple wedge-shaped areas of hypoattenuation in the spleen (solid white arrows in a), indicative of multifocal splenic infarcts. Associated thrombosis of one of the splenic hilar branches supplying the anterior upper pole of the spleen is noted (dashed arrow in a). In addition, there is marked irregular wall thickening of the contrast material–filled urinary bladder (B and black arrows in a and b). It is important to note that patients with underlying conditions (such as hypercoagulable state in the setting of malignancy) are prone to develop complications of COVID-19. (c) Axial diffusion-weighted image (DWI) of the brain obtained during a hospital stay for newly developed neurological deficits shows a confluent region of restricted diffusion (arrows) within territory supplied by the left middle cerebral artery, indicative of an acute infarct. A long segment thrombus in the left middle cerebral artery was detected (not shown).

Figure 23b.

Splenic infarcts and cystitis in an 84-year-old man with a history of newly diagnosed lung cancer who presented to the emergency department with left upper quadrant pain and urinary frequency. The test results confirmed COVID-19. (a, b) Coronal (a) and axial (b) contrast-enhanced CT images of the abdomen and pelvis show multiple wedge-shaped areas of hypoattenuation in the spleen (solid white arrows in a), indicative of multifocal splenic infarcts. Associated thrombosis of one of the splenic hilar branches supplying the anterior upper pole of the spleen is noted (dashed arrow in a). In addition, there is marked irregular wall thickening of the contrast material–filled urinary bladder (B and black arrows in a and b). It is important to note that patients with underlying conditions (such as hypercoagulable state in the setting of malignancy) are prone to develop complications of COVID-19. (c) Axial diffusion-weighted image (DWI) of the brain obtained during a hospital stay for newly developed neurological deficits shows a confluent region of restricted diffusion (arrows) within territory supplied by the left middle cerebral artery, indicative of an acute infarct. A long segment thrombus in the left middle cerebral artery was detected (not shown).

Figure 23c.

Splenic infarcts and cystitis in an 84-year-old man with a history of newly diagnosed lung cancer who presented to the emergency department with left upper quadrant pain and urinary frequency. The test results confirmed COVID-19. (a, b) Coronal (a) and axial (b) contrast-enhanced CT images of the abdomen and pelvis show multiple wedge-shaped areas of hypoattenuation in the spleen (solid white arrows in a), indicative of multifocal splenic infarcts. Associated thrombosis of one of the splenic hilar branches supplying the anterior upper pole of the spleen is noted (dashed arrow in a). In addition, there is marked irregular wall thickening of the contrast material–filled urinary bladder (B and black arrows in a and b). It is important to note that patients with underlying conditions (such as hypercoagulable state in the setting of malignancy) are prone to develop complications of COVID-19. (c) Axial diffusion-weighted image (DWI) of the brain obtained during a hospital stay for newly developed neurological deficits shows a confluent region of restricted diffusion (arrows) within territory supplied by the left middle cerebral artery, indicative of an acute infarct. A long segment thrombus in the left middle cerebral artery was detected (not shown).

Figure 24a.

Pancreatitis and enteritis in a 56-year-old woman with COVID-19. Axial (a) and coronal (b) CT images of the abdomen and pelvis obtained with oral (no intravenous) contrast material shows a heterogeneous edematous pancreas with associated inflammatory changes and small amount of peripancreatic fluid (solid arrows), indicative of pancreatitis. Note the nondistended loops of small bowel that show mild wall thickening (dashed arrows in b) and mesenteric inflammation (* in b) that, although they are nonspecific in the setting of pancreatitis, may be indicative of enteritis.

Figure 24b.

Pancreatitis and enteritis in a 56-year-old woman with COVID-19. Axial (a) and coronal (b) CT images of the abdomen and pelvis obtained with oral (no intravenous) contrast material shows a heterogeneous edematous pancreas with associated inflammatory changes and small amount of peripancreatic fluid (solid arrows), indicative of pancreatitis. Note the nondistended loops of small bowel that show mild wall thickening (dashed arrows in b) and mesenteric inflammation (* in b) that, although they are nonspecific in the setting of pancreatitis, may be indicative of enteritis.

Figure 25.

Urinary bladder hemorrhage in an 85-year-old man with COVID-19 pneumonia who developed hematuria and acute renal failure. Transverse gray-scale (left) and color Doppler (right) US images show a distended urinary bladder (B) filled with avascular heterogeneous echogenic material, indicative of urinary bladder hemorrhage (arrows).

Figure 26a.

Rhabdomyolysis in a 34-year-old man who presented with minor trauma and was diagnosed with COVID-19 in the emergency department. Laboratory analysis results demonstrated an extremely high creatine kinase level of 35 145 U/L (normal range, 39–308 U/L). (a–c) Coronal (a) and axial (b, c) contrast-enhanced CT images of the pelvis show an enlarged right gluteal region (arrows) without associated fracture. (d–f) Axial (d) and coronal (e) contrast-enhanced chest CT images and a CT image with an artificial intelligence deep learning algorithm for the detection of pulmonary embolism (f) show bilateral multifocal multilobar peribronchovascular patchy airspace and ground-glass opacities (arrows in d), which are a typical finding for COVID-19. Multiple segmental and subsegmental right lower lobe pulmonary emboli (arrows in e and f) were also detected.

Figure 26b.

Rhabdomyolysis in a 34-year-old man who presented with minor trauma and was diagnosed with COVID-19 in the emergency department. Laboratory analysis results demonstrated an extremely high creatine kinase level of 35 145 U/L (normal range, 39–308 U/L). (a–c) Coronal (a) and axial (b, c) contrast-enhanced CT images of the pelvis show an enlarged right gluteal region (arrows) without associated fracture. (d–f) Axial (d) and coronal (e) contrast-enhanced chest CT images and a CT image with an artificial intelligence deep learning algorithm for the detection of pulmonary embolism (f) show bilateral multifocal multilobar peribronchovascular patchy airspace and ground-glass opacities (arrows in d), which are a typical finding for COVID-19. Multiple segmental and subsegmental right lower lobe pulmonary emboli (arrows in e and f) were also detected.

Figure 26c.

Rhabdomyolysis in a 34-year-old man who presented with minor trauma and was diagnosed with COVID-19 in the emergency department. Laboratory analysis results demonstrated an extremely high creatine kinase level of 35 145 U/L (normal range, 39–308 U/L). (a–c) Coronal (a) and axial (b, c) contrast-enhanced CT images of the pelvis show an enlarged right gluteal region (arrows) without associated fracture. (d–f) Axial (d) and coronal (e) contrast-enhanced chest CT images and a CT image with an artificial intelligence deep learning algorithm for the detection of pulmonary embolism (f) show bilateral multifocal multilobar peribronchovascular patchy airspace and ground-glass opacities (arrows in d), which are a typical finding for COVID-19. Multiple segmental and subsegmental right lower lobe pulmonary emboli (arrows in e and f) were also detected.

Figure 26d.

Rhabdomyolysis in a 34-year-old man who presented with minor trauma and was diagnosed with COVID-19 in the emergency department. Laboratory analysis results demonstrated an extremely high creatine kinase level of 35 145 U/L (normal range, 39–308 U/L). (a–c) Coronal (a) and axial (b, c) contrast-enhanced CT images of the pelvis show an enlarged right gluteal region (arrows) without associated fracture. (d–f) Axial (d) and coronal (e) contrast-enhanced chest CT images and a CT image with an artificial intelligence deep learning algorithm for the detection of pulmonary embolism (f) show bilateral multifocal multilobar peribronchovascular patchy airspace and ground-glass opacities (arrows in d), which are a typical finding for COVID-19. Multiple segmental and subsegmental right lower lobe pulmonary emboli (arrows in e and f) were also detected.

Figure 26e.

Rhabdomyolysis in a 34-year-old man who presented with minor trauma and was diagnosed with COVID-19 in the emergency department. Laboratory analysis results demonstrated an extremely high creatine kinase level of 35 145 U/L (normal range, 39–308 U/L). (a–c) Coronal (a) and axial (b, c) contrast-enhanced CT images of the pelvis show an enlarged right gluteal region (arrows) without associated fracture. (d–f) Axial (d) and coronal (e) contrast-enhanced chest CT images and a CT image with an artificial intelligence deep learning algorithm for the detection of pulmonary embolism (f) show bilateral multifocal multilobar peribronchovascular patchy airspace and ground-glass opacities (arrows in d), which are a typical finding for COVID-19. Multiple segmental and subsegmental right lower lobe pulmonary emboli (arrows in e and f) were also detected.

Figure 26f.

Rhabdomyolysis in a 34-year-old man who presented with minor trauma and was diagnosed with COVID-19 in the emergency department. Laboratory analysis results demonstrated an extremely high creatine kinase level of 35 145 U/L (normal range, 39–308 U/L). (a–c) Coronal (a) and axial (b, c) contrast-enhanced CT images of the pelvis show an enlarged right gluteal region (arrows) without associated fracture. (d–f) Axial (d) and coronal (e) contrast-enhanced chest CT images and a CT image with an artificial intelligence deep learning algorithm for the detection of pulmonary embolism (f) show bilateral multifocal multilobar peribronchovascular patchy airspace and ground-glass opacities (arrows in d), which are a typical finding for COVID-19. Multiple segmental and subsegmental right lower lobe pulmonary emboli (arrows in e and f) were also detected.

Figure 27a.

Hypoxic ischemic encephalopathy in a 2-day-old full-term newborn boy who was born by cesarean delivery in a 32-year-old woman with COVID-19. Coagulopathy was diagnosed at birth, with an elevated international normalized ratio of 2.0. The infant died on day 2 following birth. Sagittal gray-scale US images of the neonatal brain obtained at the level of the right (a) and left (b) thalami (T) show increased echogenicity within the thalami (arrows), compatible with hypoxic ischemic encephalopathy. The adjacent midline structures are intact, and no germinal matrix or intraventricular hemorrhage was visualized. The lateral ventricles were normal in size. No parenchymal mass, hematoma, or extra-axial fluid collections were depicted.

Figure 27b.

Hypoxic ischemic encephalopathy in a 2-day-old full-term newborn boy who was born by cesarean delivery in a 32-year-old woman with COVID-19. Coagulopathy was diagnosed at birth, with an elevated international normalized ratio of 2.0. The infant died on day 2 following birth. Sagittal gray-scale US images of the neonatal brain obtained at the level of the right (a) and left (b) thalami (T) show increased echogenicity within the thalami (arrows), compatible with hypoxic ischemic encephalopathy. The adjacent midline structures are intact, and no germinal matrix or intraventricular hemorrhage was visualized. The lateral ventricles were normal in size. No parenchymal mass, hematoma, or extra-axial fluid collections were depicted.

Figure 28a.

Tonsillitis in a 15-year-old boy who presented to the emergency department with fever, sore throat, malaise, and right neck swelling and was diagnosed with elevated d-dimer levels and inflammatory marker levels. The test results were positive for COVID-19. (a–c) Axial (a) and coronal (b, c) contrast-enhanced neck CT images show enlarged palatine tonsils (black arrows in a and arrows in b). A subtle ill-defined asymmetric area of hypoattenuation is depicted within the enlarged left palatine tonsil, consistent with phlegmon or early abscess (white arrow in a). Associated cervical lymphadenopathy (arrows in c) is depicted. (d) Sagittal power Doppler US image of the right superior neck shows a near-complete occlusive thrombus (arrows) in the right jugular vein (RT IJV).

Figure 28b.

Tonsillitis in a 15-year-old boy who presented to the emergency department with fever, sore throat, malaise, and right neck swelling and was diagnosed with elevated d-dimer levels and inflammatory marker levels. The test results were positive for COVID-19. (a–c) Axial (a) and coronal (b, c) contrast-enhanced neck CT images show enlarged palatine tonsils (black arrows in a and arrows in b). A subtle ill-defined asymmetric area of hypoattenuation is depicted within the enlarged left palatine tonsil, consistent with phlegmon or early abscess (white arrow in a). Associated cervical lymphadenopathy (arrows in c) is depicted. (d) Sagittal power Doppler US image of the right superior neck shows a near-complete occlusive thrombus (arrows) in the right jugular vein (RT IJV).

Figure 28c.

Tonsillitis in a 15-year-old boy who presented to the emergency department with fever, sore throat, malaise, and right neck swelling and was diagnosed with elevated d-dimer levels and inflammatory marker levels. The test results were positive for COVID-19. (a–c) Axial (a) and coronal (b, c) contrast-enhanced neck CT images show enlarged palatine tonsils (black arrows in a and arrows in b). A subtle ill-defined asymmetric area of hypoattenuation is depicted within the enlarged left palatine tonsil, consistent with phlegmon or early abscess (white arrow in a). Associated cervical lymphadenopathy (arrows in c) is depicted. (d) Sagittal power Doppler US image of the right superior neck shows a near-complete occlusive thrombus (arrows) in the right jugular vein (RT IJV).

Figure 28d.

Tonsillitis in a 15-year-old boy who presented to the emergency department with fever, sore throat, malaise, and right neck swelling and was diagnosed with elevated d-dimer levels and inflammatory marker levels. The test results were positive for COVID-19. (a–c) Axial (a) and coronal (b, c) contrast-enhanced neck CT images show enlarged palatine tonsils (black arrows in a and arrows in b). A subtle ill-defined asymmetric area of hypoattenuation is depicted within the enlarged left palatine tonsil, consistent with phlegmon or early abscess (white arrow in a). Associated cervical lymphadenopathy (arrows in c) is depicted. (d) Sagittal power Doppler US image of the right superior neck shows a near-complete occlusive thrombus (arrows) in the right jugular vein (RT IJV).

Figure 29a.

Coronary artery dilatation and decreased ventricular ejection fraction in a 9-year-old boy with a recent history of COVID-19 who presented with new onset of hypotension, kidney disease, and elevated troponin and d-dimer levels (same patient as in Movies 2 and 3). Parasternal short-axis echocardiograms show lack of tapering in the left anterior descending (LAD) coronary artery (arrows in a) and the right coronary artery (RCA) (arrows in b). Left ventricular ejection fraction was decreased (not shown). Ao =aorta, L MCA = left main coronary artery. (Case courtesy of Misra Nilanjana, MD, Northwell Health, New Hyde Park, NY.)

Figure 29b.

Coronary artery dilatation and decreased ventricular ejection fraction in a 9-year-old boy with a recent history of COVID-19 who presented with new onset of hypotension, kidney disease, and elevated troponin and d-dimer levels (same patient as in Movies 2 and 3). Parasternal short-axis echocardiograms show lack of tapering in the left anterior descending (LAD) coronary artery (arrows in a) and the right coronary artery (RCA) (arrows in b). Left ventricular ejection fraction was decreased (not shown). Ao =aorta, L MCA = left main coronary artery. (Case courtesy of Misra Nilanjana, MD, Northwell Health, New Hyde Park, NY.)