Radiographic features of COVID-19 infection at presentation and significance of chest X-ray: Early experience from a super-specialty hospital in India

Abstract

Background: Due to the relative early lockdown in India, relative greater availability of reverse transcription polymerase chain reaction (RT-PCR) testing, and mandate to admit all positive corona virus disease 2019 (COVID-19) patients, the protocol in our hospital is to perform a baseline chest X-ray (CXR) at the time of admission and for follow up. There are currently limited publications demonstrating the radiographic findings and the role of CXR of COVID-19 patients at presentation.

Aims: Evaluatethe radiographic findings on CXR in COVID-19 patients at presentation. Recommend a guideline for its judicious use.

Settings and design: Retroprospective study performed on RT-PCR confirmed COVID-19 patients admitted in our hospital between March 31,2020 to May 25, 2020. The study included symptomatic and asymptomatic patients. CXR was performed for218 patients.

Materials and methods: Portable bedside CXR was performed. The CXRs were evaluated by three radiologists to record the findings and grade the disease. All variables were expressed as mean, ranges, counts, and percentages.

Results: 157 patients (72%) were symptomatic and 61 (28%) were asymptomatic. 104 CXRs (48%) were abnormal (97 in symptomatic (62%) and fourin asymptomatic (6%)). 74 patients (47%) in the symptomatic group had known comorbidities and of these, 62 (84%) had abnormal CXR. 97 CXRs (93%) had bilateral findings and 87 CXRs (84%) had peripherally predominant abnormalities. The lower zone was the most common area of involvement (73%). Ground glass opacity (GGO) was the most common finding (94%-98 CXRs). Mild disease was seen in 56 (54%).

Conclusion: CXR can be used to assess symptomatic COVID-19 patients at presentation and to grade the severity of disease. It may be avoided in asymptomatic patients.

Keywords: COVID-19; Chest X-ray (CXR); consolidation; ground glass opacity.

Figure 1 (A-D)

CXR AP views of four different COVID-19 patients at presentation demonstrating various specific findings. (A) Subtle GGOs (arrows) are seen in bilateral lower zones. (B) Consolidation (arrow) is seen in the right lower zone and GGOs are seen in left lower zone (arrow heads). (C) Consolidations are seen in the bilateral lower zones and left mid zone (thick arrows); peripheral GGOs (arrow heads) are seen bilaterally and nodules (thin arrows) are seen in the right mid zone. (D) Reticular opacities are seen in bilateral lower zones (arrows) along with small GGOs in the right lower zone (arrow head)

Chart 1

Bar diagram demonstrating the age range of all symptomatic and asymptomatic patients in years (X-axis) and their numerical counts (Y-axis)

Figure 2 (A and B)

CXR AP views of two different COVID-19 patients demonstrating bilateral and unilateral abnormalities. (A) 42 Y/M presented with six days of fever, cough, and malaise. CXR shows bilateral lower zone peripheral GGOs (arrows). (B) 37 Y/M presented with six days of fever and history of recent contact with a COVID-19 patient. CXR shows unilateral abnormality of consolidation in the right lower zone (arrow)

Figure 3 (A and B)

CXR AP views of two different COVID-19 patients demonstrating asymmetrical and symmetrical abnormalities. (A) 72 Y/M presented with fever and malaise since 10 days. CXR shows bilateral lung parenchymal abnormalities (right more than left) with areas of bilateral lower zone consolidations (arrows) mixed with right middle zone GGOs (arrow head). (B) 64 Y/F with history of diabetes mellitus presented with fever and dry cough since six days. CXR shows bilateral symmetrical lung parenchymal abnormalities with areas of consolidations (arrows) mixed with GGOs (arrow head)

Figure 4 (A-C)

CXR AP views of three different COVID-19 patients demonstrating radiographic grading of severity of disease. (A) Mild grade: small areas of GGOs occupying bilateral lower zones and the abnormal white area is less than the normal black area. (B) Moderate grade: GGOs seen in bilateral peripheral and central lung parenchyma and the areas of white and black are equal. (C) Severe grade: GGOS seen diffusely infiltrating the lung parenchyma and the white area is more than the black area

Figure 5 (A and B)

(A) CXR AP view of a 30 Y/M asymptomatic COVID-19 patient showing small GGOs in bilateral lower zones (arrows). (B) CXR AP view of a 32 Y/F presenting with fever and cough since fivedays and history of contact with COVID-19 patient shows pleural effusion on right side without any other specific lung parenchymal abnormality