COVID-19 Infection in Octagenarian Patients: Imaging Aspects and Clinical Correlations

Abstract

Introduction: Computed tomography (CT) of the chest, although not a screening test or diagnosis of infection with the new coronavirus, has a fundamental role in assessing the extent of lung involvement and complications such as pleural effusion. Considering the higher morbidity and mortality of elderly patients due to this infection, the objective of this study was to evaluate the imaging aspects and clinical correlations of an extreme age (≥80 years) with a confirmed diagnosis for COVID-19.

Methods: This was a retrospective and single-center cohort study. CT scans were categorized qualitatively and quantitatively. In the first case, 3 descriptors were used to describe CT findings: "compatible" (findings of greater specificity for COVID-19: opacities with attenuation in ground glass with peripheral and bilateral distribution, with rounded morphology, with or without consolidations, crazy-pavement aspect, inverted halo sign, or organizing pneumonia findings), "doubtful" (findings not specific or unusual for COVID-19: opacities with attenuation in ground glass with nonrounded morphology, central, diffuse, or unilateral distribution, with or without consolidation, lobar or segmental consolidation without ground-glass opacity, small centrilobular nodules with the appearance of "tree-in-bud," excavations, pleural effusion, and thickening of interlobular septa), and "negative" (absence of pneumonia signs). For the quantitative assessment, which referred to the extent of pulmonary involvement, a tomographic severity classification was used: grade 1 (lung involvement ≤25%), grade 2 (pulmonary involvement between 26 and 50%), and grade 3 (pulmonary involvement >50%).

Results: A total of 138 patients were evaluated, with an average age of 86.2 years (84 women and 34 men). The mean time interval between onset of symptoms and tomography was 5.63 days. The most prevalent comorbidity was systemic arterial hypertension (81.2%). Compatible, doubtful, and negative tests were 117 (84.7%), 20 (14.4%), and 1 (0.7%), respectively. As for compatible exams, the most common findings were opacities in peripheral ground glass and rounded morphology, followed by crazy paving. The prevalence of pleural effusion was 28.2% and consolidation was 63.7%, and none of these findings were influenced by the duration of symptoms (p = 0.08 and p = 0.2, respectively). The exams classified as grade 1, grade 2, and grade 3 were 57 (41.6%), 46 (33.6%), and 34 (24.8%), respectively. There were statistically significant associations between the classification of tomographic severity and outcomes such as invasive ventilation (p = 0.004), admission to the intensive care unit (p < 0.001), and death (p < 0.001).

Discussion/conclusion: Our results show that patients ≥80 years old present tomographic manifestations similar to those described for the general population (ground-glass opacities and "crazy paving") and that the extent of lung involvement is associated with the need for intensive care, invasive ventilation, and death. Although the literature describes an association between the stage of the disease and the appearance of consolidations and pleural effusion, this correlation was not observed in our study, which may suggest that this age-group is more predisposed to the appearance of such findings, typically described in the more advanced stages of infection.

Keywords: COVID-19 infection; Clinical correlations; Computed tomography; Elderly people; Imaging; Tomographic manifestations.

Fig. 1

Images in an 89-year-old man, with systemic arterial hypertension and obesity. Time interval between onset of symptoms and tomography was 7 days. Unenhanced chest CT scan with typical features for COVID-19 infection. a–c Axial section showing periferal and multifocal ground-glass opacity (arrows). d–f Coronal section showing pulmonary extension under 25% (Grade 1). CT, computed tomography.

Fig. 2

Images in an 88-year-old woman, with systemic arterial hypertension and obesity. Time interval between onset of symptoms and tomography was 10 days. Unenhanced chest CT scan with typical features for COVID-19 infection. a–c Axial section showing diffuse ground-glass opacities (arrows), and visible intralobular lines. d–f Coronal section showing pulmonary extension between 26 and 50% (Grade 2). CT, computed tomography.

Fig. 3

Images in an 85-year-old woman, with systemic arterial hypertension. Time interval between onset of symptoms and tomography was 6 days. Unenhanced chest CT scan with typical features for CO­VID-19 infection. a–c Axial section showing bilateral, multifocal rounded (asterisks), and peripheral ground-glass opacity (arrows). d–f Coronal section showing pulmonary extension >50% (Grade 3). CT, computed tomography.

Fig. 4

Images in an 83-year-old woman, with systemic arterial hypertension and obesity. Time interval between onset of symptoms and tomography was 19 days. Unenhanced chest CT scan with typical features for COVID-19 infection. a–c Axial section showing bilateral and multifocal ground-glass opacity (arrows) with superimposed interlobular septal thickening and visible intralobular lines (“crazy paving”). CT, computed tomography.

Fig. 5

Images in an 84-year-old woman with systemic arterial hypertension and diabetes. Time interval between onset of symptoms and tomography was 2 days. Unenhanced chest CT scan shows organizing pneumonia features. a–c Posterior and peripheral ground-glass opacities (asterisks) with consolidations areas (arrows). CT, computed tomography.

Fig. 6

Images in an 83-year-old smoker man with systemic arterial hypertension. Time interval between onset of symptoms and tomography was only 1 day. Unenhanced chest CT scan show typical CO­VID-19 infection sumperimposed with bacterial pneumonia. a, b Axial section showing central and peripheral ground-glass opacities (asterisks), segmental consolidation (arrowhead), and pleural effusion. Air bronhograms are observed in the right lower lobe, suggestive of nonviral etiology, which was confirmed by blood culture. CT, computed tomography.

Fig. 7

Images in an 84-year-old smoker woman. Time interval between onset of symptoms and tomography was 7 days. Unenhanced chest CT scan with doubtful features for COVID-19 infection. a, b Axial section showing hilar/central ground-glass opacity (arrows), consolidation with air bronchograms in the right lower lobe (asterisks) and pleural effusion. CT, computed tomography.

Fig. 8

Images in an 81-year-old smoker woman. Time interval between onset of symptoms and tomography was 10 days. Unenhanced chest CT scan with doubtful features for COVID-19 infection. a, b Axial section, pulmonary window showing cavitation in left superior lobe (white asterisk), pulmonary mass in right lower lobe (arrows). c, d Axial section, soft tissue window showing mediastinal lymph node enlargement (black asterisks). All those findings are suggestive of neoplasm etiology. CT, computed tomography.

Fig. 9

Images in an 87-year-old woman. Time interval between onset of symptoms and tomography was 3 days. Unenhanced chest CT scan with negative features for COVID-19 infection. a Axial section, soft tissue window showing right loculated pleural effusion associated with nodular thickening of mediastinal pleura. b Axial section, pulmonary window showing no significant alteration in pulmonary parenchyma. CT, computed tomography.