PDF Radiology COVID-19 Cases (March 2020)

Diagnostic Radiology - Covid 2019
Indonesian Perspective
Herlina Uinarni
Radiology Department of Pantai Indah Kapuk Hospital
Anatomy Department of Medical Faculty of Atma Jaya Catholic University, Jakarta
March 2020
HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020 1

Topics
• Introduction:
– COVID-19.
– Clinical presentation.
• Diagnosis.
• Lung Anatomy
• Normal lung on Computed Tomography (CT)-scan.
• Abnormal lung on CT-scan.
• CT reporting.
• Cases
Introduction
• COVID-19 is a viral disease also known as
SARS-CoV-2 or severe acute respiratory
syndrome coronavirus 2.
• The first cases were seen in Wuhan, China in
December 2019 before spreading globally.
• The current outbreak was recognized as a
pandemi on 11 March 2020.

Clinical Presentation
Common: Less common:
• Fever • Myalgia/arthralgia
• Cough • Headaches
• Fatigue • Sore throat
• Sputum production • Chills
• Shortness of breath • Pleuritic pain.
Rare:
-Nausea, vomiting, diarrhea.
-Nasal congestion
-Palpitations, chest tightness.

Clinical
Illness severity
• Mild: no symptoms, mild coughing and fever.

• Severe: dyspnea, hypoxia or > 50% lung
involvement on imaging.
• Critical: respiratory failure, shock, multi-organ
failure.

Complications
• The ICU patients tended to be older with more
comorbidities
• Common sequelae :
– Acute respiratory distress syndrome (ARDS)
– Acute cardiac injury: elevated troponin levels
– Myocardial ischemia
– Cardiac arrest
– Secondary infections
– Sepsis
– Multiorgan failure.
• In a small subgroup of severe ICU cases:

• Secondary hemophagocytic lymphohistiocytosis
• a cytokine storm syndrome
Diagnosis
• Common laboratory findings:
– Decreased lymphocyte count.
– Increased: high-sensitivity C-reactive protein level.
• Real-time reverse transcriptase-polymerase chain reaction
(RT-PCR) test :
– Very specific, but lower sensitivity of 65-95%  that the
test can be negative even when the patient is infected.
– The test results, can take more than 24 hours.
• CT-scan:
• Higher sensitivity but lower specificity and can play a role
in the diagnosis and treatment of the disease.

Lung Anatomy Structure
Lung interstitium structure The secondary pulmonary lobule
SONOANATOMI, TEKNIS PEMERIKSAAN DAN APLIKASI KLINIS ULTRSONOGRHY PARU. Herlina Uinarni. 2017

The airway anatomy the lobular bronchiole
Primary and secondary
• The secondary pulmonary

lobule is the smallest anatomic
unit of the lung surrounded by
connective tissue septa.
An acinus, a primary pulmonary lobule
https://www.researchgate.net/figure/Secondary-pulmonary-
lobule-as-shown-by-Miller-27-The-diagram-shows- https://epos.myesr.org/esr/viewing/index.php?module=viewing_poster&ta
secondary_fig1_237054885 sk=viewsection&pi=28671&ti=86651&si=586&searchkey=
Normal lung structure anatomy
A group of terminal bronchioles

Pulmonary arterioles
Stroma
connective tissue
Lymph vessels Pulmonary veins

Secondary lobule
• Knowledge of the lung

anatomy is essential for
understanding High-
Resolution computed
tomography (HRCT).
• The interpretation of
interstitial lung diseases
is based on the type of
involvement of the
secondary lobule.
Respiratory zone
Secundary lobules. The centrilobular artery (oxygen-poor blood) and the
terminal bronchiole run in the center. Lymphatics and veins (oxygen-rich
blood) run within the interlobular septa
Smithuis et all. Lung - HRCT Basic Interpretation

https://radiologyassistant.nl/chest/lung-hrct-basic-interpretation
Normal CT image (lung window)
Coronal view Axial view

Normal CT VRT (Volume Rendering
Technique) Bronchography

Normal and Abnormal
Radiographic (CT) patterns
Normal Reticular Alveolar Nodular Cystic

ACR Recommendations for the use of Chest
Radiography and Computed Tomography (CT) for
Suspected COVID-19 Infection
March 11, 2020, https://www.acr.org/Advocacy-and-Economics/ACR-Position-
Statements/Recommendations-for-Chest-Radiography-and-CT-for-Suspected-COVID19-Infection
• CT should not be used to screen for or as a first-line test to diagnose

COVID-19
• CT should be used sparingly and reserved for hospitalized, symptomatic
patients with specific clinical indications for CT. Appropriate infection
control procedures should be followed before scanning subsequent
patients.
• Facilities may consider deploying portable radiography units in ambulatory
care facilities for use when CXRs are considered medically necessary. The
surfaces of these machines can be easily cleaned, avoiding the need to
bring patients into radiography rooms.
• Radiologists should familiarize themselves with the CT appearance of
COVID-19 infection in order to be able to identify findings consistent with
infection in patients imaged for other reasons.
CT Protocol
• CT should receive a non-contrast

(unless iodinated contrast medium is
indicated) chest CT , with
reconstructions of the volume at
0.625-mm to 1.5-mm slice thickness
(gapless).

Chest CT Imaging Features of Coronavirus Disease
2019 (COVID-19) Pneumonia
Zu et.al. Coronavirus Disease 2019 (COVID-19): A Perspective from China. Feb 21 2020https://doi.org/10.1148/radiol.2020200490.
https://pubs.rsna.org/doi/full/10.1148/radiol.2020200490
Comparison of Common
Cold, Influenza, SARS,
MERS and Coronavirus
Disease 2019 (COVID-19)
Zu et.al. Coronavirus Disease 2019 (COVID-19): A Perspective from China. Feb 21 2020https://doi.org/10.1148/radiol.2020200490.
https://pubs.rsna.org/doi/full/10.1148/radiol.2020200490
The primary findings COVID on CT
• Ground-glass opacities (GGO) are usually
bilateral, peripheral, and basal in distribution
• Crazy paving appearance (GGOs and inter-
/intra-lobular septal thickening)
• Air space consolidation
• Bronchovascular thickening in the lesion
traction bronchiectasis

GGO represents
• Filling of the alveolar spaces with pus, edema, hemorrhage,
inflammation/tumor cells.
• Thickening of the interstitium or alveolar walls below the spatial
resolution of the HRCT as seen in fibrosis.
• GGO may either be the result of air space disease (filling of the
alveoli) or interstitial lung disease (i.e. fibrosis).
• The location of the GGO pattern can be helpfull:
– Upper zone predominance: Respiratory bronchiolitis, PCP.
– Lower zone predominance: UIP, NSIP, DIP.
– Centrilobular distribution: Hypersensitivity pneumonitis,
Respiratory bronchiolitis

Crazy paving
•  the combination of septal thickening and alveolar ground-glass

opacity creates a pattern that mimics paving. pathologies.
https://radiopaedia.org/blog?lang=us&page=32

Atypical CT findings
• These findings only seen in a small
minority of patients should raise
concern for superadded bacterial
pneumonia or other diagnoses:
– Mediastinal lymphadenopathy.
– Pleural effusions
• may occur as a complication of COVID-19
• Multiple small pulmonary nodules

• Unlike many other viral pneumonias
https://radiologyassistant.nl/chest/lk-jg-1
Other finding
• Widened vessels
– A typical finding in the area of ground
glass is widening of the vessels (arrow).
• Traction Bronchiectasis
– Finding in the areas of ground glass is
traction bronchiectasis (arrows).
• Subpleural bands and Architectural
distortion.
– There is architectural distortion with the
formation of subpleural bands (arrows).
Ground-glass opacification
(GGO)
• the air spaces in the lungs are filled with liquid and a
collapse of the lung’s alveoli.
• These ground-glass opacities appear on CT scans like a cloudy
blob, which can spread as the disease worsens in a “crazy
pavement” pattern.
Crazy paving
Smithuis et all. Lung - HRCT Basic Interpretation


Increased attenuation
Ground Glass Opacity. Consolidation.
• There is increased • There is increased

parenchymal attenuation parenchymal attenuation
WITHOUT obscuration of which OBSCURES the
the pulmonary vasculature. pulmonary vasculature.

Approach to increased attenuation
Are vascular structure
obscure?
Is there reticulation
Yes No present?
Consolidation GGO
Yes No
Is there Is there Active

traction septal disease
bronchiectasis? thickening?
Look for
Fibrosing lung “Crazy paving”
distribution &
disease DDX
ancillary
features to
narrow DDX
Differential diagnosis of crazy paving on CT imaging
W. De Wever, J. Meersschaert, J. Coolen, E. Verbeken, and J. A. Verschakelen, “ e crazy-paving pattern: a radiological-pathological correlation,”
Insights into Imag ing,vol.2,no.2,pp.117-132,2011
• Coronavirus Disease 2019 (COVID-19): A Systematic Review of Imaging Findings in 919 Patients
Read More: https://www.ajronline.org/doi/full/10.2214/AJR.20.23034 AJR 2020; 215:1–7.
Sana Salehi, Aidin Abedi1, Sudheer Balakrishnan and Ali Gholamrezanezhad

Temporal CT changes
• >50% of patients with COVID-19 have normal
CT scans within 2 days of symptom onset.
• The severity of lung abnormalities peaks
around 9-13 days.
• Ground-glass opacities dominate early,
followed by crazy paving and consolidation.
• With an improvement in the disease
course, "fibrous stripes" appear and the
abnormalities clear at 1 month and beyond.
Temporal CT changes
Ground-glass Consolidation Fibrous stripes

Crazy paving
opacities

CT findings in patients with proven COVID-19 pneumonia
https://radiogyan.com/articles/coronavirus-radiology/
Peripheral distribution of ground-

Bilateral peripheral ground-glass glass opacities (red arrow) with
opacities reverse atoll sign (yellow arrow)

CT findings in patients with proven COVID-19 pneumonia
Basal predominant ground-glass Patchy ground-glass opacities in a

opacities in a patient with COVID- patient with COVID-19 pneumonia.
19 pneumonia

Changes Over Time
• Advanced-phase disease is associated
with a significantly increased frequency of:
– GGO + reticular pattern (crazy pavin)
– Vacuolar sign
– Fibrotic streaks
– Air bronchogram
– Bronchus distortion
– Subpleural line/transparent line
– Pleural effusion

CT Involvement Score
• The severity of the lung involvement on the CT correlates with the severity
of the disease. The severity on CT can be estimated by visual assessment.
• Another method is by scoring the percentages of each of the five lobes
that is involved:
– < 5% involvement
– 5%-25% involvement
– > 75% involvement.
• The total CT score is the sum of the individual lobar scores and can range
from 0 (no involvement) to 25 (maximum involvement), when all the five
lobes show more than 75% involvement.
The percentage of lung involvement can be calculated by multiplying the
total score x 4.
CT-images of positive for COVID-19
(About 75% of the lungs are involved).
HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020

Temporal CT changes
in patients with COVID pneumonia
Duration
Timeline Predominant finding
(days)
o Normal (>50% of patients have normal CT
Early/initial
0-4 scans within 2 days of symptom onset).
stage
o GGO only, partial crazy paving, lower
number of involved lobes
Progressive o Extention of GGO

stage
5-8 o increased crazy paving appearance.
Peak
stage
9-13 o Consolidation
o Gradual resolution.
Absorption o An improvement in the disease
stage
≥14 course, "fibrous stripes" appear and the
abnormalities resolve at 1 month.
Early phase COVID-19.
• There are
widespread
GGO's without
consolidation.
• No architectural
distortion.

COVID-19 infection was assumed
to be highly likely - late phase.
• Bilateral areas of
GGO.
The ground glass
density is more
pronounced
• Fibrotic bands
(arrows).
• Dilated vessels in
affected area
https://radiologyassistant.nl/chest/lk-jg-1 (circle).
COVID-19 infection was assumed
to be highly likely - late phase.
• Bilateral
subpleural
GGO's
• Consolidation in
right lower lobe
with traction
bronchiectasis
(green arrow).
• Fibrous bands
(yellow arrow).
Imaging (CT)
differential diagnosis
Pneumocystis jirovecii Cytomegalovirus Cryptogenic organizing

pneumonia pneumonia pneumonia
Influenza A pneumonia Chronic eosinophilic pneumonia

CT Report
• https://radiologyassistant.nl/chest/lk-jg-1
Possible role of CT
• CT can play a role in:
– Patient Triage:
• no COVID-19
• possible or most likely COVID-19
• severity of the disease
• Prediction of worsening
• Prediction of improvement
• Problem solver
Triage
• Some published clinical guidelines recommend chest CT for
patients with suspected COVID-19.
• The decision to use of CT for triage depends on many

considerations:
– a priori chance of COVID-19 infection.
– CT availability, for instance can one CT be used as Corona-

CT or is there a CT near the emergency room.
– clinical suspicion in patients with negative PCR.

CT reporting proforma: COVID-19(1)

CT reporting proforma: COVID-19(2)
https://bit.ly/BSTICovid19_Database
Case 1.
Male 29 yo, fever 2 days.

CT severity score: mild

Chest X-ray

Axial Lung window

VRT Bronchogram

Small GGO is more easily seen in the vrt image

Case 2.
Male 48 yo, fever and cough 3 days


Chest X-ray

Axial Lung window

Coronal Lung window

VRT Bronchogram

Case 3.
Male 49 yo, fever and cough 4 day

 CT severity score: moderate
s

Chest X-ray

Axial Lung window

Coronal Lung window

VRT Bronchogram

Case 4
Male, 45 yo, fever and cought 6 days.

 CT severity score: moderate-
severe

Chest X-ray

Axial Lung window

Coronal Lung window

VRT Bronchogram

Case 5
Female, 36 yo
Fever and cought 5 days.
 CT severity score: moderate-severe

Axial Lung window

Coronal Lung window

VRT Bronchogram

Case 6
Male, 69 yo, vertigo 3 days, 1 day

cought.
CT severity score: moderate

Chest X-ray

Axial Lung window

Coronal Lung window

Case 7
Male 73 yo, fever and cought 7 days.

 CT severity score: moderate-
severe

Chest X-ray
18-03-2020 20-03-2020

Axial Lung window

Coronal Lung window

VRT Bronchogram

Case 8
Man 36 yo, fever and cought 4 days.

 CT severity score: mild-moderate

Axial Lung window

Coronal Lung window

VRT Bronchogram

Case 9
Man, 27 yo
10 days ago from abroad, no symptom (first),
6 days later fever and cought.
1 CT (18 March 2020)
2 Ct (24 March 2020).
CT (18 March 2020)

CT (18 March 2020)

CT (18 March 2020)

CT (24 March 2020)

CT (24 March 2020)

CT (24 March 2020)

Case 10
Man 59 yo, fever and cought 5 days,

Fatigue.
CT severity score: moderate-severe.

Axial Lung window

Coronal Lung window

VRT Bronchogram

Resume case 1-10
No Sex/age Symptom CT severity score RT-
PCR
1. Male/ 29 yo Fever 2 days Mild ?
2. Male/48 yo Fever and cough 3 days Mild ?
3. Male/49 yo Fever and cough 4 days Moderate +
4. Male/45 yo Fever and cough 6 days Moderate-severe +
5. Female/36 yo Fever and cough 5 days Moderate-severe ?
6. Male/69 yo, Vertigo 3 days, 1 day cought Moderate +
7. Male/73 yo Fever and cough 7 days Moderate-severe ?
8. Male/36 yo Fever and cough 4 days Mild-moderate ?
9. Male/27 yo 10 days ago from abroad, no Mild-moderate ?

symptom, fever in 6 days.
10 Male/59 yo Fever and cough 5 days, fatigue Moderate-severe +
Case 11
Male, 54 yo, Cought 7 days.

CT severity score: moderete-severe.

Chest X-ray

Axial Lung window

Coronal Lung window

VRT Bronchogram

Case 12
Male, 37 yo.
Cought 5 days, fever 3 days.
X-ray: 13 and 16 March 2020
Ct: 16 and 23 March 2020.
CT severity score: moderate-severe

X-ray
13-03-20 16-03-20

Ct: 16 March 2020

Axial Lung window

Coronal Lung window

VRT Bronchogram

Ct: 23 March 2020

Axial Lung window

Coronal Lung window

VRT Bronchogram

Case 13
Male, 33 yo. Fever 3 days.

Bronchiectasis.
Probable COVID-19 infection.CT severity score: mild

Axial Lung windowCT

Coronal Lung window

VRT Bronchogram

Case 14
Man, 49 yo.
CT : 21-03-20
Ct: 27-03-20
CT severity score: mild.
Chest X-ray

CT : 21-03-20

CT : 21-03-20

Ct: 27-03-20

Ct: 27-03-20

Ct: 27-03-20

Case 15
Male, 26 yo.
CT : 18-03-20
Ct: 26-03-20

Chest X-ray

CT : 18-03-20

CT : 18-03-20

CT : 18-03-20

Ct: 26-03-20

Ct: 26-03-20

Ct: 26-03-20

Case 16
Male, 84 yo.
Shortness of breath in 5 days.
CT severity score: moderate-severe.

Axial Lung window

Coronal Lung window

VRT Bronchogram

Case 17
Female, 45 yo.
CT1: 15-03-2020
Ct2: 27-03-2020

Axial Lung window

Coronal Lung window

Ct2: 27-03-2020

Ct2: 27-03-2020

Ct2: 27-03-2020

Case 18
Male, 32 yo.

Axial Lung window

Coronal Lung window

VRT Bronchogram

Case 19
Female, 56 yo.

Axial Lung window

Coronal Lung window

VRT Bronchogram

Case 20
Female, 32 yo.
Fever and epigastric pain.

Axial Lung window

Coronal Lung window

VRT Bronchogram

Resume case 11-20
No Sex/age Symptom CT severity score RT-
PCR
11. Male/ 54 yo 7 cought days. Moderate-severe +
12. Male/37 yo Cought 5 days, fever 3 days. Moderate-severe +
13. Male/33 yo Fever 3 days, post TB Mild +
14. Male/49 yo Fever and cough 3 days Mild +
15. Male/26 yo Fever and cough in 5 days Moderate-severe +
16. Male/84 yo, Shortness of breath in 5 days. Moderta severe +
17. Female/45 yo Fever and cough in 5 days Moderate +
18. Male/32 yo Fever and cough in 7 days Moderate ?
19. Female/56 yo Fever and cough in 5 days. Moderate-severe ?
20. Female/32 yo Fever and epigastric pain. Moderate-severe ?

Conclusion
• Coronavirus disease 2019 (COVID-19) presents fever
and cough are common clinical manifestations.
• Typical CT findings of COVID-19 include peripherally
distributed multifocal ground-glass opacities (GGOs)
with patchy consolidations and posterior part or
lower lobe involvement predilection
• Radiologists understanding of clinical and chest CT
imaging features of COVID-19 will help to detect the
infection early and asses the disease course.

• Dr. Th. Peter Budisusetija. MARS
• Dr. Bobby Singh. Sp. P
• Dr. Dance Theno. Sp. P
• Dr. Liliana Sugiharto. Msc. PA (K).
• All collegue and friends in Pantai Indah Kapuk (PIK) Hospital,
especially:
– Radiology Department.
– Emergency department
– Internal medicine
– All that non-medical staff PIK Hospital.

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Diagnostic Radiology - Covid 2019

HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020 1

HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020 3

HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020 4

• Mild: no symptoms, mild coughing and fever.

HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020 5

• In a small subgroup of severe ICU cases:

HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020 7

HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020 8

• The secondary pulmonary

A group of terminal bronchioles

Lymph vessels Pulmonary veins

HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020 10

• Knowledge of the lung

Smithuis et all. Lung - HRCT Basic Interpretation

Coronal view Axial view

HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020 13

HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020 14

Normal Reticular Alveolar Nodular Cystic

HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020 15

• CT should not be used to screen for or as a first-line test to diagnose

• CT should receive a non-contrast

HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020 17

HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020 20

HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020 21

•  the combination of septal thickening and alveolar ground-glass

HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020 22

• Multiple small pulmonary nodules

Smithuis et all. Lung - HRCT Basic Interpretation

HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020 25

• There is increased • There is increased

HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020 26

Is there Is there Active

HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020 30

Ground-glass Consolidation Fibrous stripes

HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020 32

Peripheral distribution of ground-

HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020 33

Basal predominant ground-glass Patchy ground-glass opacities in a

HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020 34

HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020 35

HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020

Progressive o Extention of GGO

HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020 39

Pneumocystis jirovecii Cytomegalovirus Cryptogenic organizing

Influenza A pneumonia Chronic eosinophilic pneumonia

• The decision to use of CT for triage depends on many

– CT availability, for instance can one CT be used as Corona-

– clinical suspicion in patients with negative PCR.

HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020 46

Male 29 yo, fever 2 days.

HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020 49

HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020 50

HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020 51

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HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020 53

Male 48 yo, fever and cough 3 days

HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020 54

HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020 55

HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020 56

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Male 49 yo, fever and cough 4 day

HU/FKIK ATMA JAYA/RS PIK JAKARTA 2020 59