CHEST

RADIOLOGICAL
FINDINGS
IN
COVID - 19
M. Irvanie R Harahap, MD
CENTRAL ARMY HOSPITAL GATOT SOEBROTO
2020
INTRODUCTIONS
 DEFINITION

COVID-19:
Coronavirus Disease 2019, An infectious
disease caused by a coronavirus species,
namely severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2), previously known
as the 2019 novel coronavirus (2019-nCoV).

Zhu et al – A Novel Coronavirus From Patients With Pneumonia in China, n engl j med 382;8 (2020)
 EPIDEMIOLOGY

Dec 2019:
First case in Wuhan, China
(a seafood wholesale market)

March 2020:
Global Pandemic

March 2020:
Pandemic in Indonesia

Zhu et al – A Novel Coronavirus From Patients With Pneumonia in China, n engl j med 382;8 (2020)
 EPIDEMIOLOGY
As of 16 September 2020:
The Government of Indonesia announced 228 993 (3 963 new)
confirmed cases of COVID-19, 9 100 (135 new) deaths and 164
101 recovered cases from 493 districts across all 34 provinces.

WHO – Coronavirus Disease 2019 Situation Report (2020)

 VIROLOGY

Coronavirus is a encapsulated virus with a positive,

unsegmented single-strain RNA genome. Round or elliptical
in shape and 50-200nm in diameter. Derived from the
Coronaviridae Family and Nidovirales Order.

Four coronavirus genera (α, β, γ, δ) have been identified so far,

with human coronaviruses (HCoVs) detected in the α coronavirus
(HCoV-229E and NL63) and β coronavirus (MERS-CoV, SARS-CoV,
HCoV-OC43, HCoV-HKU1 and SARS-CoV-2 ).

Li et al – Molecular immune pathogenesis and diagnosis of COVID-19, Journal of Pharmaceutical

Analysis 10 (2020).
Kausalya - Coronavirus Symptoms and Prevention Explained Through Medical Animation (2020)
 VIROLOGY

Transmission:
Viruses can be transmitted from animals to humans
(Zoonosis). The process of transmission through direct,
droplet, or faecal-oral contact. Animals that often become
hosts are bats, rats, camels and ferrets.

Human-to-human transmission occurs through droplets.

Shereen et al – COVID-19 infection: Origin, transmission, and characteristics of human coronaviruses, Journal
of Advanced Research 24 (2020)
Shereen et al – COVID-19 infection: Origin, transmission, and characteristics of human coronaviruses, Journal
of Advanced Research 24 (2020)
 CLINICAL SYMPTOMS
The Incubation Period are 1 – 14 days.
Symptoms appear on the third to eighth day

Huang et al – Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China, Lancet 2020; 395
 CLINICAL SYMPTOMS
CYTOKINE STORM:
Uncontrolled systemic inflammatory response resulting from the
release of large amounts of pro-inflammatory cytokines and
chemokines by immune effector cells in SARS-CoV infection.

ARDS and multiple organ failure

Li et al – Molecular immune pathogenesis and diagnosis of COVID-19, Journal of Pharmaceutical Analysis 10 (2020).
 LABORATORIES

The following lab abnormalities have been observed

in patients with covid-19:

Complete Blood Count: Leukopenia, lymphopenia,

thrombocytopenia

Chemistries : elevated BUN / Creatinine, AST, ALT and total

bilirubin.
Inflammatory Markers: normal or low Procalcitonin, high C-Reactive
proteins and ferritin.

Misc: elevated D-Dimer, interleukin-6 and lactate dehydrogenase

Guan W et al - Clinical Characteristics of Coronavirus Disease 2019 in China, N Engl J Med 2020; 382:1708-1720
 LABORATORIES

Gold Standart For Confirmed Cases ?

The diagnostic test used is a reverse transcription-

polymerase chain reaction (PCR) test and is commonly
conducted using a sample collection from nasopharyngeal or
oral pharyngeal swabs

Over a thousand samples from 200 patients from China,

sensitivities were reported to be is following:
bronchoalveolar 93%, sputum 72%, nasal swab 63%,
pharyngeal swab 32%, feces 29%, blood 1%, urine 0%

Hadaya J, Schumm M, Livingston EH. Testing Individuals for Coronavirus Disease 2019 (COVID-19). JAMA. 2020.
Hadaya J, Schumm M, Livingston EH. Testing Individuals for Coronavirus Disease 2019 (COVID-19). JAMA. 2020.
 OPERATIONAL DEFINITIONS

People with Acute Respiratory Infections (ARI) AND

in the last 14 days before symptoms appeared had a
history travel or live in a country / territory of
Indonesia report local transmissions.

People with any of the symptoms / signs of ARI AND

SUSPECTED at 14 days last before symptoms appeared had a
history of contact with confirmed / probable cases of
COVID-19.

People with severe ARI / severe pneumonia requires

hospital care AND does not exist other causes based
on a convincing clinical picture.

Keputusan Menteri Kesehatan Republik Indonesia Nomor Hk.01.07/Menkes/413/2020 Tentang Pedoman

Pencegahan Dan Pengendalian Coronavirus Disease 2019 (Covid-19)
 OPERATIONAL DEFINITIONS

Suspected cases with serious ARDs / ARDS / died

PROBABLE with COVID-19 reassuring clinical symptoms AND
there are no results RT-PCR laboratory examination.

A person who has tested positive for the COVID-

CONFIRM 19 virus proven by the RT-PCR laboratory
ED examination.

Symptomatic Unsymptomatic

Keputusan Menteri Kesehatan Republik Indonesia Nomor Hk.01.07/Menkes/413/2020 Tentang Pedoman

Pencegahan Dan Pengendalian Coronavirus Disease 2019 (Covid-19)
 OPERATIONAL DEFINITIONS

Face to face contact with probable cases or

confirmed cases within a radius of 1 meter and
within a time frame 15 minutes or so.

Immediate physical touch with probable or

confirmed cases (such as shaking hands, holding
hands, etc.)
CLOSE
CONTACT
People who provide direct care of probable or
confirmed cases without the use of appropriate PPE.

Any other situation indicating contact

based on the local risk assessment established by the
local epidemiological investigation teams.

Keputusan Menteri Kesehatan Republik Indonesia Nomor Hk.01.07/Menkes/413/2020 Tentang Pedoman

Pencegahan Dan Pengendalian Coronavirus Disease 2019 (Covid-19)
 CHEST
RADIOGRAPH
 RADIOGRAPH
Recommendation:
To be used as a first step for radiological
evaluation

Need less of preparations.

Simple and fast.
High in availabilities.
Can be used in many patients.
Easy to clean and decontaminate.

Can be an aid to establish diagnosis in order to

determine the next course of action for the
patient.

Aziza, Muljadi – Imajing Pneumonia COVID-19 (2020)

 RADIOGRAPH
Can be used to evaluate and follow up of
disease progression

Less sensitive when compared to CT Scan.

Chest radiography is insensitive in mild or

early COVID-19 infection.

A diagnosis of Covid-19 cannot be made

based solely on chest radiographs.

Aziza, Muljadi – Imajing Pneumonia COVID-19 (2020)

 When and how is chest radiography
requested?

All seriously ill patients (oxygen saturation <94%)

The British initially have a chest radiograph and that those who
Society of do not meet those criteria should have a chest
radiograph if “clinically required”
Thoracic
Imaging
(BSTI) If the patient is breathless, with oxygen saturation of
less than 94%, and the chest radiograph is normal or
uncertain for covid-19 à Chest CT scan

Cleverley et al - The role of chest radiography in confirming covid-19 pneumonia, : BMJ 2020;370:m2426
Decision tool for radiological management of patients with suspected
covid-19

Cleverley et al - The role of chest radiography in confirming covid-19 pneumonia, : BMJ 2020;370:m2426
 What do we find on Chest
radiography ?
Cozzi et al
(2020) Reticular – Nodular
1 Opacities

482 2 Ground Glass Opacities

Confirmed
Patients
3 Consolidations

Cozzi et al - Chest X-ray in new Coronavirus Disease 2019 (COVID-19) infection: fndings and correlation
with clinical outcome, La radiologia medica (2020).
 Bilateral, both sides of the lungs.
Mainly on the lower lobes.
Distribution
Peripheral or Subpleural predominance.

Pneumothorax.
Rarely Pleural effusions.
Lymphadenopathies.
Caviations.

Cozzi et al - Chest X-ray in new Coronavirus Disease 2019 (COVID-19) infection: fndings and correlation
with clinical outcome, La radiologia medica (2020).
 Reticular – Nodular Opacities

Interstitial involvement in COVID-19

pneumonia.
This patient shows a prevalent right
lung disease with diffuse reticular–
nodular
thickening of peribroncho-vascular
interstitium.

Cozzi et al - Chest X-ray in new Coronavirus Disease 2019 (COVID-19) infection: fndings and correlation
with clinical outcome, La radiologia medica (2020).
Ground glass opacity.

Features include ground glass opacity in both

mid and lower zones of the lungs, which is
predominantly peripheral (white arrows) with
preservation of lung marking. Linear opacity
can be seen in the periphery of the left
mid zone (black arrow).

Cleverley et al - The role of chest radiography in confirming covid-19 pneumonia, : BMJ 2020;370:m2426
Consolidations.

Showing bilateral dense

peripheral consolidation
and loss of lung markings in the
mid and lower zones (outlined
arrows).

Cleverley et al - The role of chest radiography in confirming covid-19 pneumonia, : BMJ 2020;370:m2426
 Progressions Evaluation

Normal chest radiograph Ground glass opacities in the periphery (outer

third of the lung) of both lungs in the mid and
lower zones (white arrows), preservation of lung
marking, and linear opacity in the periphery of
the left mid zone (black arrow).

Cleverley et al - The role of chest radiography in confirming covid-19 pneumonia, : BMJ 2020;370:m2426
 Progressions Evaluation

DAY 10

Dense consolidation with

loss of lung markings is
now seen behind the heart
in the left lower zone
(outlined arrow). Extension
of the peripheral ground
glass changes can be seen
in the periphery of the
right mid and lower zones
and the left mid zone
(white arrows).

Cleverley et al - The role of chest radiography in confirming covid-19 pneumonia, : BMJ 2020;370:m2426
 How to report chest radiography
findings?
BSTI has provided reporting templates with gradings
for use in CXR during the COVID-19 pandemic

https://www.bsti.org.uk/covid-19-resources/covid-19-bsti-reporting-templates/
 BSTI Grading

https://www.bsti.org.uk/covid-19-resources/covid-19-bsti-reporting-templates/
 BSTI Grading (2)

https://www.bsti.org.uk/covid-19-resources/covid-19-bsti-reporting-templates/
 BSTI Grading (3)

https://www.bsti.org.uk/covid-19-resources/covid-19-bsti-reporting-templates/
https://radiopaedia.org/cases/left-lower-lobe-pneumonia-1
 Pneumothorax

Visible right
visceral pleural
edge is seen as a
very thin, sharp
white line and no
lung markings are
seen peripheral to
this line.

https://radiopaedia.org/cases/pneumothorax-with-apical-bleb?lang=gb
 Cardiogenic
pulmonary oedema

There is symmetrical area

shadowing in the central
region of both lungs, left
heart enlargement with
congestion in the
pulmonary veins and
bilateral small to
moderate sized pleural
effusions.

https://radiopaedia.org/cases/cardiogenic-pulmonary-oedema-1?lang=gb
 Classic / Probable
COVID-19

Diffuse bilateral ill

defined peripheral
airspace opacification
in both lungs with
sparing of the apices.
No pleural effusions.

https://radiopaedia.org/cases/covid-19-pneumonia-95?lang=gb
Milliary Tuberculosis

Widespread randomly
distributed
innumerable tiny
nodules in both lungs.
There is no
consolidation or pleural
fluid and no
mediastinal or hilar
nodal enlargement.

https://radiopaedia.org/cases/miliary-tuberculosis-5?lang=gb
 Conclusions

Coronavirus Disease 2019, An infectious

disease caused by a coronavirus species,
namely severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2),

Chest Radiography are recommended to be

used as a first step for radiological
evaluation
 Conclusions

BSTI à Decision tool for radiological

management of patients with suspected
covid-19
Chest Radiography findings: Reticular-nodular,
ground glass opacities, consolidations on
bilateral, subpleural, lower lobes
predominance.
A diagnosis of Covid-19 cannot be made based
solely on chest radiographs.
THANK YOU