RESEARCH LETTER
Diagnostic Performance of Chest X-Ray for
COVID-19 Pneumonia During the SARS-CoV-2
Pandemic in Lombardy, Italy
Simone Schiaffino, MD,* Stefania Tritella, MD,* Andrea Cozzi, MD,†
Serena Carriero, MD,‡ Lorenzo Blandi, MD,§∥
Laurenzia Ferraris, MD, PhD,∥ and Francesco Sardanelli, MD*†
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Abstract: Chest x-ray (CXR) can play a role in diagnosing patients
with suspected severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2) infection, but only few small-scale studies are
available. We assessed the diagnostic performance of CXR in
consecutive patients presenting at the emergency room at the Poli-
clinico San Donato, Milan, Italy from February 24 to April 8, 2020
for suspected SARS-CoV-2 infection. The results of CXR were
classified as positive or negative according to the original pro-
spective radiologic reports. To overcome the limitations of reverse
transcriptase-polymerase chain reaction (RT-PCR) swab, especially
oscillating sensitivity, we added the information obtained from
phone calls to discharged patients with negative initial RT-PCR.
Thus, we included 535 patients with concomitant CXR and RT-
PCR on admission (aged 65±17 y; 340 males, 195 females), resulting
in 408 RT-PCR positive and 127 negative patients at the composite
reference standard. Original CXR reports showed an 89.0% sensi-
tivity (95% confidence intervals [CI], 85.5%-91.8%), 60.6% specif-
icity (95% CI, 51.6%-69.2%), 87.9% positive predictive value (95%
CI, 84.4%-90.9%), and 63.1% negative predictive value (95% CI,
53.9%-71.7%). The adoption of CXR alongside RT-PCR to triage
patients with suspected SARS-CoV-2 infection could foster a
safe and efficient workflow, counteracting possible false negative
RT-PCR results.
Key Words: COVID-19, SARS-CoV-2, coronavirus, pneumonia,
viral, chest x-ray
(J Thorac Imaging 2020;35:W105–W106)
BRIEF INTRODUCTION
The current reference standard for severe acute respi-
ratory syndrome coronavirus 2 (SARS-CoV-2) infection is
reverse transcriptase-polymerase chain reaction (RT-PCR),
which, however, has limited sensitivity.1 Chest x-ray (CXR)
From the *Unit of Radiology, IRCCS Policlinico San Donato; ∥Hos-
pital Infection Control Committee, IRCCS Policlinico San Donato,
San Donato Milanese; †Department of Biomedical Sciences for
Health, Università degli Studi di Milano; ‡Postgraduate School in
Radiodiagnostics, Università degli Studi di Milano, Milano; and
§Postgraduate School in Hygiene and Preventive Medicine, Uni-
versità degli Studi di Pavia, Pavia, Italy.
This study was partially supported by Ricerca Corrente funding from
Italian Ministry of Health to IRCCS Policlinico San Donato.
S.S. declares to have received travel support from Bracco Imaging and to
be a member of the speakers’ bureau for General Electric. F.S.
declares to have received grants from or to be a member of speakers’
bureau/advisory board for Bayer, Bracco, and General Electric. The
remaining authors declare no conflicts of interest.
Correspondence to: Andrea Cozzi, MD, Department of Biomedical
Sciences for Health, Università degli Studi di Milano, Via Man-
giagalli 31, Milano 20133, Italy (e-mail: andrea.cozzi1@unimi.it).
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/RTI.0000000000000533
J Thorac Imaging  Volume 35, Number 4, July 2020
Copyright r 2020 Wolters Kluwer Health, Inc. All rights reserved.
and computed tomography (CT) can play a role in the
diagnostic pathway,1,2 but to date, only a few small-scale
studies have reported on CXR.3 Our aim was therefore to
assess the diagnostic performance of CXR performed at
presentation at our hospital emergency room (ER) in a
relatively large population, negotiating known sensitivity
shortcomings of the initial RT-PCR by building a composite
reference standard.
METHODS
This IRB-approved retrospective observational study
was carried out at IRCCS Policlinico San Donato (San
Donato Milanese, Italy), including consecutive patients
presenting to the ER for suspected SARS-CoV-2 infection
from February 24 to April 8, 2020, all of them undergoing
both digital CXR and nasopharyngeal swab for RT-PCR.
Anteroposterior bedside CXR was performed in the ER
within 12 hours from admission. CXRs were classified as
positive or negative according to original radiologic reports.
We took RT-PCR as the reference standard, considering
laboratory-confirmed cases as those with positive or weakly-
positive swab. RT-PCR-negative patients, without a second
swab performed at our institution, were contacted by phone
to ask whether, after discharge, they underwent a second
swab at another institution, or they were hospitalized for
COVID-19 infection in another institution, or whether they
had COVID-19-suggestive symptoms during quarantine.
Diagnostic performance indexes for CXR were presented as
sensitivity, specificity, positive predictive value (PPV), neg-
ative predictive value (NPV), and their 95% confidence
interval (CI). Statistical analyses were carried out using
Microsoft Excel 2019 (Microsoft Corporation, Redmond,
WA).
RESULTS
We included in this study 535 patients with con-
comitant CXR and swab at ER admission (aged 65 ± 17 y,
mean ± SD, 340 males). The initial swab was positive in 398/
535 cases (74.4%) and negative in 137/535 (25.6%). Forty
swab-negative patients had a second swab, 9 (22.5%) with a
positive result, and 31 (77.5%) confirmed as negative. The
composite reference standard converted one weakly positive
swab to a negative case, considering a second negative swab
performed 5 days after at another institution. Eleven neg-
ative swabs were converted to positive cases, 3 of which
were because of a third positive swab within 8 days. This
finally resulted in 408 positives and 127 negatives at the
composite reference standard. Using the composite
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Schiaffino et al J Thorac Imaging  Volume 35, Number 4, July 2020

FIGURE 1. Bedside anteroposterior chest x-rays of suspected COVID-19 patients as classified by the radiologist on duty. Chest x-rays in
afterwards-confirmed COVID-19 patients were correctly (A, true positive) and incorrectly (B, false negative) classified: in (A), bilateral
patchy consolidations can be seen with a predominant peripheral distribution and apical saving, whereas, in (B), blurred small peri-hilar
opacity in the right lower peri-hilar region (red oval) was misinterpreted by the radiologist. Chest x-rays in afterwards-confirmed non-
COVID-19 patients were correctly (C, true negative) and incorrectly (D, false positive) classified: in (C), no findings are attributable to
COVID-19, whereas in (D), the radiologist misinterpreted the presence of a “noticeable interstitial prominence” in the right lower peri-
hilar region.

reference standard, CXR found 363 true positives (Fig. 1A),
45 false negatives (Fig. 1B), 77 true negatives (Fig. 1C), and
50 false positives (Fig. 1D), resulting in an 89.0% sensitivity
(95% CI, 85.5%-91.8%), 60.6% specificity (95% CI: 51.6%-
69.2%), 87.9% PPV (95% CI: 84.4%-90.9%), and 63.1%
NPV (95% CI: 53.9%-71.7%).
COMMENT
As highlighted by various authors,1–3 the role of CXR
in the diagnosis of COVID-19 must be driven by several
factors: (1) lack of an immediate reliable molecular diag-
nosis; (2) possible limited availability of CT and difficulties
in fast sanitization of CT rooms, also considering the need
to use CT for other-than-COVID-19 diseases; (3) ease of
CXR performance in isolated rooms in the ER; and (4) high
prevalence of COVID-19 in the presence of pandemic out-
break. The last factor, that is, a very high pretest proba-
bility, associated with disease spectrum skewed to a high
disease severity and strong reduction in the prevalence of
non-COVID-19 pneumonia, boosted bedside CXR diag-
nostic performance.4 In our experience, limited to one center
in Lombardy, Italy, and to real-life reporting without
independent image review, CXR showed a much higher
sensitivity than previously reported,3 approaching that of
CT and even surpassing its reported specificity.5 In con-
clusion, also considering that CXR diagnostic performance
could be further enhanced by artificial intelligence
applications,6 the adoption of CXR imaging alongside
RT-PCR for COVID-19-suspected patients’ triaging can
warrant a safe and efficient workflow.
ACKNOWLEDGMENTS
The authors thank their following colleagues at IRCCS
Policlinico San Donato for their contribution to the clinical
work, which allowed to plan and write this article: Pietro
Bertolotti, Bijan Babaei Paskeh, Giuseppe Buragina, Luca
Alessandro Carbonaro, Saverio Chiaravalle, Laura Menicagli,
Cristian Giuseppe Monaco, and Riccardo Spairani.
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