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Coronavirus Outbreak: What the 58
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Department of Radiology Should 61
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12 Q5 Soheil Kooraki, MD a, Melina Hosseiny, MD b, Lee Myers, MD c, Ali Gholamrezanezhad, MD c 65
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14 Abstract 67
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16 In December 2019, a novel coronavirus pneumonia emerged in Wuhan, China. Since then, this highly contagious coronavirus has been 69
17 spreading worldwide, with a rapid rise in the number of deaths. Novel coronavirus–infected pneumonia (NCIP) is characterized by 70
18 fever, fatigue, dry cough, and dyspnea. A variety of chest imaging features have been reported, similar to those found in other types of 71
coronavirus syndromes. The purpose of the present review is to briefly discuss the known epidemiology and the imaging findings of 72
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coronavirus syndromes, with a focus on the reported imaging findings of NCIP. Moreover, the authors review precautions and safety
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measures for radiology department personnel to manage patients with known or suspected NCIP. Implementation of a robust plan in
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the radiology department is required to prevent further transmission of the virus to patients and department staff members.
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Key Words: Coronavirus, CT cut scan, chest, pneumonia, viral, radiography, radiology, outbreak, safety
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24 J Am Coll Radiol 2020;-:---. Copyright ª 2020 American College of Radiology 77
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26 BACKGROUND The virus, which has been reported in 28 countries as of 79
27 Coronaviruses are nonsegmented, enveloped, positive-sense, this writing, has shown human-to-human transmission and 80
28 single-strand ribonucleic acid viruses, belonging to the is feared to have the potential to cause a pandemic [2,3]. 81
29 Coronaviridae family [1]. Six types of coronavirus have been The mean incubation period is estimated to be 5.2 days, 82
30 identified that cause human disease: four cause mild which allows air travelers to spread the disease globally [4]. 83
31 respiratory symptoms, whereas the other two, Middle East Evidence shows that virus transmission can occur during the 84
32 respiratory syndrome (MERS) coronavirus and severe incubation period in asymptomatic patients. Moreover, high 85
33 acute respiratory syndrome (SARS) coronavirus, have sputum viral loads were found in a patient with NCIP 86
34 caused epidemics with high mortality rates. during the recovery phase [5]. As of February 5, 2020, more 87
35 In December 2019, a new type of coronavirus called than 25,000 confirmed cases have been reported worldwide, 88
36 2019 novel coronavirus was extracted from lower respiratory with a rapid rise in the number of deaths. The Word Health 89
37 tract samples of several patients in Wuhan, China. These Organization has announced the outbreak a global health 90
38 patients presented with symptoms of severe pneumonia, emergency. 91
39 including fever, fatigue, dry cough, and respiratory distress. Imaging is critical in assessing severity and disease pro- 92
40 Novel coronavirus–infected pneumonia (NCIP) is believed gression in coronavirus infection. Radiologists should be 93
41 to have originated in a wet “seafood market” in Wuhan. aware of the imaging manifestations of the novel coronavirus 94
42 infection. A variety of imaging features have been described 95
43 in similar coronavirus-associated syndromes. In this brief 96
a
44 Keck School of Medicine, University of Southern California, Los Angeles, review, we discuss the epidemiologic and radiologic features 97
California.
45 b
Department of Radiological Sciences, David Geffen School of Medicine,
of coronavirus syndromes, with a focus on the known im- 98
46 University of California at Los Angeles, Los Angeles, California. aging features of NCIP. In addition, precautions and safety 99
measures for radiology department personnel in managing 100
c
47 Division of Emergency Radiology, Department of Radiology, Keck School
of Medicine, University of Sothern California, Los Angeles, California.
48 patients with known or suspected NCIP are discussed. 101
Corresponding author and reprints: Ali Gholamrezanezhad, MD, Division
49 of Emergency Radiology, Department of Radiology, Keck School of SARS: EPIDEMIOLOGY AND IMAGING 102
50 Medicine, University of Sothern California, 1500 San Pablo Street, Los
SARS coronavirus was first recognized in 2003 after a global 103
51 Angeles, CA 90033; e-mail: ali.gholamrezanezhad@med.usc.edu.
outbreak originating in southern China. The virus spread to 104
The authors state that they have no conflict of interest related to the ma-
52 29 countries globally, affecting 8,422 patients, with a 105
Q 3 terial discussed in this article.
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Graphical abstract
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131 mortality rate of 11%. The transmission of this coronavirus MERS: EPIDEMIOLOGY AND IMAGING 183
132 occurs via large droplets and direct inoculation [6]. The MERS coronavirus infection was first reported in Jeddah, 184
133 virus may remain viable for up to 24 hours on dry surfaces, Saudi Arabia, in 2012 [10]. Since then, approximately 185
134 but it loses its infectivity with widely available disinfectants 2,500 laboratory-confirmed human infections have been 186
135 such as Clorox and formaldehyde [7]. reported in 27 countries, with a mortality rate reaching 187
136 Initial chest radiography in individuals with SARS will more than 30% [11]. The risk for transmission to family 188
137 frequently show focal or multifocal, unilateral, ill-defined members and health workers seems to be low. Despite 189
138 air-space opacities in the middle and lower peripheral lung the potential for epidemics through Hajj pilgrimages in 190
139 zones [8], with progressive multifocal consolidation over a Saudi Arabia, there has not been a notable outbreak 191
140 course of 6 to 12 days involving one or both lungs [9]. recently. It seems that in contrast to the human-to- 192
141 Chest CT will show areas of ground-glass opacity and human pathway as the main route of virus spread in 193
142 consolidation in involved segments. SARS coronavirus, the transmission in MERS coronavirus 194
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153 Fig 1. Chest CT scan from a 50-year-old male Chinese patient with a confirmed diagnosis of novel coronavirus-infected
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154 pneumonia. The patient presented with low-grade fever, cough, sneezing, fatigue, and lymphopenia. Multiple peripheral 206
155 ground-glass opacities are present in both lungs (predominant on the right side), with a subpleural distribution. Imaging 207
156 finding are nonspecific and might be seen with other viral pneumonias as well. Images are courtesy of Min Liu, MD, 208
157 Department of Radiology, China-Japan Friendship Hospital (Beijing, China). 209
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223 Fig 2. Initial chest CT scan of a 78-year-old male Chinese patient with fever, cough, and fatigue showing multiple small 275
224 asymmetric peripheral and subpleural areas of ground-glass opacities in the posterior segment of the right upper lobe and 276
225 the apical segments of the bilateral lower lobes. The imaging findings are highly nonspecific. The diagnosis of novel 277
226 coronavirus–infected pneumonia was established on the basis of analysis of respiratory secretions. Images are courtesy of Bin 278
227 Cao, MD, and Yimin Wang, MD, Department of Pulmonary and Clinical Care Medicine, China-Japan Friendship Hospital 279
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occurs mainly through nonhuman, zoonotic sources (eg, clinical manifestations of NCIP in 41 patients [16].
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bats, camels) [12,13]. According to that report, abnormal chest imaging findings
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In 83% of patients with MERS coronavirus infection, were observed in all patients, with 40 having bilateral
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initial radiography will show some degree of abnormality, disease at initial imaging. This early report on the
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with ground-glass opacities being the most common finding presentation of the NCIP in intensive care unit patients
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[14]. Likewise, CT will show bilateral and predominantly indicated bilateral subsegmental areas of air-space consoli-
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ground-glass opacities, with a predilection to basilar and dation, whereas in non–intensive care unit patients, tran-
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peripheral lung zones, but observation of isolated consoli- sient areas of subsegmental consolidation are seen early, with
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dation (20%) or pleural effusion (33%) is not uncommon bilateral ground-glass opacities being predominant later in
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in MERS [15]. the course of the disease (Figs. 1-3). Serial chest radiography
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of a 61-year-old man who died of NCIP showed progres-
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NCIP: WHAT DO WE KNOW? sively worsening bilateral consolidation during a course of
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Patients with novel coronavirus infection present with 7 days. Another report on 99 individuals with confirmed
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pneumonia (ie, fever, cough, and dyspnea). Although fatigue NCIP described similar imaging findings, with bilateral lung
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is common, rhinorrhea, sore throat, and diarrhea uncom- involvement in 75% and unilateral involvement in 25%
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monly occur. A recent report in The Lancet described the [17]. Another study of five individuals in a family cluster
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258 Fig 3. Follow-up chest CT scan of the same patient as in Figure 2, 7 days later. The clinical scenario deteriorated over the 310
259 course of 7 days, and follow-up chest CT showed extensive confluent ground-glass opacities with areas of consolidation in 311
260 both lungs. The patient died the same day. Images are courtesy of Bin Cao, MD, and Yimin Wang, MD, Department of 312
261 Pulmonary and Clinical Care Medicine, China-Japan Friendship Hospital (Beijing, China). 313
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315 with NCIP [18] described bilateral patchy ground-glass medical staff members who had been exposed to SARS 367
316 opacities, with more extensive involvement of lungs paren- coronavirus, the risk for virus transmission was significantly 368
317 chyma in older family members. The reported imaging reduced by using droplet and contact precautions [21]. 369
318 features most closely resemble those of MERS and SARS. CT and MR machine gantries, noninvasive ultrasound 370
319 No pleural effusion or cavitation has been reported so far in probes, blood pressure cuffs, and image viewing station 371
320 confirmed cases of NCIP, but pneumothorax was reported mice and keyboards need to be disinfected after every 372
321 in 1% of patients (1 of 99) in a study by Chen et al [17]. contact with suspected patients. According to the Spaulding 373
322 Overall, the imaging findings are highly nonspecific and classification of the Centers for Disease Control and 374
323 might overlap with the symptoms of H1N1 influenza, Prevention and FDA, these surfaces need to be either 375
324 cytomegalovirus pneumonia, or atypical pneumonia. The washed with soap and water or decontaminated using a low- 376
325 acute clinical presentation and history of contact with a level or intermediate-level disinfectant, such as iodophor 377
326 novel coronavirus-infected patient or history of recent germicidal detergent solution, ethyl alcohol, or isopropyl 378
327 travel to an eastern Asian country (eg, China) should raise alcohol. Environmental services staff members need to be 379
328 clinical suspicion for the diagnosis of NCIP. Although specifically trained for professional cleaning of potentially 380
329 further investigations on the clinical and radiologic aspects contaminated surfaces after each high-risk patient contact [22]. 381
330 of the novel coronavirus are ongoing, imaging will continue Radiology departments should contact their equipment 382
331 to be a crucial component in patient management. vendors to find the safest disinfectant for each piece of 383
332 equipment in use. 384
333 US health care imaging facilities need to be prepared 385
334 PRECAUTIONS FOR RADIOLOGY for the escalating incidence of new cases of coronavirus. If 386
335 DEPARTMENT PERSONNEL appropriately prepared, radiology department staff members 387
336 Radiographers are among the first-line health care workers can take greater measures to manage the impact of the 388
337 who might be exposed to 2019 novel coronavirus. Diag- coronavirus outbreak on the facility and personnel. A 389
338 nostic imaging facilities should have guidelines in place to multidisciplinary committee should convene to outline 390
339 manage individuals known or suspected novel coronavirus guidelines for imaging facility personnel to prevent virus 391
340 infection. The novel 2019 coronavirus is highly contagious spread thorough human-to-human contact and the depart- 392
341 and is believed to transmit mostly through respiratory ment equipment. Implementation of a robust plan can 393
342 droplets, but there is uncertainty as to whether the virus can provide protection against further transmission of the virus 394
343 be transmitted by touching a surface or an item that is to patients and staff members. 395
344 contaminated (ie, a fomite). A thorough understanding of 396
345 the routes of virus transmission will be essential for patients’ TAKE-HOME POINTS 397
346 and health care professionals’ safety. Droplets have the 398
347 greatest risk of transmission within 3 ft (91.44 cm), but they - The imaging features of NCIP are highly nonspecific 399
348 may travel up to 6 ft (183 cm) from their source [19]. For and are more often bilateral with subpleural and 400
349 the purpose of diagnostic imaging in individuals with peripheral distribution and range from ground-glass 401
350 NCIP, whenever possible, portable radiographic equipment opacities in milder forms to consolidations in more 402
351 should be used to limit transportation of patients. On the severe forms. 403
352 basis of experience with SARS, the use of a satellite - If properly prepared, radiology department personnel 404
353 radiography center and dedicated radiographic equipment can take greater measures to manage the impact of 405
354 can decrease the risk for transmission from known infected the coronavirus outbreak on the department and staff. 406
355 individuals. If a patient needs to be transported to the 407
- Continued data collection and larger epidemiologic
356 radiology department, he or she should wear a surgical mask 408
studies are needed for both a full range of imaging
357 during transport to and from the department. The Centers 409
findings and routes of transmission.
358 for Disease Control and Prevention guidelines for SARS 410
359 coronavirus recommended respiratory protection using a 411
360 fit-tested N95 mask or higher or a surgical mask if an N95 ACKNOWLEDGMENTS 412
361 mask is unavailable. In addition, the droplet precaution The authors thank Bin Cao, MD, Department of Pulmo- Q 4 413
362 instruction recommends appropriate personal protective nary and Clinical Care Medicine, Min Liu, MD, Depart- 414
363 equipment, including a disposable isolation gown with fluid- ment of Radiology, and Yimin Wang, MD, Department of 415
364 resistant characteristics, a pair of disposable gloves with Pulmonary and Clinical Care Medicine, China-Japan 416
365 coverage over gown cuffs, eye protection with goggles, and Friendship Hospital (Beijing, China) for their valuable 417
366 probably a face mask over goggles [20]. In a study of 254 contributions to this article. 418

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419 REFERENCES 13. MacIntyre CR. The discrepant epidemiology of Middle East respira- 471
420 1. Weiss SR, Leibowitz JL. Coronavirus pathogenesis. Adv Virus Res tory syndrome coronavirus (MERS-CoV). Environ Syst Decis 472
2011;81:85-164. 2014;34.
421 14. Das KM, Lee EY, Al Jawder SE, et al. Acute Middle East respiratory 473
2. Wang C, Horby PW, Hayden FG, Gao GF. A novel coronavirus
422 outbreak of global health concern. Lancet 2020;395:470-3. syndrome coronavirus: temporal lung changes observed on the chest 474
423 3. Zhu N, Zhang D, Wang W, et al. A novel coronavirus from patients radiographs of 55 patients. AJR Am J Roentgenol 2015;205:W267-74. 475
15. Das KM, Lee EY, Langer RD, Larsson SG. Middle East respiratory
424 with pneumonia in China 2019. N Engl J Med. In press.
syndrome coronavirus: what does a radiologist need to know? AJR Am
476
4. Li Q, Guan X, Wu P, et al. Early transmission dynamics in Wuhan,
425 China, of novel coronavirus-infected pneumonia. N Engl J Med. In J Roentgenol 2016;206:1193-201. 477
426 press. 16. Huang C, Wang Y, Li X, et al. Clinical features of patients infected 478
with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-
427 5. Rothe C, Schunk M, Sothmann P, et al. Transmission of 2019-nCoV 479
infection from an asymptomatic contact in Germany. N Engl J Med. 506.
428 In press. 17. Chen N, Zhou M, Dong X, et al. Epidemiological and clinical char- 480
429 6. Chan-Yeung M, Xu RH. SARS: epidemiology. Respirology acteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, 481
430 2003;8(suppl):S9-14. China: a descriptive study. Lancet 2020;395:507-13. 482
7. Sampathkumar P, Temesgen Z, Smith TF, Thompson RL. SARS: 18. Chan JF, Yuan S, Kok K-H, et al. A familial cluster of pneumonia
431 associated with the 2019 novel coronavirus indicating person-to-person 483
epidemiology, clinical presentation, management, and infection con-
432 trol measures. Mayo Clin Proc 2003;78:882-90. transmission: a study of a family cluster. Lancet 2020;395:514-23. 484
433 8. Paul NS, Roberts H, Butany J, et al. Radiologic pattern of disease in 19. Siegel JD, Rhinehart E, Jackson M, Chiarello L; Health Care Infection 485
Control Practices Advisory Committee. 2007 guideline for isolation
434 patients with severe acute respiratory syndrome: the Toronto experi-
precautions: preventing transmission of infectious agents in health care
486
ence. Radiographics 2004;24:553-63.
435 9. Wong KT, Antonio GE, Hui DS, et al. Severe acute respiratory syn- settings. Am J Infect Control 2007;35(10 suppl 2):S65-164. 487
436 drome: radiographic appearances and pattern of progression in 138 20. Centers for Disease Control and Prevention. Supplement I: 488
infection control in health care, home, and community settings:
437 patients. Radiology 2003;228:401-6. 489
10. Zaki AM, van Boheemen S, Bestebroer TM, Osterhaus AD, public health guidance for community-level preparedness and
438 Fouchier RA. Isolation of a novel coronavirus from a man with response to severe acute respiratory syndrome (SARS) Available at: 490
439 pneumonia in Saudi Arabia. N Engl J Med 2012;367:1814-20. https://www.cdc.gov/sars/guidance/i-infection/index.html. Accessed 491
440 11. World Health Organization. Middle East respiratory syndrome coro- February 2, 2020. 492
navirus (MERS-CoV). Available at: https://www.who.int/emergencies/ 21. Seto WH, Tsang D, Yung RW, et al. Effectiveness of precautions
441 against droplets and contact in prevention of nosocomial transmission of 493
mers-cov/en/. Accessed February 4, 2020.
442 12. Mobaraki K, Ahmadzadeh J. Current epidemiological status of severe acute respiratory syndrome (SARS). Lancet 2003;361:1519-20. 494
443 Middle East respiratory syndrome coronavirus in the world from 1.1. 22. Mirza SK, Tragon TR, Fukui MB, Hartman MS, Hartman AL. 495
Microbiology for radiologists: how to minimize infection transmission
444 2017 to 17.1.2018: a cross-sectional study. BMC Infect Dis
in the radiology department. Radiographics 2015;35:1231-44.
496
2019;19:351.
445 497
446 498
447 499
448 500
449 501
450 502
451 503
452 504
453 505
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455 507
456 508
457 509
458 510
459 511
460 512
461 513
462 514
463 515
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465 517
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