Clinico-Radiological Evaluation and Correlation of CT

Chest Images with Progress of Disease in COVID-19

Patients
Sudhir Bhandari*, Govind Rankawat**, Meenu Bagarhatta, Ajeet Singh,
Aparna Singh, Vishal Gupta, Shrikant Sharma, Raman Sharma
*
Senior Professor, Department of Medicine, SMS Medical college, Jaipur, Rajasthan; ** Corresponding
Author: Resident/Fellow student, Department of General Medicine, SMS Medical College,
Jaipur, Rajasthan, India; • ORCID Govind rankawat https://orcid.org/0000-0003-3708-3068. •
E-mail: govindrankawat@gmail.com • Department of General medicine (S. Bhandari, G. Rankawat,
A. Singh, V. Gupta, S. Sharma, R. Sharma,), Department of Radiodiagnosis (M. Bagarhatta, Aparna
Singh) SMS Medical college and attached group of Hospital, Jaipur, Rajasthan, India

Abstract
Purpose: The present study was undertaken to investigate and quantify the severity of COVID-19 infection on high-resolution
chest computed tomography (CT) and to determine its relationship with clinical parameters. This study also aimed to see
CT changes with clinical recovery or progression of disease.
Materials and methods: In an attempt to provide extensive information pertaining to clinical and radiological characteristics
of COVID-19, the present study was undertaken in 80 hospitalized patients. The patients were COVID-19 confirmed positive
by genomic analysis through RT-PCR at tertiary care center in Jaipur. Initially all patients were evaluated for their clinical
parameters and then correlated with HRCT chest after hospitalization. CT findings correlated with duration of disease to
assess progress or recovery.
Results: A total of 80 patients of laboratory confirmed COVID-19 test by RT-PCR at SMS Hospitals, Jaipur were assessed. Among
the confirmed cases, most of patients were young adults in the fifth and sixth decade of age group with mean age of 50.40
years. There was a male preponderance (59% male and 41% female). Out of total analyzed patients, 39 patients (48.75%)
were symptomatic, among them fever (79.47%), cough (74.35%), shortness of breath (36%) and sore throat (17.94%) were
the most common presenting clinical manifestations. A few patients (12.82%) also had other symptoms like headache, chest
pain, pain abdomen, altered sensorium etc. 54% patients had some underlying co morbid disease in sample population.
The most prevalent comorbidities were Diabetes mellitus (56%), Hypertension (48.83%), COPD/K-chest (12%), CAD (9.32%)
and others (11.62%) like hypothyroidism, anemia, CVA etc. The lung pathological changes were evaluated by HRCT imaging
and by assigning CT severity score. We found Typical COVID findings in 50% patients, Indeterminate in 11%, Atypical in 11%
and 28% patients had Negative CT chest for COVID. The clinical status of patients correlated with the CT severity score, with
mild cases showing score <15/25 in 45.83% patients and severe cases showing CT severity score >15/25 in 87.50% patients.
The CT features varied with duration and course of disease. Proportional GGO was higher (59.37%) in early phase and it was
lower (12.5%) in later stage of disease.
Conclusion: The varied spectra of COVID-19 presentation included fever, cough, shortness of breath, sore throat etc. Diabetes
mellitus, hypertension, COPD/K-Chest and CAD were found as major comorbid conditions. Symptomatic presentation of
COVID-19 was observed to be higher in patients with co morbid disease, especially if multiple. HRCT chest in COVID-19
patients had a major diagnostic and prognostic importance as positive CT findings were more prominent in symptomatic
patients and co-morbid patients. Clinical symptoms of patients directly correlated with CT severity index. CT imaging was
found to be useful in predicting clinical recovery of patients or progression of disease.

Introduction Score-5 (>75% area involved), making the total score 25.
A CT Severity Score was assigned out of 25 based on the
Since November 2019, the rapid outbreak of coronavirus
percentage area involved in each of the 5 lobes.
disease 2019 (COVID-19), which arose from severe
To assess the temporal changes of CT findings date of
acute respiratory syndrome coronavirus 2 (SARS-CoV-
onset of illness of each patient and date of CT acquisition
2) infection, has become a public health emergency
for each patient was noted. Sequential imaging was done
of international concern. 1 COVID-19 has contributed
for a few patients to look for disease progression specially
to an enormous adverse impact globally. Infection by
recovery and to guide medical therapy. In early phases,
COVID-19 can result in a range of clinical outcomes, from
areas of pure ground glass haziness were seen with visible
asymptomatic to severe life-threatening course or death.
underlying broncho-vascular markings. The density of
Characterization of epidemiological, clinical, co morbid
lesions in the intermediate and late phases of disease
features with recovery and mortality of COVID-19 is
was higher and was seen as areas of consolidation along
crucial for development and implementation of effective
with few areas of pure GGOs. Both rounded and linear
control strategies and management protocol. Current
patterns of opacification were noted with peripheral
estimates are that the incubation period is generally 3
and/or central distribution of opacities. Vacuolar sign
to 7 days, and up to 14 days. 2 As per literature median
(sign of absorption of lesion and early resolution) was
age of patients is 47–59 years with around 41.9–45.7% of
also described in CT images. Curvilinear bands and sub-
patient population being of female gender. 3 The elderly
pleural sparing, also thought to be signs of resorption
and those with underlying diseases are more seriously
and retraction also noted. Atoll sign or reverse halo sign
ill after infection. 4 Children and infants can also be
seen as an area of GGO surrounded by consolidation,
infected. On admission, many patients have reported
represents a stage of organizing pneumonia. Based on
as having at least one co morbidity with diabetes,
time of onset of illness (time of onset of symptoms in
hypertension, and cardiovascular and cerebrovascular
symptomatic patients or time of positive RT-PCR in
diseases being most commonly reported conditions. 5,14
asymptomatic patients) to time of scan duration, our
The SARS-CoV-2 is highly homologous to SARS-CoV
sample population were classified as early, intermediate
and may cause severe illness similar clinically to
and late phases. Patients were considered to be in the (I)
SARS. 6 Symptoms resulting from COVID-19 infection
early phase of illness if this duration was <5 days, (II)
in the prodromal phase includes fever, dry cough, and
intermediate phase of illness for 5-10 days duration and
malaise, which are nonspecific. 4,7 Some patients may
late if the scan was done 11 days after the date of onset
not even have any obvious symptoms. Therefore, chest
of illness.
computed tomography (CT), in particular high-resolution
computed tomography (HRCT), represents valuable tools Variables: The patient characteristics were collected
in identifying patients with COVID-19 infections in an at baseline and confirmed cases were diagnosed based
early stage when clinical symptoms may be unspecific on positive viral nucleic acid test result on throat swab
or sparse. 8-10 For every suspected patient, chest CT is samples. The variables evaluated included age and
indispensable for definitive diagnosis and reexamination. gender distribution, clinical manifestations, co morbid
According to the World Health Organization and the status, CT characteristic, CT severity score, follow-up CT
Centers for Disease Control and Prevention guidelines, images and their correlation with each other and were
chest radiography and CT were the major diagnostic categorized for analysis and necessary preventive and
components when SARS was prevalent. 11 The clinical curative protocol was initiated. Age distribution graphs
and imaging manifestations in the early stage of were constructed and sex ratio (i.e., male: female [M:F]
COVID-19 are particularly important. They can be used ratio) was calculated. The clinical profile of COVID-19
to confirm the diagnosis, adjust the treatment plan, and positive patients was evaluated in terms of percentage
infer the prognosis. The purpose of our study was to prevalence. Co morbid status of patients was documented
characterize the clinical and HRCT features in patients as percentage prevalence of COVID-19 in such patients
with COVID-19 infection retrospectively, and to facilitate and its correlation with symptomatic presentation. CT
early identification and early isolation. We also aimed to images were evaluated and assigned CT severity score,
explore the change in HRCT on a spectrum of duration CT characteristics, pattern of opacity distribution, type
of disease and whether there was a correlation between of opacities characteristic, characteristics of lesion
clinical and imaging features in the course of the illness. and these findings correlated with symptomatology
As in with influenza, Severe Acute Respiratory Syndrome and co-morbidity of patients. Prevalence of GGO and
coronavirus (SARS-CoV) 12 and Middle East Respiratory consolidation was correlated with total radiologically
Syndrome coronavirus (MERS-CoV) 13 COVID-19 more positive patients in early, intermediate and late phase of
readily predisposes to respiratory failure and death in disease. Proportion of symptomatic patients with their
susceptible patients. 14 Recovery and mortality of patients characteristic CT findings correlated with time duration
from COVID-19 is influenced by their respiratory system of CT imaging from date of onset of illness.
involvement and other systemic comorbidities. Statistical analysis
The present hospital based, observational descriptive
Method
study conducted on 80 COVID-19 patients at SMS Medical
Study Design: The present descriptive, retrospective College Hospital, Jaipur to investigate epidemiological
analysis was done on eighty COVID-19 positive patients distribution, clinical manifestation, co morbid status,
admitted in S.M.S. Medical College Hospital, Jaipur, HRCT chest characteristics and clinic-radiological
Rajasthan from 15th April to 5th May 2020. COVID-19 progression of disease for emerging COVID-19 infection
was declared a public health emergency of pandemic at SMS Medical College Hospital, Jaipur, Rajasthan. The
proportions and subsequently formal screening and descriptive statistics for quantitative data was expressed
diagnostic investigations for SARS-CoV-2 was initiated as mean and standard deviation and qualitative data was
throughout India. Our institutional review board expressed as proportions.
approved this retrospective study. Informed consent
Results
was waived as the study involved no potential risk to
patients. The privacy and confidentiality of patients Serial data from COVID-19 positive patients were
was observed as per norms. To ensure the quality and collected, evaluated, interpreted and correlated with each
integrity of clinical, laboratory, and imaging data, here other to know severity of disease by their clinical and
we included 80 patients with COVID-19 who had been radiological imaging in order to determine prognostic
admitted to our institution. and diagnostic importance of HRCT chest. A total of 80
Data Collection laboratory confirmed COVID-19 patients by RT-PCR
We retrospectively collected the clinical and chest admitted at SMS Medical College Hospital, Jaipur,
imaging data. This included epidemiological data, Rajasthan till 5th May 2020, were assessed. In our study
clinical manifestation, co-morbidities of patients, CT group most of patients in fifth and sixth decades with
chest characteristics, CT severity score. After collection mean age 50.40 year. Percentage distribution of patients
of all required data and careful medical chart review, according to age group was found as <20 year 5%, 20-40
the clinical data of laboratory-confirmed patients was year 23.75%, 40-60 year 40%, >60 year 31.25% (graph 1).
compiled and tabulated. The diagnosis of COVID-19 was Females patients (41%) were lesser than males (59%)
made based on the World Health Organization interim with an average sex ratio of female: male being 0.69 in
guidance, wherein confirmed cases denoted were patients our study (graph 2). Out of total analyzed patients, 39
whose RT-PCR assay findings for nasal and pharyngeal patients (48.75%) were symptomatic while 41 patients
swab specimens were positive. 3 The epidemiological (51.25%) were asymptomatic in our study population
data (age, sex, residence) was recorded and clinical data, (graph 3). In symptomatic patient fever (79.47%), cough
inclusive of recent exposure history, clinical symptoms (74.35%), shortness of breath (36%) and sore throat
and signs, co morbidities, was obtained. All 80 patients (17.94%) were the most common presenting clinical
underwent initial CT scan of chest with an average 4 days manifestations while a few patients (12.82%) also had
of hospitalization. The admitted patients were serially other symptoms like headache, chest pain, pain abdomen,
followed up for their symptomatology complex, with altered sensorium etc. Prevalence of various clinical
recovery of patients being confirmed with first negative presentation in our study sample population distributed
oropharyngeal or nasopharyngeal sample by RT-PCR as fever in 39%, cough in 36.25%, SOB in 18%, sore throat
for COVID-19. A dedicated CT scan machine was used in 8.75% and other manifestation in 6.25% (graph 4). 54%
for scanning of COVID patients and proper disinfection patients had some or other underlying co morbid disease
protocol was followed. To assess the temporal changes in sample population (graph 5). The most prevalent
of CT findings date of onset of illness of each patient co morbidity among sample population was noted
and date of CT acquisition for each patient was noted. as follow: Diabetes mellitus in 30%, Hypertension in
Sequential imaging was done in a few patients to look 26.25%, Chronic obstructive pulmonary disease (COPD)/
for disease progression and to guide medical therapy. Old K-chest in 6%, Coronary artery disease (CAD) in
Review of CT images 5% and other diseases like hypothyroidism, anemia,
CVA in 6.25%. The percentage prevalence of comorbid
Thin section CT images were acquired on a 128 slice
disease among total comorbid patients were found
Ingenia machine. The CT images were evaluated for the
as Diabetes mellitus in 56%, Hypertension in 48.83%,
presence of ground glass haziness (seen as increased
COPD/K-chest in 12%, CAD in 9.32% and other diseases
attenuation with visible broncho-vascular markings),
in 11.62% (graph 6). Out of eighty patients 51 patients
“crazy-paving” (Ground Glass Opacities with interlobular
were found to be radiologically positive on HRCT
thickening), consolidation (increased attenuation of air
chest imaging while 29 patients (36.25%) had normal or
space opacification). The distribution of lesions centrally
non-COVID CT findings. In this study, we assessed the
and peripherally, and anteriorly and posteriorly was
involvement of lungs with CT chest images, in which
also noted. Lesions were further characterized as having
nearly two third patients (63.75% patients) had positive
vacuolations, reverse halo sign, curvilinear bands and
CT findings while less than half of patients (48.755)
sub-pleural sparing. Note was also made of any additional
were symptomatic. CT severity score of asymptomatic
findings such as nodules, cavities, cysts, pleural effusion
radiologically positive patients was found to be <5/25.
and mediastinal lymphadenopathy. Any other pre-
The lung pathological changes were evaluated according
existing lung diseases such as TB, bronchiectasis, and
to HRCT imaging severity score, and we found Typical
emphysema were separately noted.
COVID findings in 50% patients, Indeterminate in 11%,
C T f i n d i n g s we r e o ve r a l l c l a s s i f i e d a s T y p i c a l , Atypical in 2.5% and 36.25% patients had normal CT
Indeterminate, Atypical or Negative for CT features of chest findings. Among radiologically positive patients
COVID-19 pneumonia. Typical features are those that 78.43% patients had typical COVID-19 findings on HRCT
are reported in the literature to be frequently and more chest.
were symptomatic while 41 patients (51.25%) were asymptomatic in ourSymptomatic clinical
study population (graph 3). presentation
In symptomatic higher (69.23%)
specifically in patient
COVID-19 pneumonia
fever (79.47%), likeshortness
cough (74.35%), bilateral, in patients who had Typicalmost
of breath (36%) and sore throat (17.94%) were the COVID-19
common findings in CT
peripheral GGOs with or without consolidation or
presenting clinical manifestations while a few patients (12.82%) also had other symptoms like headache, chest pain,
images while it was lower in indeterminate and atypical
pain
abdomen, altered sensorium etc. Prevalence of various clinical presentation in our study sample population distributed as
crazy paving. Indeterminate features are those that are
fever in 39%, cough in 36.25%, SOB in 18%, sore throat in 8.75% CT and findings. Percentage
other manifestation in 6.25% symptomatic
(graph 4). 54% presentation in
reported in COVID-19 pneumonia specifically enough to
patients had some or other underlying co morbid disease in sampleCOVID-19
population (graph 5). The most
patients withprevalent co morbidity
respect to CT Characteristics
amongconfident
arrive at a relatively sample population was noted asdiagnosis
radiological follow: Diabetes
likemellituswere
in 30%, Hypertension in 26.25%, Chronic obstructive
pulmonary disease (COPD)/Old K-chest in 6%, Coronary artery disease found as 67.50%
(CAD) in 5% in andTypical, 44.44%
other diseases like in Indeterminate,
multifocal, diffuse, perihilar or unilateral GGOs. Atypical
hypothyroidism, anemia, CVA in 6.25%. The percentage prevalence 50% in atypical
of comorbid and total
disease among 24.13%
comorbidinpatients
normal CT findings
features are those that are reported to be uncommon (graph 7). Average CT severity index had been found
or not occurring in COVID-19 pneumonia like
Graph 1: Age Distribution Of COVID lobar or Graph 2: Sex Distribution
8.44. Symptomatic of COVID had found higher (in
presentation
Patients For
segmental consolidation without GGOs or small nodules CT-chest Patients for CT-Chest
87.50% patients) who had CT severity index >15/25
or cavitation or pleural effusion. Negative <20 for pneumonia
5% while symptomatic presentation lesser (only in 45.83%
implies that there are >60no parenchymal abnormalities 20-40 that patients) who had CT severity Female index <15/25. Percentage
can be attributed to31% infection. 15 24% <20 symptomatic Male presentation 41%in COVID-19 patients with
were symptomatic while 41 patients (51.25%) were asymptomatic in our study population (graph 3). In symptomatic
The 3 lung lobes on fever
the (79.47%),
right and 2 lobes onshortness
the 20-40
left 59%
patient cough (74.35%), of breath respect
(36%) andto CTthroat
sore severity
(17.94%) index were
were the most87.50%
common in patients who
were individuallypresenting
assessed andmanifestations
clinical percentage involvement
while a few patients
40-60(12.82%)had CT severity index 16-20, 36.36% inpain
also had other symptoms like headache, chest pain, CT severity index
abdomen, altered sensorium etc. Prevalence of various clinical presentation in our study sample population distributed as
of the lobe was noted fever based
in 39%, oncoughvisual assessment.
in 36.25%, SOB in 18%,Visual >60throat in of
sore 11-15,
8.75% and 28.57% in CT severity
other manifestation index4).of54%
in 6.25% (graph 5-10 and 60.86% in
severity scoring ofpatients
CT chest wasorclassified
had some as Score-1
other underlying co morbid (<5% CT population
disease in sample severity(graphindex of 1-5
5). The prevalent1B).
most(figure Coincidently 38.70%
co morbidity
among sample 40-60
population was noted as follow: Diabetes mellitus in 30%, Hypertension in 26.25%, Chronic obstructive
area involved), Score-2 (5-25% area involved), Score-3 symptomatic patients Female had zero CT severity index (graph
40%
pulmonary disease (COPD)/Old K-chest in 6%, Coronary artery disease (CAD) in 5%Maleand other diseases like
(25-50% area involved), Score-4 (50-75% area involved),
hypothyroidism, anemia, CVA in 6.25%. The percentage prevalence 8). of comorbid disease among total comorbid patients
were found as Diabetes mellitus in 56%, Hypertension in 48.83%, COPD/K-chest in 12%, CAD in 9.32% and other diseases
in 11.62% (graph 6). Out of eighty patients 51 patients were found to be radiologically positive on HRCT chest imaging
Graph 1: Age Distribution Of COVID Graph 2: Sex Distribution of COVID
while 29 patients (36.25%) had normal or non-COVID CT findings. In this study, we assessed the involvement of lungs
Patients For CT-chest Patients for CT-Chest
with CT chest images, in which nearly two third patients (63.75% patients) had positive CT findings while less than half
<20
of patients (48.755) were symptomatic. CT severity score of asymptomatic radiologically positive patients was found to
be <5/25. The lung pathological 5%changes were evaluated according to HRCT imaging severity score, and we found Typical
>60
COVID findings 20-40 in 11%, Atypical in 2.5% and 36.25% patients had Female
in 50% patients, Indeterminate normal CT chest
31% 24% 78.43%
findings. Among radiologically positive patients <20 patients had typical
MaleCOVID-19 findings on41% HRCT chest.
Symptomatic clinical presentation higher (69.23%) in patients who had Typical 59%COVID-19 findings in CT images while
20-40
it was lower in indeterminate and atypical CT findings. Percentage symptomatic presentation in COVID-19 patients with
respect to CT Characteristics were found as 67.50% in Typical,
40-60 44.44% in Indeterminate, 50% in atypical and 24.13% in
normal CT findings (graph 7). Average CT severity index had been found 8.44. Symptomatic presentation had found
higher (in 87.50% patients) who had CT severity index>60 >15/25 while symptomatic presentation lesser (only in 45.83%
patients) who had CT severity index <15/25. Percentage symptomatic presentation in COVID-19 patients with respect to
CT severity index were 87.50% 40-60in patients who had CT severity index 16-20, 36.36% in CT severity index of 11-15,
40% Female Male
28.57% in CT severity index of 5-10 and 60.86% in CT severity index of 1-5 (figure 1B). Coincidently 38.70% symptomatic
patients had zero CT severity index (graph 8).
were found as Diabetes mellitus in 56%, Hypertension in 48.83%, COPD/K-chest in 12%, CAD in 9.32% and other diseases
in 11.62% (graph 6). Out of eighty patients 51 patients were found to be radiologically positiveFigureon HRCT 1: chest imaging
Coronal
while 29 patients (36.25%) had normal or non-COVID CT findings. In this study, we assessed sections of a 56year lungs
the involvement of old
with CT chest images, in which nearly two third patients (63.75% patients) had positive CT male findings while less
patient showthan(A)
half
of patients (48.755) were symptomatic. CT severity score of asymptomatic radiologically positivePresence of mixed pattern to
patients was found
be <5/25. The lung pathological changes were evaluated according to HRCT imaging severitywith score, and
bothwe GGO
found Typical
and
COVID findings in 50% patients, Indeterminate in 11%, Atypical in 2.5% and 36.25% patients had
consolidation.normal CT (B)
chest
findings. Among radiologically positive patients 78.43% patients had typical COVID-19predominance findings on HRCT chest.
of lesions
Symptomatic clinical presentation higher (69.23%) in patients who had Typical COVID-19 findings in CTinimages
can be noted while
the lower
it was lower in indeterminate and atypical CT findings. Percentage symptomatic presentationlobes in COVID-19 patients
in. The CT severity with
respect to CT Characteristics were found as 67.50% in Typical, 44.44% in Indeterminate, 50% score in this case was in
in atypical and 24.13%
normal CT findings (graph 7). Average CT severity index had been found 8.44. Symptomatic 21/25presentation had found
higher (in 87.50% patients) who had CT severity index >15/25 while symptomatic presentation lesser (only in 45.83%
patients) who had CT severity index <15/25. Percentage symptomatic presentation in COVID-19 patients with respect to
CT severity index were 87.50% in patients who had CT severity index 16-20, 36.36% in CT severity index of 11-15,
HRCT chest of 28.57%
our study population
in CT severity showed
index of 5-10 variety
and 60.86% in CT severity involvement. OutCoincidently
index of 1-5 (figure 1B). of study38.70%
patients), 30 population
symptomatic(80
patients had zero CT severity index (graph 8).
of opacity characteristics. Out of radiologically positive patients had right upper lobe involvement, 29 patients
patients 25 patients (49.01%) had isolated Ground glass had right middle lobe involvement, Figure 1: 42 patients had right
Coronal
opacities (GGO) while another 25 patients (49.01%) had lower lobe involvement, 36 patients hadsections of a 56year old left upper lobe
male patient show (A)
both GGO and consolidation (figure 1A, 2) and only involvement, 43 patients had left
Presence lower
of mixed lobe involvement.
pattern
one patient (1.25%) had isolated consolidation. HRCT Out of total radiological with affected
both GGO 51 patients,
and average
HRCT chest of our study population showed variety of opacity characteristics. Out of radiologically positive patients 25 (B)
consolidation.
chest had different lobe(49.01%)
patients distribution of opacities
had isolated Ground in(GGO) 83.33%
glass opacities patients
while another had
25 patients predominant
(49.01%) had both GGO lower lobe involvement
predominance of and
lesions
which 8 patients (10%) had only one lobe affection, 10
consolidation (figure 1A, 2) and only one patient (1.25%) hadin COVID-19. Among study
isolated consolidation. HRCT chest had population
in the lower31 patients had
different
can be noted lobe
distribution of opacities in which 8 patients (10%) had only one lobe affection, 10 patients (12.50%) had two lobes
patients (12.50%) had two
affection, lobes
4 patients (5%)affection,
had three lobes4affection,
patients predilection
5 patients (6.25%) towards
had four lobes involvement
affection and
lobes in. The CTofseverity
24 patients (30%) hadposterior surface of
score in affected
this case was
(5%) had three lobes affection,
all five 5 while
lobes affection patients
none of(6.25%)
lobe of lungshad
affected inlung, 2 patient
29 patients (36.25%). Inhad
total anterior
radiologicallysurface
21/25
51involvement while
patients, 33 patients (64.70%) had more than two lobe affection, 39 patients (76.47%) had bilateral lung involvement. Out
four lobes affectionof and
study 24 patients
population (30%)30had
(80 patients), allhad
patients five 18lobe
right upper patients
involvement,had both had
29 patients anterior
right middle andlobe posterior surface
lobes affection while none of lobe of lungs affected in
involvement, 42 patients had right lower lobe involvement, 36 involvement (figure 3). Among radiologically
patients had left upper lobe involvement, 43 patients had positive
left lower lobe involvement. Out of total radiological affected 51 patients, average 83.33% patients had predominant lower
29 patients (36.25%). In total inradiologically
lobe involvement COVID-19. Among study affected patients
population 31 patients 96.07% patients
had predilection had complete
towards involvement of posterioror partial posterior
51 patients, 33 patients
surface of(64.70%)
lung, 2 patienthad more surface
had anterior thaninvolvement
two surface
while affection.
18 patients had both anterior and posterior surface
involvement (figure 3). Among radiologically positive patients 96.07% patients had complete or partial posterior surface
lobe affection, 39 patients
affection. (76.47%) had bilateral lung

Graph 3: Clinical Presentation of Graph 4: Clinical Manifestation of COVID

COVID Patients For CT-chest patients

79%
74.35%
80%
% patients

60%
Asymptomatic Symptomatic
49% 39% 36.25% 36%
51%
40%
18% 17.94%
20% 12.82%
8.75% 6.25%

0%
Fever Cough SOB Sore Others
Throat
Clinical features
Symptomatic Asymptomatic
% among Total patients % among Symptomatic patients

Graph 5: Comorbidity in COVID Graph 6: Co-morbidities in COVID patients

Patients 56%
60%
48.83%
50%
Non 40%
Comorbid 30%
% of patients

comorbid 26.25%
patients Patients 30%
46% 54%
20% 12% 9.32% 11.62%
6% 5.00% 6.25%
10%
0%

Comorbidity
Comorbid Patients Non comorbid patients % among Total patients % among Co-morbid patients

Graph 7: CT characteristics v/s Clinical Graph 8: CT severity index v/s Clinical

presentation in COVID patients presentation in COVID patients

13 1
1
No. of patients

5 9
22
No. of patients

19 7
5
27
4 1 7
7
14
12 4
2
0
0 Up to 5 6 to 10 11 to 15 16 to 20 21 to 25
CT characteristics
CT severity index
Symptomatic patients Asymptomatic patients Symptomatic patients Asymptomatic patients

Graph 7: CT characteristics v/s Clinical Graph 8: CT severity index v/s Clinical

presentation in COVID patients presentation in COVID patients
HRCT chest of study HRCT chest population
of study population hadhadvariable variable axialaxial distribution ofpatients (57.5%)
opacities, among them 5radiologically examined in early phase,
patients had central distribution,
distribution 13 of opacities, 27 patients had peripheral
among them 5 patients had distribution, 18 1 patients
central had both central and peripheral distribution
19 patients (23.75%) in intermediate (figure 4) while 1 patient phase, 15 patients
1
had no axial distribution. 9 Out of total radiologically affected patients, 45 patients (88.23%) had predilection towards
No. of patients

5
distribution, 27 patients 22
hadof peripheral 5 distribution,chest imaging18 (18.75%) in findings
late phase of disease progression (graph 9).
No. of patients

involvement periphery
19
of lungs. CT7
also showed some specific which includes pleural effusion
patients had both 7central and peripheral distribution
in 6 patients (7.5%), pulmonary nodules in 6 patients (7.5%), In early phase of disease (<5 days),other
thoracic lymphadenopathy in 19 patients (23.75%) and among radiologically
27
4 1 7
nonspecific findings like14granuloma, cyst, hemangioma etc. in 7 patients (8.75%) (table 1). In our study population CT
(figure 4) while 1 patient chest done had no axial
at various 12 phasedistribution.
of disease
2 4 with an average Out of positive
time duration from onsetpatients
of illness to(32
dateout
of CTof 46) 59.37%
imaging was found patients had GGO
total radiologically affected to be 6.7 days. patients,
In this scenario45 patients 46 patients (88.23%)
(57.5%)
0 while
radiologically remaining
examined in early 40.63%
phase, 19 had both
patients GGO
(23.75%) in and consolidation
intermediate phase,0 15 patients Up to 5 6 to 10(18.75%)
11 to 15 16 in
to 20late
21 tophase
25 of disease progression (graph 9). In early phase of disease (<5 days),
had predilection CT characteristics towards
among radiologically involvement positive patients of (32 periphery
out of 46) 59.37% patients in imaging
had GGO while of remaining
HRCT 40.63% chest.hadIn bothintermediate
GGO phase of
of lungs. CT chest Asymptomaticimaging also showed some patients specific disease (6-10 days), among radiologically positive
CT severity index
and consolidation in imaging of HRCT chest. In intermediate phase of disease (6-10 days), among radiologically positive
Symptomatic patients patients Symptomatic patients Asymptomatic
patients (11 out of 19) 45.45% patients had GGO while remaining 54.54% had both GGO and consolidation in imaging of
findings which includes HRCT chest. pleural
In late phase effusion
of diseasein (>106days), patients patients
among radiologically (11
positive out(8of
patients out19)
of 15)45.45% patients
12.50% patients had had GGO while
(7.5%),
HRCT chest ofpulmonary nodules
GGO,
study population had variable axial 75.00% in
distribution 6 and
patients
patients
of opacities,had
among both
themGGO5(7.5%),
patientsand thoracic
had consolidation
central
(figure 4) while 1 patient
remaining
distribution, (figure 5) while remaining54.54% had had
12.50% patients both GGO and consolidation in
only consolidation
27 patients had peripheral distribution, 18 in patients
imaging had bothof central
HRCT peripheral
chest 10).
distribution
(graph
lymphadenopathy in 19 affected
had no axial distribution. Out of total radiologically patients (23.75%)
patients, 45 patients (88.23%) had and predilection
involvement of periphery of lungs. CT chest imaging also showed some specific findings which includes pleural effusion
other
towards imaging of HRCT chest. In late phase of disease (>10
nonspecific findings like granuloma, cyst, hemangioma
in 6 patients (7.5%), pulmonary nodules in 6 patients (7.5%), thoracic lymphadenopathy in 19 patients (23.75%) and other
nonspecific findings like granuloma, cyst, hemangioma etc. in 7 patients (8.75%) (table 1). In our study population CT
days), among radiologically positive patients (8 out of
etc. indays.
7 patients
In this scenario (8.75%) (table 1). examined
In our study phase, 19population
chest done at various phase of disease with an average time duration from onset of illness to date of CT imaging was found
to be 6.7 46 patients (57.5%) radiologically in early patients (23.75%) in 15) 12.50% patients had GGO, 75.00% patients had both
Figure 2 Axial section
CT
amongchest
radiologicallydone at(32various
out of 46) 59.37% phase ofwhiledisease with
intermediate phase, 15 patients (18.75%) in late phase of disease progression (graph 9). In early phase of disease (<5 days),
positive patients patients had GGO remaining 40.63% had both GGO an GGO and consolidation the CT5)
(figure
through while
chest of a remaining 12.50%
and consolidation in imaging of HRCT chest. In intermediate phase of disease (6-10 days), among radiologically positive
average 42year old male patient
patients (11 out oftime
19) 45.45%duration
patients had GGO while from remainingonset
54.54% hadof illness
both GGO to date
and consolidation in imagingof of patients had only consolidation in imaging of HRCT chest
HRCT chest. In late phase of disease (>10 days), among radiologically positive patients (8 out of 15) 12.50% patients had reveals (A) ground glass
CT
GGO,imaging
75.00% patients had was
both GGO found to be
and consolidation (figure6.7 days.
5) while In this
remaining 12.50% patientsscenario
had only consolidation 46 (graph 10). opacities in bilateral
in imaging of HRCT chest (graph 10).
upper lobes and (B)
mixed consolidation and
Figure 2 Axial section
GGO pattern in the
through the CT chest of a lower sections of the
42year old male patient
reveals (A) ground glass
same patient.
opacities in bilateral
upper lobes and (B)
mixed consolidation and
GGO pattern in the
lower sections of the TABLE 1: IMAGING CHARACTERISTICS ON HRCT-CHEST
same patient. Number of % Among total patients % Among radiologically
CT Features
patients (N= 80) positive patients (N=51)
Opacity distribution (Axial)
No Axial 1 1.25% 1.96%
Central 5 6.25% 9.80%
Peripheral 27 33.75% 52.94%
Both 18 22.50% 35.29%
Underlying Lung Disease
Pulmonary Emphysema 4 5% 7.84%
Figure 3: Coronal
sections of a 52year old Atelectasis 4 5% 7.84%
male patient show that Bronchiolitis 6 7.5% 11.76%
(A) The lesions were K-chest 4 5% 7.84%
mainly present in the Others 6 7.5% 11.76%
posterior coronal section Other findings
and (B) Lesion absent in Pleural Effusion 6 7.5% 11.76%
the anterior coronal Pulmonary Nodules 6 7.5% 11.76%
section. Thoracic lymphadenopathy 19 23.75% 37.25%
Others findings 7 8.75% 13.72%
Ground Glass Opacity & Consolidation
Both Absent 29 36.85% 56.86%
GGO present 25 31.25% 49.01%
GGO & Consolidation both
25 31.25%
present 49.01%
Consolidation present 1 1.25% 1.96%
Number of Lobe Affected
0 29 36.25% 56.86%
1 8 10% 15.68%
2 10 12.50% 19.60%
3 4 5% 7.84%
4 5 6.25% 9.80%
5 24 30% 47.05%
>2 33 41.25% 64.70%
B/L Lung Disease 39 48.75% 76.47%
U/L 11 13.75% 21.56%
Frequency of Lobe Involvement
Right Upper Lobe 30 37.50% 58.82%
Right Middle Lobe 29 36.25% 56.86%
Right Lower Lobe 42 52.50% 82.35%
Figure 4: HRCT chest scan in a 31year old male patient Figure 5: HRCT chest of COVID-19 patient (A) At early phase Left Upper Lobe 36 45% 70.58%
(A) axial and (B) coronal sections shows peripheral (Day 4) of disease show presence of GGOs (B) At late stage of Left Lower Lobe 43 53.75% 84.31%
areas of GGO and consolidation and sub-pleural disease (Day 11) show areas of consolidation representing Involved surface of lungs
sparing. CT severity score in this patient was 12/25. signs of organizing pneumonia. Anterior 2 2.50% 3.92%
Posterior 31 38.75% 60.78%
Both 18 22.50% 35.29%
CT Chest Characteristics
Graph 9: CT images in different phase of Graph 10: Opacity characteristics according • Typical 40 50% 78.4%
disease in COVID-19 to duration of disease • Indeterminant 9 11% 17.64%
• Atypical 2 2.5% 3.92%
35 32 80.00% 75.00% • Absent 29 36.25% 56.86%
70.00%
CT Severity Index
30 59.37% • 0 31 38.75%
25 60.00% 54.54%
• Up to 5 23 28.75% 46.93%
• 6 to 10 7 8.75% 17.94%
No. of patients

45.45%
% of patients

50.00%
20 40.63% • 11 to 15 11 13.75% 28.20%
14
15
40.00% • 16 to 20 8 10% 20.51%
11
30.00% • 21 to 25 0 0% 0%
8 8
10 7
20.00% Discussion:
12.50% 12.50%
5
10.00%
0
The dread and specter of COVID-19 made its first appearance in Wuhan, China and it has spread like wildfire out a
0 0

Early Intermediate Late across precincts of China and across the globe with a pace that has taken everyone by surprise. Confirmed cases of COV
0.00%
Early Intermediate Late
Disease progression Duration of disease 19 is being reported from all corners of the world and subsequently World Health Organization (WHO) officially decla
Radiologically positive patients Radiologically negative patients GGO Both GGO & Consolidation COVID-19 a pandemic on March 11, 2020 (16). Research is underway to understand more about transmissibility, sever
Consolidation
and other features associated with COVID-19 (17). The virus, SARS-CoV-2, of COVID-19 has been found to have hig
levels of transmissibility with higher potential of pandemicity, as the effective reproductive number (R) of COVID-19 (2
Discussion: is estimated toEspecially
be higher than the for those
reported who
effective were unaware
reproduction number (R) of of SARS the concealed
(1.77) at this early stage (18). T
SARS-relateddiscomfort, HRCT
coronaviruses are covered by spikecan assist
proteins that clinicians
contain a variable and epidemic
receptor-binding domain (RBD). T
The dread and specter of COVID-19 made its first(19) RBD binds to angiotensin-converting enzyme-2 (ACE-2) receptor found in the heart, lungs, kidneys, and gastrointesti
tract workers
thus facilitating viral with
entry intofinding potentially
target cells. Based infectious
on genomic sequencing, the RBDpatients.
of SARS-CoV-2 appear
appearance in Wuhan, China and it has spread like be a mutated version of its most closely related virus, RaTG13, sampled from bats (Rhinolophus affinis) (20). The mutat
However, theinFleischner
humans. Binding ofSociety guidelines suggested
wildfire out and across precincts of China and across increased the the RBD
receptors inthat
affinity to ACE-2 the SARS-CoV to the angiotensin-converting enzyme 2 (AC
2) the typeimaging is not routinely indicated in asymptomatic
II pneumocytes in the lungs triggers a cascade of inflammation in the lower respiratory tract (21
globe with a pace that has taken everyone by surprise. has been demonstrated that when the SARS spike protein binds to the ACE-2 receptor Pathogens, the complex
proteolyticallyor mildly
processed symptomatic
by type 2 transmembrane protease patients
TMPRSS2 ofleading
COVID-19.
to cleavage of This was
ACE-2 and activation of
Confirmed cases of COVID-19 is being reported from spike protein (22), similar to the mechanism employed by influenza and human metapneumovirus, thus facilitating v
corroborated by our study where 29/80 patients who
entry into the target cell. It has been suggested that cells in which ACE-2 and TMPRSS2 are simultaneously present
were
all corners of the world and subsequently World Health most susceptibleasymptomatic
to entry by SARS-CoV or who(23)
underwent
. Early indications are CT in early phase
that SARS-CoV-2 virus alsoof the ACE-2
requires
Organization (WHO) officially declared COVID-19 a
disease showed no CT features of COVID-19 pneumonia.
pandemic on March 11, 2020 (16). Research is underway
HRCT chest of our study population showed variety
to understand more about transmissibility, severity, and
of opacity characteristics, among radiologically positive
other features associated with COVID-19. 17 The virus,
patients nearly half of patients showed typical GGO
SARS-CoV-2, of COVID-19 has been found to have
while another half showed mixed pattern of GGO and
higher levels of transmissibility with higher potential of
consolidation. Mostly early CT on admission characterized
pandemicity, as the effective reproductive number (R) of
by GGO and in late stage consolidation tends to be more
COVID-19 (2.9) is estimated to be higher than the reported
dominating than GGO. The distribution of these lesions in
effective reproduction number (R) of SARS (1.77) at this
our study was mostly peripheral and posterior involving
early stage.18 The SARS-related coronaviruses are covered
the lower lobes more frequently. The predilection for these
by spike proteins that contain a variable receptor-binding
areas has also been reported previously. In patients who
domain (RBD). This RBD binds to angiotensin-converting
were imaged in the later stage of disease, findings such
enzyme-2 (ACE-2) receptor found in the heart, lungs,
as vacuolations within opacification, linear consolidation
kidneys, and gastrointestinal tract 19 thus facilitating viral
and reverse halo sign were seen suggesting organization
entry into target cells. Based on genomic sequencing, the
of the underlying disease process. Subsequently,
RBD of SARS-CoV-2 appears to be a mutated version of
subpleural sparing and curvilinear bands appeared likely
its most closely related virus, RaTG13, sampled from bats
due to retraction process suggesting resolution stage. In
(Rhinolophus affinis). 20 The mutation increased the RBD
our experience, even if the total percentage area of lung
affinity to ACE-2 in humans. Binding of the SARS-CoV to
involved remained the same, appearance of features
the angiotensin-converting enzyme 2 (ACE-2) receptors
such as vacuolation, subpleural sparing and curvilinear
in the type II pneumocytes in the lungs triggers a cascade
band formation indicated resorption stage and even
of inflammation in the lower respiratory tract. 21 It has
corroborated with clinical features of improvement. A
been demonstrated that when the SARS spike protein
long-term follow-up of these patients should be done
binds to the ACE-2 receptor Pathogens, the complex
to assess if these findings completely resolve or some
is proteolytically processed by type 2 transmembrane
evidence of fibrotic changes persists.
protease TMPRSS2 leading to cleavage of ACE-2 and
activation of the spike protein,22 similar to the mechanism The data collected at our hospital indicates that CT
employed by influenza and human metapneumovirus, findings vary according to the time of scan from the
thus facilitating viral entry into the target cell. It has onset of illness. This concurs with the results observed by
been suggested that cells in which ACE-2 and TMPRSS2 Bernheim et al and Pan et al who suggested progression
are simultaneously present are most susceptible to entry of disease in the form of GGOs in early stage to “crazy-
by SARS-CoV. 23 Early indications are that SARS-CoV-2 paving” and consolidation in later stages. In addition,
virus also requires ACE-2 and TMPRSS2 to enter cells. 24 the CT findings also correlate with clinical status,
Viral entry and cell infection trigger the host’s immune showing a higher CT severity score in clinically worse
response, and the inflammatory cascade is initiated by patients. Thus, the percentage involvement of lung and
antigen-presenting cells (APC). The process starts with CT severity score can help prognosticate and tailor
the APC performing two functions: (1) presenting the the clinical management of patients. In radiologically
foreign antigen to CD4 +-T-helper (Th1) cells, and (2) positive patient multiple lobe affection by COVID-19
releasing interleukin-12 to further stimulate the Th1 has been more popular compare to other bacterial or
cell. The Th1 cells stimulate CD8 +-T-killer (Tk) cells lobar pneumonia, among them nearly two third patients
that will target any cells containing the foreign antigen. had more than two lobe involvement with bilateral lung
In addition, activated Th1 cells stimulate B-cells to affection in 76% patients. Most of radiologically positive
produce antigen-specific antibodies. It is apparent that COVID-19 patients (96%) had complete or some posterior
COVID-19 infection occurs through exposure to the virus, surface involvement while nearly one third patients had
and both immune suppressed and normal population mixed involvement of anterior and posterior surface of
appear to be susceptible. Some studies have reported lung. As per view of axial distribution most of patients
an age distribution of adult patients between 25 and 89 (nearly 88%) had peripheral distribution of opacities
years old. Most adult patients to be afflicted have been in COVID-19 positive patients. CT chest imaging also
observed to be in age range of 35 and 55 years. 25 A study showed some specific findings which includes pleural
on early transmission dynamics of the virus has reported effusion, pulmonary nodules, thoracic lymphadenopathy
the median age of patients to be 59 years, ranging from 15 and other nonspecific findings like granuloma, cyst,
to 89 years, with majority (59%) patients affected being hemangioma etc. In present study duration of disease
male. 26 It has been suggested that population most at risk correlated with CT chest characteristics and CT severity
may be people with poor immune function such as older index. In these patients average CT severity index
people and those with renal and hepatic dysfunction (26). remained same in each phases of disease while opacities
characteristics especially GGO and consolidation varied in
I n t h e p r e s e n t s t u d y a n a t t e m p t wa s m a d e t o
different phases of disease. GGO, a characteristic feature
outline distribution of age, gender, clinical features
of initial stage of disease found maximum in early phase
at presentation, co morbidity of patients, HRCT chest
of disease while in intermediate and late phase of disease
findings in COVID-19 patients, severity of patients
proportional pure GGO reduced. In intermediate phase
on the basis of CT imaging and their correlation
nearly half of patients had both GGO and consolidation
with symptomatology and comorbidity of patients to
on CT images while rest half had pure GGO pattern. In
put diagnostic, therapeutic and prognostic tools for
late stage nearly three fourth patients had both GGO and
COVID-19 disease. A total of 80 patients were analyzed
consolidation while remaining patients had pure GGO or
along the course of the study. Most of COVID-19 patients
consolidation in equal proportion. These characteristic
of our study group in SMS Medical College Hospital,
changes were in favor of resolving pneumonia. No
Jaipur, Rajasthan were in their fourth to sixth decades
significant difference was observed in distribution of
of life with mean age with a mean age of 50.40 year and
opacities and involvement of particular lobe or surface
male gender was affected more as compared to females,
with progression of disease.
with an average sex ratio being 0.69 in our study group.
In symptomatic patients, fever and cough were the most Conclusion
common presenting features, followed by shortness of The varied spectra of COVID-19 presented with fever,
breath, sore throat and headache while few patients also cough, shortness of breath, sore throat etc. Diabetes
presented with chest pain and non-respiratory symptoms mellitus, hypertension, COPD/K-Chest and CAD were
like pain abdomen, fatigue, joints pain, altered sensorium, found as major comorbid condition. Clinical severity of
etc. In our study group nearly one third of asymptomatic disease was higher in patients that had underlying co
patients were found to be radiologically positive. This morbid disease, especially in patients with multiple co
small percentage of asymptomatic COVID-19 patients, morbid conditions. HRCT chest in COVID-19 patients
act as major carrier for transmission of virus in society, had major diagnostic and prognostic importance as
poses a real diagnostic and containment challenge for positive CT findings more prominent in symptomatic
health care professionals. It was observed in the present patients and co-morbid patients. CT severity index also
study co morbidities have a tangible impact on clinical directly correlated with clinical symptoms of patients.
characteristics and course in COVID-19 positive patients. CT imaging useful to see clinical recovery of patients.
It has been observed that COVID-19 patients have The results of this study confirmed that chest CT is
circulatory and endocrine co morbidities. Patients with at important in the diagnosis and management of the
least one or more co morbidity have been reported with COVID-19 infection. Despite meticulous treatments,
poor clinical outcomes. In the present study population most patients demonstrated progressions in the early
54% patients had underlying co morbid disease with stage from illness onset, according to the follow-up CT
multiple co morbid diseases being was more prevalent. examinations. Our clinical findings show that radiological
The most prevalent co morbidity observed in present features positively correlate with the severity of lung
study was Diabetes mellitus in followed by Hypertension, abnormalities quantified on initial CT. Being familiarized
Chronic obstructive pulmonary disease (COPD)/Old with the clinical and CT features and the early changes
K-chest, Coronary artery disease (CAD) and other of the COVID-19 infection is of paramount importance.
diseases like hypothyroidism, anemia, CVA etc. Limitations: This study has some limitations. First,
Currently the diagnosis of COVID-19 in clinic is this is a modest-sized case series of patients admitted
dependent on the detection of SARS-CoV-2 nucleic to the hospital. At the time of data collection, RT-PCR
acid by RT-PCR. However, it was reported that the tests for the diagnosis of COVID-19 had been available
accuracy rate is lower because it can be influenced by only for suspected patients. Besides, we only included
the viral load, the stage of the disease and the quality of hospitalized patients for their clinical and CT correlation
specimens obtained from the upper respiratory tract. 27 with follow- up CT examinations to ensure more
The prominent radiological feature of COVID-19 is information on clinical and CT characteristics. Possible
bilateral ground glass opacity in the chest CT scans. 28 In selection bias should be noted, and further study of a
this study, we assessed the involvement of lungs with larger cohort is required to obtain a definitive answer.
CT chest images, in which nearly two third patients Second, the quantitative and semiquantitative methods
(63.75% patients) had positive CT findings while less than for measuring the pulmonary lesions may have certain
half of patients (48.755) were symptomatic. CT severity subjectivity. Third, the susceptibility of COVID-19 was
score of asymptomatic radiologically positive patients considered (initially and incorrectly) to be very low
was found to be <5/25. In present study more than among infants, children, and adolescents, so we did not
three fourth of patients among radiologically positive retrospectively study these groups. Fourth CT imaging
patients had Typical CT chest images findings which not be possible in severely or critically ill patients. More
includes GGO in bilateral, peripheral and lower lobe effort should be made to identify the clinical and imaging
predominance distribution of opacities. Symptomatic features in these groups in future studies.
clinical presentation higher (69.23%) in patients who Ethical approval: Approval was not required.
had Typical COVID-19 findings in CT images while it Author contributions: S. Bhandari, A. Singh and G.
was lower in indeterminate and atypical CT findings. Rankawat formulated the research questions, designed
Patients who had typical CT findings mostly presented the study, developed the preliminary search strategy, and
symptomatically. Severity of clinical status of COVID-19 drafted the manuscript; M. Bagarhatta and Aparna Singh
patients correlated with CT severity index, average CT do HRCT chest and radiological examination of patients.
severity index of our study population had been found S. Bhandari, G. Rankawat, M. Bagarhatta refined the
8.44. The clinical status of patients correlated with the search strategy by conducting interative database queries
CT severity score, with mild cases showing score <15/25 and incorporating new search terms; G. Rankawat,
in 45.83% patients and severe cases showing CT severity Aparna Singh, V. Gupta collected and analysed data; S.
score >15/25 in 87.50% patients. As CT severity index Bhandari and A. Singh, conducted the quality assessment.
raised clinical status of patients deteriorated hence this All authors critically reviewed the manuscript for
show poor prognostic indicator for COVID-19 patients. At relevant intellectual content. All authors have read and
present, the judgment of the patient’s condition mainly approved the final version of the manuscript.
depends on symptoms and signs, blood oxygen saturation,
Funding The authors have not declared a specific grant
etc., while CT images are not used as a main reference
for this research from any funding agency in the public,
index. When the disease develops rapidly, the probability
commercial or not for profit sectors.
of death is greatly increased. However, we found that
Availability of data and materials: The data that
CT imaging changes in some patients, especially young
support the findings of this study are available from the
patients, appears before the onset of signs and symptoms
corresponding author [Dr. Govind Rankawat, Email ID
due to the differences in tolerability. We scored the chest
govindrankawat@gmail.com], upon reasonable request.
CT imaging and found that clinically severe patients
showed higher CT imaging score compared to that Declaration of competing interest: All authors report
in non-severe patients. These data suggested that CT no potential conflicts. All authors have submitted the
imaging score may be an informative indicator to predict ICMJE Form for Disclosure of Potential.
the severity of the disease. In the early stages, single or A c k n o wl e d g m e n t s : I w o u l d l i k e t o t h a n k s t h e
multiple small ground glass infiltration, consolidation, anonymous referees for their useful suggestion. I would
and interstitial thickening could be seen. As the disease like to thanks to my professionals Dr. Abhishek Agrawal,
progressed, severe cases had more consolidation and air Dr. C. L. Nawal, Dr. S. Banerjee, Dr. Prakash Keswani,
bronchograms in the involved lobes. The diffuse lesions, Dr. Sunil Mahavar, Dr. R S Chejara, Dr. Vidyadhar Singh,
shown as “white lungs,” were seen in the most severely Dr. Kapil Choudhary, Department of General Medicine
affected patients. Fibrous bands could be seen during SMS Medical college and attached group of Hospital,
the remission stage. The distribution manners, together Jaipur for their valuable support and Department of
with the GGOs, are very characteristic and impressive. Radiodiagnosis for providing radiological information
Cautious attention to symptoms and CT examination, of COVID-19 patients.
are helpful for early detection of COVID-19 infection.
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