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H O S T E D BY Available online at www.sciencedirect.com

ScienceDirect 64
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2 Radiology of Infectious Diseases xxx (xxxx) xxx 67
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5 Review 70
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Chest CT features and their role in COVID-19 72
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10 Q2 Meng Li a,b 75
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Department of Diagnostic Radiology, National Cancer Center, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 77
13 Beijing 100021, China 78
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National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, 79
15 China
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Received 5 March 2020; revised 19 March 2020; accepted 7 April 2020
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Available online ▪ ▪ ▪
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21 Abstract 86
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Since December 2019, the novel coronavirus disease (COVID-19) has spread rapidly throughout China. This article reviews the chest CT
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features of COVID-19 and analyzes the role of chest CT in this health emergency.
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© 2020 Beijing You’an Hospital affiliated to Capital Medical University. Production and hosting by Elsevier B.V. This is an open access article
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under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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Keywords: COVID-19; Computed tomography; Chest; Imaging features
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1. Introduction aim of this article is to review the chest CT features and
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analyze its value in this COVID-19 pandemic.
In December 2019, a novel pathogenic human coronavirus, 100
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37 called 2019 novel coronavirus, was identified in Wuhan, Hubei
2. Chest CT features of COVID-19 102
38 Province, China [1]. It can achieve human-to-human trans- 103
39 mission between close contacts, and can cause serious coro- 104
40 To date, many descriptive studies and case reports have
navirus disease (COVID-19), especially pneumonia [2e4]. On 105
41 focused on the CT manifestations of COVID-19 [6e14]. Ac- 106
January 30, 2020 the World Health Organization (WHO)
42 cording to the literature, the typical findings of chest CT im- 107
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announced that the outbreak of COVID-19 has become a
Public Health Emergency of International Concern, and ages of individuals with COVID-19 are multifocal bilateral 108
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further declared it a pandemic on March 11, 2020. Although patchy ground-glass opacities (GGOs) or consolidation with
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46 the Chinese government has adopted timely and effective interlobular septal and vascular thickening, mostly in the pe-
ripheral fields of the lungs. The respective incidence rate of 111
47 measures to prevent and control the spread of COVID-19, the 112
48 GGOs and consolidation are about 86% and 29% [15]. The
scope and effect of this outbreak is rapidly evolving [5]. As of 113
49 most common morphology of these opacities are patchy and 114
March 20, 2020, there were 81,263 confirmed cases, 3250
50 round ones, followed by triangular and linear ones [16,17]. 115
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deaths and 70,560 recovered cases in China. Thanks to its
high-resolution and lack of the overlap of organizational The triangular or angular GGOs under the pleura with thick- 116
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structures, chest computed tomography (CT) is an important ened internal interlobular septa is considered a new sign that
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54 noninvasive examination for the diagnosis of lung disease. The one research paper has termed the “spider web” [17]. Special
classic signs, including “crazy paving” or “reverse halo”, can 119
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56 also be seen, while cavitation, nodules, pleural effusions, and
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57 lymphadenopathy are rare. 122
58 CT findings can change as the disease progresses. In the 123
E-mail address: lmcams@163.com.
59 early stage, chest CT shows small lobular and subsegmental 124
Peer review under responsibility of Beijing You'an Hospital affiliated to
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Capital Medical University. patchy GGOs, interstitial changes, and thickening vascular
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https://doi.org/10.1016/j.jrid.2020.04.001
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2352-6211/© 2020 Beijing You’an Hospital affiliated to Capital Medical University. Production and hosting by Elsevier B.V. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Please cite this article as: Li M, Chest CT features and their role in COVID-19, Radiology of Infectious Diseases, https://doi.org/10.1016/j.jrid.2020.04.001
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1 lumens throughout. Notably, 20/36 (56%) of early patients 3. Role of chest CT in the diagnosis and follow up of 66
2 (0e2 days after the onset of symptoms) had a normal CT COVID-19 67
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finding in a recent study [16]. In the progressive and peak
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stage, the lesions gradually progress to multiple GGOs in the As there are currently no specific antiviral drugs to treat 70
6 lungs, and some patients may have dense consolidation in the COVID-19, so early detection and adherence to medical 71
7 lobes. The interlobular septum in GGOs becomes thickened, isolation becomes essential. As an etiological diagnosis, the 72
8 similar to the “crazy paving” sign. In severe cases, patients positive result of reverse transcriptase polymerase chain re- 73
9 may have diffuse lesions in both lungs, some showing as action (RT-PCR) test in laboratory for respiratory specimens is 74
10 “white lung”. Air bronchogram and blood vessel penetration considered the practicable gold standard for COVID-19 75
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signs are common. In the absorption or remission stage, the diagnosis [10,29]. However, the RT-PCR test itself also has
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GGOs and consolidation resolves with no “crazy paving” sign, limitations. First, false-negative results can occur with the RT- 78
14 and subpleural parenchymal fibrosis lesions can be seen. PCR test because of, for example, incorrect sampling location 79
15 Therefore, CT can both indicate disease evolution and evaluate of the swab test, and insufficient viral material in the specimen 80
16 the clinical severity and extent of COVID-19 [17e23]. or procedural error. Therefore, the RT-PCR test for COVID-19 81
17 These manifestations are also compatible with other viral is considered to have high specificity but sensitivity has been 82
18 pneumonias, especially Severe Acute Respiratory Syndrome reported to be as low as 59 %e71% [30,31]. Second, the RT- 83
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(SARS) coronavirus, which was first detected in China's PCR process is time-consuming. Third, at the beginning of the
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Guangdong Province in late 2002 [24,25]. Different viral epidemic outbreak, shortages in test kit supplies meant the 86
22 pneumonias, in fact, share many nonspecific overlapping im- needs of the large number of people in Wuhan and Hubei 87
23 aging features. Given this, CT alone can often differentiate and Province could not be met. The result of such limitations may 88
24 confirm the etiology of pneumonia with difficulty. This shows be the delay of medical isolation and the transmission of 89
25 the limitation of imaging. However, where the differential infection. 90
26 diagnosis is between COVID-19 and non-COVID-19 viral CT examination, however, can compensate for the above 91
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pneumonia, radiologists from China and the United States shortcomings and play an important auxiliary role in the
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have had high specificity but moderate sensitivity according diagnosis and subsequent management of COVID-19 patients. 94
30 the most recent research [26]. This suggests that a negative First, CT can decrease the chance of false-negative results in 95
31 diagnosis of COVID-19 may exclude patients who in fact have the RT-PCR assay. CT is more sensitive than initial RT-PCR 96
32 COVID-19. Diagnostic mistakes have often been made when (98% vs. 71%, and 88% vs. 59%) according to two recent 97
33 the chest CT findings are either subtle in the early stage of reports, and many suspected patients with atypical CT findings 98
34 COVID-19 or when the chest CT findings are atypical. but a negative RT-PCR test have been found [30e33]. 99
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Epidemiological factors such as contact exposure to sick in- Therefore, it is necessary to repeat the swab test for such
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dividuals and clinical information should be used to support patients. Second, since CT equipment is widespread in China 102
38 the diagnosis. and the CT scan process is relatively simple and quick, CT can 103
39 Due to then general inaccessibility of autopsy and biopsy be used as a rapid screening tool for suspected patients in the 104
40 findings, there remains a lack of research into the correlation severe epidemic center when RT-PCR results are unavailable. 105
41 of pathology and radiology; nevertheless, there are a small It is suggested that in emergencies, patients whose CT findings 106
42 number of pathological case reports. In a report of two cases show COVID-19 may be first medically isolated and later 107
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who underwent surgery for lung adenocarcinoma and were undergo RT-PCR testing to confirm the diagnosis. This con-
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retrospectively found to have had COVID-19, the accidental forms to the principle of “early detection and early isolation” 110
46 histologic results revealed alveolar edema, proteinaceous ex- for infectious diseases. In brief, a combination of RT-PCR and 111
47 udates, focal reactive hyperplasia of pneumocytes with in- CT may be more helpful for the diagnosis and management of 112
48 flammatory cellular infiltration, and multinucleated giant cells individuals with COVID-19. 113
49 [27]. There were no prominent formations of hyaline mem- CT can be used as a follow-up tool to monitor the disease 114
50 branes, which may indicate that these cases were in the early evolution and evaluate the severity of COVID-19 patients for 115
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stage of COVID-19. In a report of one death with biopsy, the its invasiveness and objectivity. Furthermore, CT can predict
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histological examination showed bilateral diffuse alveolar the prognosis. Imaging appearance of bilateral lung involve- 118
54 damage (DAD) with cellular fibromyxoid exudations, and ment is regarded as an additional index and account for the 119
55 pulmonary edema with hyaline membrane formation [28]. highest score in MuLBSTA system (multilobular infiltration, 120
56 From the two articles, we can speculate that the pathological hypo-lymphocytosis, bacterial coinfection, smoking history, 121
57 findings of COVID-19 are interstitial pneumonia with edema hyper-tension and age) for predicting the mortality in COVID- 122
58 in the early stage, and combined DAD in severe cases. These 19 patients compared to other virus pneumonia [34,35]. In the 123
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features may be the pathological basis of GGOs and consoli- Chinese National Health Commission's recently released
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dations in the radiological findings of COVID-19. “Program for diagnosis and treatment of novel coronavirus 126
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Please cite this article as: Li M, Chest CT features and their role in COVID-19, Radiology of Infectious Diseases, https://doi.org/10.1016/j.jrid.2020.04.001
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