NiTra PiYaViSetPat, MD

MedPark Hospital
King Chulalongkorn Memorial Hospital
❖Acute COVID-19 usually lasts until 4 weeks from the onset of
symptoms, beyond which replication-competent SARS-CoV-2
has not been isolated.
❖Post Acute Sequelae of COVID-19 (PASC), 2 categories:
1) Subacute or ongoing symptomatic COVID-19: symptoms and
abnormalities present from 4–12 weeks beyond acute COVID-19.
2) Chronic or post-COVID-19 syndrome: symptoms and
abnormalities persisting or present beyond 12 weeks of the onset
of acute COVID-19 and not attributable to alternative diagnoses.

Nalbandian A, et al. Post-acute COVID-19 syndrome. Nature Medicine. Mar 2021

Nalbandian A, et al. Post-acute COVID-19 syndrome. Nature Medicine. Mar 2021
❖Recognize temporal radiological changes of acute
COVID-19.
❖Recognize post acute pulmonary parenchymal
sequelae of COVID-19.
❖Pitfall in follow-up with chest imaging.
❖Guideline in follow-up with chest imaging.
❖ Early stage (0-4 days after onset):
▪ GGO - main features
▪ Distribution: Typically subpleural in lower lobes, unilateral/bilateral.

❖ Progressive stage (5-8 days after the onset):

▪ Rapidly increased extent to bilateral multi-lobe distribution with diffuse
GGO, crazy-paving pattern & consolidation.
❖ Peak stage (9-13 days after the onset):
▪ Consolidation: slowly increased extent to the peak involvement.
▪ Presence of residual parenchymal bands.

❖ Absorption stage (≥14 days after the onset):

▪ Gradually absorbed consolidation, resolved crazy-paving pattern.

Time Course of Lung Changes On Chest CT During Recovery From

2019 Novel Coronavirus (COVID-19) Pneumonia; Pan et al, Radiology 2020
28
22Mar
Mar2020
2020Day
Day15
9 24
16 Mar
Mar 2020
2020 Day
Day 11
3
Day
3

Day
21
 ❖ The predominant pattern of abnormalities
▪ GGO - after symptom onset
▪ Mixed pattern during illness days 12-17.
❖ The extent of CT abnormalities:
▪ Progressed rapidly after symptom onset
▪ Peaked during illness days 6-11.
▪ Followed by persistence of extent.

Temporal Changes of CT Findings in 90 Patients with COVID-19 Pneumonia: A Longitudinal Study

Wang et al, Radiology 2020
DOI = 11 days

9 days
after
M62 COVID-19: 7 days after RT-PCR confirmed & Cytokine storm

19 days after RT-PCR confirmed

❖Residual pulmonary disease - sometimes referred to as
▪ Post-COVID interstitial lung disease (ILD)
▪ Post-COVID pulmonary fibrosis (PCPF)
▪ Persistent Post COVID-19 ILD
❖The etiology of lung disease after COVID-19 may be a sequelae
▪ Prolonged mechanical ventilation, ventilator-induced lung injury.
▪ COVID-19–induced acute respiratory distress syndrome (ARDS).
▪ Direct injury from the virus.
Post-COVID-19 Pulmonary Fibrosis: Novel Sequelae of the Current Pandemic. J Clin Med. Jun 2021.
 ❖ Lack of a known recovery trajectory of COVID-19 pneumonia.
❖ Wang et al; 90 patients
▪ ~ 94% of hospitalized patients: persistent lung findings on discharge CT.
▪ M.C pattern = GGO.
❖ Liu et al: 149 patients of mild covid within 3 weeks after D/C
▪ 53.0% - resolution of lung opacities.
▪ >40% - residual abnormalities, mainly GGO and fibrous stripe.

Wang Y, et al. Temporal Changes of CT Findings in 90 Patients with COVID-19 Pneumonia: A Longitudinal Study. Radiology Mar 2020
Liu D, et al. The pulmonary sequalae in discharged patients with COVID-19: a short-term observational study. Respir Res. May 2020.
❖Myall et al: At 4 weeks after D/C,
▪ 38% (316/837) – fully recovery.
▪ 39% (325/837) - ongoing symptoms.
➢ 138/325 (42.9%): No evidence of physiological impairment or persistent change on CXR.
➢ 110/325 (33.8%): Functional or physiological impairment w/o radiological evidence.
➢ 77/325 (24%) – CT & referred to the post–COVID-19 lung disease MDT.
❖59/77 (76.6%) : CT at 6 weeks - persistent parenchymal abnormality
o 35/59 (59%) – organizing pneumonia.
o 24/59 (40.7%) - only minor ground glass (<15% of lung involvement).
▪ 4.8% (35/837) or 10.8% (35/325) - interstitial lung disease, predominantly
organizing pneumonia, with significant functional deficit.

Myall KJ, et al. Persistent Post-COVID-19 Interstitial Lung Disease. An Observational Study of Corticosteroid
Treatment. Ann Am Thorac Soc. May 2021.
❖Han et al: 114 of patients recovered from severe COVID-19
within 6 months of disease onset:
▪ 38% (43/114) - Complete radiologic resolution.
▪ 27% (31/114) - Residual GGO or interstitial thickening.
▪ 35% (40/114) - Fibrotic-like changes.
➢ Older age (> 50 years).
➢ Acute respiratory distress syndrome.
➢ Higher baseline CT lung involvement score (>18/25).

Han X, et al. Six-month Follow-up Chest CT Findings after Severe COVID-19 Pneumonia. Radiology Apr 2021.
 3 months 65/83 [78%]
Interlobular septal
GGO 78% thickening 34% Reticulation 33% Subpleural lines 11%

6 months 40/83 [48%]

Interlobular
Reticulation Subpleural Mosaic Bronchiectasis
GGO 46% septal thickening
16% lines 5% attenuation 4% 1%
13%

9 months 22/83 [27%]

Interlobular septal
GGO 24% thickening 5%
Reticulation 4% Subpleural lines 1%

Wu X et al, 3-month, 6-month, 9-month, and 12-month respiratory outcomes in patients following COVID-19-related
hospitalisation: a prospective study. The Lancet Respiratory Medicine 2021
❖At 12 months:
▪ 20 (24%) patients: abnormal HRCT and no significant
improvement when compared with 9 months.
▪ None of the HRCT scans showed evidence of established
fibrosis.
▪ None showed evidence of progressive interstitial changes.

Wu X et al, 3-month, 6-month, 9-month, and 12-month respiratory outcomes in patients following
COVID-19-related hospitalisation: a prospective study. The Lancet Respiratory Medicine 2021
14 Jul 21 1 Aug 21 21 Aug 21 = 5 wks
May 22 Jun 19
Jun 08 Sep 17
Oct 25, 20 weeks after COVID-19 infection
❖CT findings:
▪ GGO: the most frequent CT finding, up to 2/3 or more.
▪ Band-like and perilobular opacities: possibly in part consistent with
organizing pneumonia.
▪ Reticulation and interstitial thickening.
▪ Mosaic attenuation pattern:
➢ Small airway disease or pulmonary vascular microthrombosis: unclear.
▪ Honeycombing, uncommonly reported and may potentially be a/w a
preexisting fibrosing lung disease.
❖A greater extent of CT abnormalities a/w longer hospitalization,
ICU admission, and ventilation.
 Sep 14
Sep 02,
7 days after PCR confirmed
Sep 02 Sep 14
Piyavisetpat N, et al. ‘Ring of fire’ appearance in COVID-19 pneumonia. BMJ Case Rep 2020
 Defined as Increased extension of the GGO or consolidation,
and decreased attenuation, 3-4 weeks after acute phase of pneumonia.

Han X, et al. Six-month Follow-up Chest CT Findings after Severe COVID-19 Pneumonia. Radiology Apr 2021.
12 Jun 2021 7 Jul 2021
2 Aug 2021, 6 weeks after Dx Covid-19 Pneumonia
Evaluating COVID-19 survivors in the first 3 months after D/C:
based on the severity of acute COVID-19 &
whether the patient received ICU-level care.
4-6 weeks after D/C: in patients w/ Clinical assessment for
severe acute COVID-19 i.e., severe respiratory, psychiatric &
pneumonia, required ICU care, elderly thromboembolic sequelae,
or have multiple comorbidities. rehabilitation needs.
Clinical PFTs, 6MWTs, HRCT, CTPA , or
12 assessment & sputum sampling & discharged from FU
weeks CXR in all echocardiogram based on this 12-week
patients. according to clinical judgment. assessment.
❖ Should Chest CT Scan Be Routinely Performed in Patients with
Persisting Respiratory Symptoms after COVID-19?
▪ Chest CT scan is recommended to be routinely performed in
patients with persisting respiratory symptoms after COVID-19.
➢ Moderate recommendation for.
➢Remark: Consensus was reached when strong and weak
recommendations are merged, 68% gave a strong recommendation for
and 32% a weak recommendation for.

Funke-Chambour M et al, Swiss Recommendations for the Follow-Up and

Treatment of Pulmonary Long COVID. Respiration 2021.
❖ Persistent air trapping: previously identified after SARS
infection and can occur after other viral infections.
❖ Some patients after COVID-19 infection:
▪ New emphysema, cysts, and mosaic attenuation.
▪ Suggests that the infection may sometimes result in airflow
obstruction
▪ Expiratory CT should be routine in the patient following
COVID-19.

Solomon JJ, et al. CT of Post-Acute Lung Complications of COVID-19. Radiology 2021.

❖ Follow-up: Unenhanced CT performed supinely should be
sufficient in the vast majority of COVID-19 patients.
❖ Expiratory CT: may be helpful if a suspicion of residual small
airway disease.
❖ Prone position: to distinguish mild or limited COVID-19
pneumonia from normal dependent density.
❖ Contrast enhanced dual-energy CT:
▪ Might be performed in dyspneic patients with DLCO to help identify
possible perfusion defects 20 to microvascular thrombosis.
Martini K et al, COVID-19 pneumonia imaging follow-up: when and how?
A proposition from ESTI and ESR. Eur Radiology 2021.
❖ The rate and severity of the long-term pulmonary
complications of COVID-19: presently unknown.
❖ The trajectory of radiological changes: heterogeneous.
❖ Comparison with acute phase imaging is important to
understand the temporal course of the abnormality.
❖Post-COVID-19 pneumonia changes:
▪ Mainly consistent with prior organizing pneumonia.
▪ Likely to disappear within 12 months of recovery from the acute
infection in the majority of patients.
❖Awaiting longer term follow-up studies to determine if these
CT features will persist or resolve.
❖Follow-up at 3 months with chest CT in patients with
persistent respiratory symptoms.