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Coronavirus Disease 2019 (COVID-19)
Coronavirus Disease 2019 (COVID-19)
Salehi et al.
Systematic Review of COVID-19 Imaging Findings
Cardiopulmonary Imaging
Original Research
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S
2019-nCoV, outbreak, pneumonia, radiology, systematic
review, viral an unidentified origin emerged in early stages, whereas CT findings may be
from Wuhan, China, and were present even before symptom onset [5, 6]. In
doi.org/10.2214/AJR.20.23034
reported to the World Health Or- the intermediate to advanced stages of the dis-
S. Salehi and A. Abedi contributed equally to this study. ganization (WHO) on December 31, 2019 [1]. ease, chest radiographs may show progression
On January 7, 2020, the 2019 novel coronavi- of features of acute respiratory distress syn-
Received February 27, 2020; accepted without revision rus (2019-nCoV; later renamed severe acute drome (ARDS) (Fig. 1). Furthermore, CT find-
February 29, 2020. respiratory syndrome coronavirus 2 [SARS- ings have proven to be diagnostic in a number
1 CoV-2]) was confirmed as the cause of these of cases with an initial false-negative reverse
All authors: Department of Radiology, Keck School of
Medicine, University of Southern California, reported cases, and the outbreak was subse- transcription polymerase chain reaction (RT-
1500 San Pablo St, Los Angeles, CA 90033. Address quently named coronavirus disease (COVID- PCR) screening test [7, 8]. An assessment of
correspondence to A. Gholamrezanezhad 19) [2]. The WHO declard the outbreak a 41 patients with a laboratory-confirmed COV-
(ali.gholamrezanezhad@med.usc.edu). global health emergency on January 30, ID-19 diagnosis revealed abnormal chest CT
Supplemental Data
2020. As of February 20, 2020, a total of findings in all cases [9]. Subsequently, multi-
Available online at www.ajronline.org. 75,761 cases and 2130 deaths had been re- ple case series were published, aiming to de-
ported in more than 30 countries [3]. fine the CT features of COVID-19 pneumonia.
AJR 2020; 215:1–7 Because of the primary involvement of the With growing global concerns about the
ISSN-L 0361–803X/20/2151–1
respiratory system, chest CT is strongly rec- COVID-19 outbreak, a comprehensive un-
ommended in suspected COVID-19 cases, derstanding of the diagnostic imaging hall-
© American Roentgen Ray Society for both initial evaluation and follow-up [4]. marks, atypical features, and evolution of
Risk of Bias
Two reviewers independently rated the quality
of included studies using the National Institutes of
Health Quality Assessment Tool for Case Series
Studies [12] (Table 1).
• Pubmed: n = 421 through WHO database In another study, Chung et al. [22] charac-
• Embase: n = 487 (n = 1245)
• Google Scholar: n = 1636 terized the CT manifestations of COVID-19
pneumonia in 21 patients and reported bilat-
eral lung involvement in 76% and peripher-
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TABLE 1: Quality Ratings of Included Studies According to NIH Quality Assessment Tool for Case Series Studies
Questiona Overall Rating
First Author
[Reference No.] 1 2 3 4 5 6 7 8 9 Reviewer 1 Reviewer 2
Huang [9] Yes Yes NR CD NA Yes CD Yes Yes Fair Fair
Xie [8] Yes Yes NR CD NA Yes CD Yes Yes Fair Fair
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clearly and fully described, including a case definition?, 3 = Were the cases consecutive?, 4 = Were the subjects comparable?, 5 = Was the intervention clearly
described?, 6 = Were the outcome measures clearly defined, valid, reliable, and implemented consistently across all study participants?, 7 = Was the length of follow-up
adequate?, 8 = Were the statistical methods well-described?, 9 = Were the results well-described? (Source: National Heart, Lung, and Blood Institute; National
Institutes of Health; U.S. Department of Health and Human Services)
bYang Z, et al., preliminary data.
cYang W,et al., preliminary data.
lar septal thickening. In the rapid progression tive opacities, reticular opacities (referred to found that more than 85% of the patients
stage (days 3–7 of symptomatic presentation), as “strip-like opacities”), bronchial wall thick- showed imaging signs associated with dis-
CT findings include large, light consolida- ening, and interlobular septal thickening. ease progression such as increase in GGO,
tive opacities and air bronchograms [4]. Dur- Song et al. [19] reported CT findings as- consolidative opacities, and interstitial sep-
ing the consolidation stage (second week of sociated with disease progression, includ- tal thickening (referred to as “enlarged fi-
symptomatic presentation), reductions in den- ing an increased rate of consolidative opaci- brous stripes”) [6]. In some patients with
sity and size of the consolidative opacities ties. Pan et al. [6] assessed the follow-up CT pulmonary nodules on initial CT, follow-up
may be seen. About 2–3 weeks after the on- scans of 63 patients that were obtained with- CT showed an increase in number and size
set, CT may show dispersed patchy consolida- in 3–14 days after an initial CT study. They or fusion of the nodules. However, they
TABLE 2: Common Patterns and Distribution on Initial CT Images of global concerns about the COVID-19 out-
919 Patients With Coronavirus Disease (COVID-19) break, a comprehensive understanding of the
No. (%) of Reported Cases/
diagnostic imaging hallmarks, atypical fea-
Imaging Finding No. of Studies Total No. of Patients tures, and evolution of chest imaging find-
ings is essential for effective patient manage-
Bilateral involvement 12 435/497 (87.5)
ment and treatment.
Peripheral distribution 12 92/121 (76.0) The known imaging features of initial CT
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nia. However, there seemed to be a close re- Study Limitations 63 patients in Wuhan, China. Eur Radiol 2020
lation between the pattern of CT findings A number of included studies were limited Feb 13 [Epub ahead of print]
and disease course. Several studies report- in terms of sample size, data availability, and 7. Huang P, Liu T, Huang L, et al. Use of chest CT in
ed temporal changes in CT findings in fol- methodologic quality. Therefore, the report- combination with negative RT-PCR assay for the
low-up examinations, including a transition ed findings should be interpreted cautiously 2019 novel coronavirus but high clinical suspicion.
from isolated GGO to a superimposition of within that context. Furthermore, our study Radiology 2020 Feb 12 [Epub ahead of print]
consolidation on GGO with cavitation over was limited to the articles published in Eng- 8. Xie X, Zhong Z, Zhao W, Zheng C, Wang F, Liu J.
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time. Some studies suggested that CT mani- lish. Considering the epicenter of COVID-19, Chest CT for typical 2019-nCoV pneumonia: rela-
festations of COVID-19 may vary across age Chinese literature should be included in fu- tionship to negative RT-PCR testing. Radiology
groups, with a predominance of consolida- ture systematic reviews. We will continue to 2020 Feb 12 [Epub ahead of print]
tive opacities in older patients and GGO in monitor the literature, and this review will be 9. Huang C, Wang Y, Li X, et al. Clinical features of
younger patients. However, there is a pauci- updated when new evidence emerges. patients infected with 2019 novel coronavirus in
ty of evidence on the long-term pulmonary Wuhan, China. Lancet 2020; 395:497–506
effects of this infection [29]. Current studies Conclusion 10. World Health Organization website. WHO data-
are limited by their short follow-up periods, This review of available English studies base of publications on coronavirus disease (CO-
and CT findings in recovered patients have of COVID-19 provides insight into the ini- VID-2019). www.who.int/emergencies/diseases/
yet to be formally documented. tial and follow-up CT imaging findings for novel-coronavirus-2019/global-research-on-novel-
The correlation between CT findings and the disease. coronavirus-2019-ncov. Accessed February 19,
disease severity and mortality can be con- 2020
cluded from a number of studies. In severe- Acknowledgments 11. Moher D, Liberati A, Tetzlaff J, Altman DG;
ly ill patients, the most commonly reported We thank Fenxiang Song and Yuxin Shi of PRISMA Group. Preferred reporting items for
CT findings were bilateral and multilobar in- the Department of Radiology, Shanghai Pub- systematic reviews and meta-analyses: the
volvement and subsegmental consolidative lic Health Clinical Center, Shanghai, China, PRISMA statement. PLoS Med 2009; 6:e1000097
opacities. ARDS was the most common in- for their valuable contributions to this article. 12. National Heart, Lung, and Blood Institute website.
dication for transfer to the ICU, with the ma- Study quality assessment tools. www.nhlbi.nih.
jority of COVID-19 mortalities occurring References gov/health-topics/study-quality-assessment-tools.
among patients with ARDS in the ICU. 1. World Health Organization website. Pneumonia Accessed February 16, 2020
Published clinical guidelines strongly rec- of unknown cause: China. www.who.int/csr/don/05- 13. Fang Y, Zhang H, Xu Y, Xie J, Pang P, Ji W. CT
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F O R YO U R I N F O R M AT I O N
A data supplement for this article can be viewed in the online version of the article at: www.ajronline.org.