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Образна диагностика в условията на COVID-19 пандемия

date : 22.05.2020

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"Quality is not an act. It is a habit."


Aristotle


A PCR-NEGATIVE, IgG/IgM-POSITIVE SARS-CoV-2

date : 16.04.2020


Dr. Orlin Zlatarski
Prof. Galina Kirova
Dr. Kaloyana Kaleva


Acibadem City Clinic Tokuda Hospital

o.zlatarski@hotmail.com


Keywords: COVID-19, Chest CT, pneumonia, triage, RT-PCR test


Clinical history: A 70 yo male with a 7-day history of severe fatigue, muscle pain, fever up to 39C, throat pain, a non-productive cough presented to the Emergency Department. The physical examination - body T - 37C, BP - 120/70 mmHg, respiratory rate of 32 breaths/min, O2 saturation of 85%. The first RT-PCR for COVID-19 was negative; IgG/IgM immunoassay was positive for both IgM and IgG. On day 16 and after the patient was intubated, the RT-PCR from bronchial lavage showed a positive result.


Imaging findings:

Figure 1: Baseline chest radiography (day 12 from the onset of the clinical symptoms) showing bilateral ground glass opacifications with fine reticular changes, and a heart shadow configuration characteristic for hypertension - an elongated left ventricular contour Figure 2: Axial chest HRCT (day 14 from the clinical symptoms) (A-D; superior to inferior) at different levels. Diffuse GGO changes, with reticular and interlobular septal thickening. Consolidation. Relative sparing of apical and basal segments. Pleural effusion. Figure 3: Coronal chest HRCT (A-C; posterior to anterior) reconstructions at different levels. Diffuse GGO changes, with reticular and interlobular septal thickening. Consolidation. Relative sparing of apical and basal segments.


Final diagnosis: Viral pneumonia, caused by the COVID-19 (SARS-CoV2) Virus


Discussion:

Imaging characteristics include pure GGO, GGO and reticulations and/or thickened interlobular septa, GGO and consolidation. The changes are located peripherally, predominantly in the posterior segments (dorsal to the mid-axillary line) of the lung parenchyma. It is important to note, that one single negative RT-PCR test from the upper airways does NOT indicate negative COVID-19. It is of utmost importance that the laboratory findings be considered together with the radiological findings - an approach now being adopted almost universally.


Differential diagnosis:

Non-SARS-CoV2 viral pneumonia; other diseases presenting with diffuse ground-glass opacity on chest CT.


Take home messages:

• Knowledge of radiological findings suggestive of COVID-19 are of paramount importance. • Upper respiratory tract swab tests given for RT-PCR sampling in patients who are at different stages of disease development are of uncertain sensitivity. • Unfortunately, although presenting early on, CT changes cannot always be differentiated from those seen in other pneumoniae.


Bibliography:

1. HuiLi, Feng J. et al. Multiple Negative of RT-PCR Testing of COVID-19 Pneumonia: A Case Report. https://researchgate.com/article/rs-16094/v1 (09.03.2020) DOI: 10.21203/rs.3.rs-16094/v1 2. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19); https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-COVID-19-final-report.pdf 3. Lee ЕYP, Ng MY, Khong PL; COVID-19 pneumonia: what has CT taught us?; The Lancet; Infection Disease 2020;20:384-385 4. Song F, Shi N, Shan F et al. Emerging 2019 Novel Coronavirus (2019-nCoV) Pneumonia. Radiology 2020;2951:210-217; DOI: 10.1148/radiol.2020200274 5. Kay F, Abbara S. The Many Faces of COVID-19 - Spectrum of Imaging Manifestations. 2020 (Pre-print) 6. Li Y, Xia L. Coronavirus Disease 2019 (COVID-19): Role of Chest CT in Diagnosis and Management. AJR 2020;214:1-7; https://www.ajronline.org/doi/pdf/10.2214/AJR.20.22954



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