Covid-19: A Radiologist Perspective (11 Pics)

Thought some of you may be interested in what we are seeing radiographically in cases of Covid-19. The American College of Radiology (ACR) does not endorse the use of imaging for screening or diagnosis of Covid-19, because the findings are non-specific and can be seen in other situations, to include Influenza, and the presence of a normal exam does not exclude the diagnosis. That being said, interesting patterns have emerged in the disease process as case series have come out from around the world beginning with China. A typical early case of Covid-19 may look like the Chest CT above. Here we have an axial slice at the level of the lower lobes of the lung demonstrating concerning (and ultimately confirmed) findings for Covid-19, which I saw through the ER a few nights ago.

A magnified image of one of the areas of pulmonary consolidation in the left lower lobe of the lung. Concerning findings for this case include multiple peripheral groundglass opacities with a basilar predominance. This one has a slightly rounded morphology and a subtle "reverse halo" appearance. The disease may progress to include much more pronounced/worse pulmonary findings, but it is this early stage that is most interesting to me. The problem with Covid for the radiology department largely lies in tech interaction with potentially infected patients (whether known or unknown), as well as the sterilization of rooms and equipment after imaging which may take a lot of time and are labor intensive. All of this has lead to a massive reduction in imaging of patients as we back away from elective indications. Hope everyone is staying safe and looking out for one another.

Here is a normal lung for comparison.

Normal Lung: CT Scan lower chest at the lung bases. Air on CT or "CAT Scan" is black so all that darkness on the image is healthy, aerated lung with normal pulmonary vessels which exchange CO2 from the body with Oxygen from the airway.

Confirmed Covid-19 Case: 28 yo Male. You can see areas of the lung which have become opacified, that is the normal air-filled lung is replaced by an infiltrate due to underlying infection/inflammation. This would be typical for a more early, likely less clinically severe case with symptoms such as cough, fever, malaise, shortness of breath.

Confirmed Covid-19 Case with ARDS: 40 yo Male. Here you can see more dense, extensive pulmonary opacities where much of the normal black lung is replaced by white infiltrate (color is descriptive of the CT only, not reflective of the actual pathology). Additionally fluid is building up around the outside of the lungs between the chest cavity (Pleural effusion). This is what we worry about, and why many of the severe and hospitalized Covid cases seem to by dying. This is a case of Covid that has gone on to develop ARDS (Acute Respiratory Distress Syndrome). Without getting too much in the weeds, ARDS is a clinical diagnosis (mostly non-specific on imaging) that can be a manifestation of many disease processes but appears to be happening with relative frequency with Covid-19. To put it simply, as the inflammation progresses it may get to a point where the innumerable tiny thin-walled sacs that exchange CO2 for Oxygen (alveoli) are so damaged that they begin to fill with fluid. Since humans aren't adapted to breathing under water, you can imagine that the ability to oxygenate the blood and remove the CO2 byproducts is severely hampered. Patients will begin to get severely short of breath, their blood oxygen levels will fall (hypoxemia), and their heart will try to compensate by pumping faster (tachycardia). The fluid buildup around the lungs will also hamper their ability to take deep adequate breaths. At this time patients will likely require intubation and mechanical ventilation. If it is severe enough even a machine may not be able to do the work, and in extreme cases it may be necessary to remove the blood from the body and oxygenate it across a membrane (Extracorporeal Membrane Oxygenation of ECMO). At any rate as soon as the lungs go, other organs may follow, leading to death. I don't mean to be morbid or scare people, but THIS is why the virus is so dangerous (along with it's high rate of transmissibility), and why you are avoiding social situations right now. The elderly and chronically ill seem to be particularly prone to developing ARDS, so socially isolate for your parents and grandparents if for noone else. Even people who recover may have significant scarring of the lungs.

Above we have a presenting Chest X-ray in an early 30's individual showing multiple primary basilar (lower) lobe opacities.

This individual just flew on a plane from one of the hottest Covid areas in the country to my town, reporting that he had been feeling slightly ill for the last 10 days with cough, but apparently "didn't think my illness was that bad".

Axial CT through mid chest demonstrating mutiple areas of primarily groundglass consolidation. The imaging on this appears worse than the first case I showed on this website, but doesn't look like ARDS at this point. Please note that this is a presumptive Covid-19 case at this point (came through a few hours ago), and is not confirmed. However, the fact that this individual willingly went through 2 airports and got on a plane right now absolutely infuriates me.

Another axial image lower in the chest with multiple additional opacities. This individual is relatively young but I would imagine has relatively severe respiratory symptoms given the extent of infection/inflammation. Certainly seems to be clinically worsening if they got on a plane sick, and then were ill enough to have to go to the hospital when they got to their destination.

Just another coronal image (different orientation like if you sliced bread top to bottom not front to back) showing the same thing. I wanted to share this case to impress on you that A) Young people may be severely affected by this virus. You are not immune because you are young and healthy. and B) Noone right now is special and should take liberties that put the people around you at risk. This is an insane once in a lifetime event, and should be treated with respect. This individual potentially unnecessarily exposed 2 whole airports full of people, a plane full of people, and now my radiology technologists and ED colleagues. Please think about the potential your infection has to cause pain, suffering, and death to others and STAY TO YOURSELVES.