Clinical and CT imaging features of 2019 novel coronavirus disease (COVID-19)
Authors: Ying Zhu, Zhen-Hua Gao, Yang-Li Liu, Dan-Yang Xu, Tian-Ming Guan, Zi-Ping Li, Jian-Yi Kuang, Xiang-Min Li, You-You Yang, Shi-Ting Feng
Journal: Journal of Infection (2020)

Tang JW, et al. and colleagues have written to this Journal describing the emergence of 2019 novel coronavirus disease (COVID-19).1Tang J.W. Tambyah P.A. Hui D.S.C. Emergence of a novel coronavirus causing respiratory illness from Wuhan, China.J Infect. 2020 Jan 28; https://doi.org/10.1016/j.jinf.2020.01.014Abstract Full Text Full Text PDF Scopus (113) Google Scholar We have had an opportunity to examine in detail the chest computed tomography (CT) findings in cases with microbiologically confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, to familiarize radiologists and clinicians with the imaging manifestations of this new outbreak. Meanwhile, we also studied the clinical characteristics of the cases, combined with CT manifestations, to provide more clues for the correct diagnosis of the disease. Fourteen patients (P1-P14) aged from 10 to 75 years were referred to the fever clinic of our hospital, 7 of them (P8-P14) were from Hui-Ya branch of our hospital. P9 and P14 had diabetes and other patients had no underlying diseases. Among the 14 cases, 10 of them had a history of exposure to Wuhan or Hubei, while, P6 and P7 had no clear epidemiological history. P3/P4, P10/P11 were family clustering disease. All the patients performed oropharyngeal swabs test and confirmed as COVID-19. Common respiratory viruses, mycoplasma and chlamydia were negative. For patients' venous blood tests at disease onset, as given in (Table 1), we found that leucocytes and lymphocytes were slightly decreased or normal, eosinophil count were slightly decreased in 12 cases and normal in 2 cases. Neutrophil counts were normal for all the patients, and CRP was increased in 6 cases. PCT was normal or slightly elevated.Table 1Clinical characteristics of the 14 patients infected with 2019-nCoV.PatientGenderAge, yearsEpidemiology2019-nCoV-RNA test results of oropharyngeal swabsChief complaintCRP, mg/L, 0.00-10.00WBC#, x10^9/L, 4.00-10.00NEUT#, x10^9/L, 1.80-6.40LY#, x10^9/L, 1.00-3.30EO#, x10^9/L, 0.05-0.50PCT, ng/mL, 0.00-0.05P1F27Went to Wuhan 17 days agoThe second test was positiveFever (<38°)5.783.772.550.980.01NAP2F32Went to Wuhan 12 days agoTwo tests were positiveFever for 1 day (<38°)1.473.402.220.800.01NAP3F56Went to Hubei 1 day agoThe first test was positiveFatigue and fever for 1 day (<38°)6.405.693.451.420.200.04P4F32Family cluster with P3The second test was positiveFever for 1 hour (<38°)1.606.875.301.010.120.04P5F63Went to Wuhan 2 days agoTwo tests were positiveFever (<38°)2.854.083.130.550.01NAP6F54No clear history related to WuhanThe first test was positiveFever (40°C)63.795.894.151.310.01NAP7F49No clear history related to WuhanThe first test was positiveFever10.363.762.560.940.00NAP8F35Went to Wuhan 14 days agoThe first test was positive, the second test was negativeFever for half day (37.5°C)6.503.251.931.100.000.027P9F63Went to Wuhan 7 days agoThe fourth test was positiveFever for 2 days (37.1°C)88.205.925.200.550.000.208P10M41Contacted with person from Wuhan 25 days agoThe first test was positiveFever for 2 days (37.8°C)15.906.133.431.990.000.028P11F10Family cluster with P10Two tests were positiveAsymptomatic (37.1°C)0.006.925.111.590.000.020P12F66Went to Wuhan 4 days agoThe first test was positiveDizziness, vomiturition, fever (38.9°C) and myalgia for more than 1 day25.806.844.991.560.000.065P13F54Went to Wuhan 3 days agoThe first test was positiveChills and headache for 3 days, fever (37.6°C) for 1 day9.703.382.340.610.010.050P14M75From WuhanThe first test was positiveCough and fever 1 week (38.9°C)78.705.364.280.930.000.105Abbreviations: F, female; M, male; CRP, C-reactive protein; WBC, white blood cells; NEUT, neutrophil; LY, lymphocyte; EO, eosnophils; #: cell count; NA, not applicable. Note: The normal reference value range is listed behind the blood test index. Open table in a new tab Abbreviations: F, female; M, male; CRP, C-reactive protein; WBC, white blood cells; NEUT, neutrophil; LY, lymphocyte; EO, eosnophils; #: cell count; NA, not applicable. Note: The normal reference value range is listed behind the blood test index. On admission, 11 patients (P1–P11) underwent high resolution chest CT examination and their manifestations were shown in (Table 2). P1 (Fig. 1, F0, A1–A4): CT images showed patchy-like pure ground glass opacity (GGO) involving subpleural regions of the right middle lobe (Fig. 1, F0, A3, arrow) and the right lower lobe. The slightly thickened interlobular septa within the lesion makes it appear the crazy paving sign (Fig. 1, F0, A2, arrowhead). P2 (Fig. 2, P2, A1-A2): CT images showed mixed GGO and consolidation that appeared at subpleural area of the right middle lobe and the right lower lobe. The lesion presented as patchy-like morphology. P3 (Fig. 2, P3, A1-A2): CT images showed two well circumscribed, round nodular-like GGO lesions (Fig. 2, P3, arrow) located in the central area of the left upper lobe. P4 (Fig. 2, P4): CT images showed a small nodular-like pure GGO (Fig. 2, P4, arrow) located in the central area of the left lower lobe. P5 (Fig. 2, P5): CT images showed a slight of irregular pure GGO (Fig. 2, P5, arrow) located in the subpleural region of the right lower lobe. P6 (Fig. 2, P6, A1-A2): CT images showed bilateral multi-focal mixed GGO and consolidation appeared at subpleural area of lung. Mild bronchiectasis (Fig. 2, P6, A2, arrow) can also be observed within the lesion. P7 (Fig. 2, P7, A1–A4): CT images showed bilateral subpleural lesions, among which the lesion in the left lower lobe was nodular-like with pseudocavitary sign (Fig. 2, P7, A3, arrow). P8 (Fig. 3, P8) and P9 (Fig. 3, P9): CT images showed bilateral subpleural lesions with crazy paving sign. P10 (Fig. 3, P10, A1-A2): CT images showed bilateral multiple lesions, some of them were pure GGO located in the central region of the lung. P11 (Fig. 3, P11, A1-A2): CT images showed bilateral subpleural small nodular-like lesions.Table 2Imaging characteristics during the first visit.Imaging characteristicsP1P2P3P4P5P6P7P8P9P10P11Lobar location RUL√√√√ RML√√√√ RLL√√√√√√√√√ LUL√√√√ LLL√√√√√√Distribution Subpleural√√√√√√√√ Random or diffuse√√√Morphology Patchy-like√√√√√√ Nodular-like√√√ Both√√Contour Clear√√√ Blurry√√√√√√√√Attenuation GGO only√√√√√ Mixed GGO and consolidation√√√√√√Consolidation onlyOther signs Reticulation√ crazy paving√√√√ Cavitation Bronchiectasis√ Pleural effusion LymphadenopathyAbbreviations: RUL-right upper lobe, RML-right middle lobe; RLL-right lower lobe, LUL-left upper lobe, LLL-left lower lobe; GGO, ground glass opacity. "P#" represents one patient. Note: Check mark (√) indicate the appearance of the corresponding sign. Open table in a new tab Fig. 2The initial CT images of P2-P7. CT images of P2 (Fig. 2, P2, A1-A2), P5 (Fig. 2, P5), P6 (Fig. 2, P6, A1-A2) and P7 (Fig. 2, P7, A1–A4) showed subpleural lesions, a nodular-like lesion with pseudocavitary sign (Fig. 2, P7, A3, arrow) and mild bronchiectasis (Fig. 2, P6, A2, arrow) were also observed within the lesion. CT images of P3 (Fig. 2, P3, A1-A2) and P4 (Fig. 2, P4) showed round nodular-like GGO lesions (P3 and P4, arrow) located in the central area of the lung.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig. 3The initial CT images of P8-P11. CT images of P8 (Fig. 3, P8) and P9 (Fig. 3, P9) showed bilateral subpleural lesions with crazy paving sign. CT images of P10 (Fig. 3, P10, A1-A2) showed bilateral multiple lesions, some of them were pure GGO located in the central region of the lung. CT images of P11 (Fig. 3, P11, A1-A2) showed bilateral subpleural small nodular-like lesions.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Abbreviations: RUL-right upper lobe, RML-right middle lobe; RLL-right lower lobe, LUL-left upper lobe, LLL-left lower lobe; GGO, ground glass opacity. "P#" represents one patient. Note: Check mark (√) indicate the appearance of the corresponding sign. P1 had three follow-up CTs (Fig. 1, F1–F3). The time interval between initial chest CT and follow-up were 4, 8, 14 days. Follow-up 1(Fig. 1, F1, B1–B4): CT images showed diseases progression. The lesions showed diversified morphology and distribution, appearing as coexisted nodular-like (Fig. 1, F1, B4, arrow) and patchy-like lesions as well as peribronchial (Fig. 1, F1, B2, arrowhead), central and subpleural distribution. CT images of F1 showed the that lesions were migratory manifested as the absorption of the primary lesions and the emergence of new lesions. CT images of Follow-up 2 (Fig. 1, F2, C1-C4) and Follow-up 3 (Fig. 1, F3, D1–D4) showed the diseases were obviously absorbed. In the current study, we investigated the detailed information including clinical features and CT imaging characteristics of 6 patients with COVID-19. Our research has some new findings on the basis of previous study: (1) The decrease of eosinophil count may be helpful for the early diagnosis of the disease. Nevertheless, till now, there is no study refer to blood tests2Huang C. Wang Y. Li X. et al.Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.Lancet. 2020; 395https://doi.org/10.1016/S0140-6736(20)30183-5Abstract Full Text Full Text PDF Scopus (32423) Google Scholar,3Wang D. Hu B. Hu C. et al.Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China.JAMA. 2020; https://doi.org/10.1001/jama.2020.1585Crossref Scopus (16024) Google Scholar mentioned eosinophil, which is worthy of further study. (2) Our CT study found that COVID-19 has a variety of manifestations. In the early stage of the disease, the lesion can manifest as round nodular-like GGO in the central area of the lung lobe, which is different from the common imaging manifestations that are patchy-like lesion in subpleural region.4Song F. Shi N. Shan F. et al.Emerging Coronavirus 2019-nCoV Pneumonia.Radiology. 2020; https://doi.org/10.1148/radiol.2020200274Crossref Scopus (871) Google Scholar, 5Xie X. Zhong Z. Zhao W. et al.Chest CT for Typical 2019-nCoV Pneumonia: Relationship to Negative RT-PCR Testing.Radiology. 2020; https://doi.org/10.1148/radiol.2020200343Crossref Scopus (1249) Google Scholar, 6Pan Y. Guan H. Zhou S. et al.Initial CT findings and temporal changes in patients with the novel coronavirus pneumonia (2019-nCoV): a study of 63 patients in Wuhan, China.Eur Radiol. 2020; https://doi.org/10.1007/s00330-020-06731-xCrossref Scopus (706) Google Scholar (3) The follow-up CT images showed the lesions are migratory manifested as the absorption of the primary lesions and the emergence of new lesions, which had not been reported yet. (4) The false negative rate of oropharyngeal swabs seems high. As we know that, oropharyngeal swabs are the recommended upper respiratory tract specimen types for SARS-CoV-2 diagnostic testing,7Chan J.F. Yuan S. Kok K.H. et al.A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster.Lancet. 2020; 395https://doi.org/10.1016/S0140-6736(20)30154-9Abstract Full Text Full Text PDF PubMed Scopus (6145) Google Scholar,8To K.K. Tsang O.T. Chik-Yan Yip C. et al.Consistent detection of 2019 novel coronavirus in saliva.Clin Infect Dis. 2020; https://doi.org/10.1093/cid/ciaa149Crossref Scopus (1233) Google Scholar so a new detection technique should be developed as soon as possible. The authors declare that they have no competing interests.