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Can Chest CT Features Distinguish Patients with Negative from Those with Positive Initial RT-PCR Results for Coronavirus Disease (COVID-19)?

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Can Chest CT Features Distinguish Patients with Negative from Those with Positive Initial RT-PCR Results for Coronavirus Disease (COVID-19)? Cardiopulmonary Imaging • Original Research Chen et al. Chest CT of COVID-19 Cardiopulmonary Imaging Original Research Can Chest CT Features Distinguish Patients With Negative From Those With Positive Initial RT-PCR Results for Coronavirus Disease (COVID-19)? Dandan Chen1 OBJECTIVE. The purpose of this study was to explore the value of CT in the diagnosis of Xinqing Jiang1 coronavirus disease (COVID-19) pneumonia, especially for patients who have negative initial Yong Hong2 results of reverse transcription–polymerase chain reaction (RT-PCR) testing. Zhihui Wen1 MATERIALS AND METHODS. Patients with COVID-19 pneumonia from January Shuquan Wei3 19, 2020, to February 20, 2020, were included. All patients underwent chest CT and swab Guangming Peng4 RT-PCR tests within 3 days. Patients were divided into groups with negative (seven patients) Xinhua Wei1 and positive (14 patients) initial RT-PCR results. The imaging findings in both groups were recorded and compared. Chen D, Jiang X, Hong Y, et al. RESULTS. Twenty-one patients with symptoms (nine men, 12 women; age range, 26–90 years) were evaluated. Most of the COVID-19 lesions were located in multiple lobes (67%) in both lungs (72%) in our study. The main CT features were ground-glass opacity (95%) and consolidation (72%) with a subpleural distribution (100%). Otherwise, 33% of patients had other lesions around the bronchovascular bundle. The other CT features included air bron- chogram (57%), vascular enlargement (67%), interlobular septal thickening (62%), and pleural effusions (19%). Compared with that in the group with positive initial RT-PCR results, CT of the group with negative initial RT-PCR results was less likely to show pulmonary consolida- tion (p < 0.05). CONCLUSION. The less pulmonary consolidation found at CT, the greater is the possi- bility of negative initial RT-PCR results. Chest CT is important in the screening of patients in whom disease is clinically suspected, especially those who have negative initial RT-PCR results. Keywords: coronavirus disease, COVID-19, CT, pneumonia, reverse transcription–polymerase chain reaction, RT-PCR n December 31, 2019, the World COVID-19 pneumonia is a new disease Health Organization (WHO) was outbreak with potentially far-reaching pub- doi.org/10.2214/AJR.20.23012 O alerted to several cases of a re- lic health ramifications first found in Wuhan, Received February 26, 2020; accepted after revision spiratory illness of unknown China, on December 30, 2019, by the Wuhan April 3, 2020. causation emerging from Wuhan, China, and Municipal Health Commission [4]. Accord- rapidly spreading elsewhere in China and ing to current diagnostic criteria, laboratory abroad. As of March 25, 2020, there were examinations, such as swab tests, have be- 1Department of Radiology, Guangzhou First People’s Hospital, School of Medicine, South China University of more than 81,000 confirmed cases and more come a standard and formative assessment Technology, Guangzhou 510180, China. Address than 3200 deaths attributed to this illness in for the diagnosis of SARS-CoV-2 infection correspondence to X. Wei ([email protected]). China. Analysis of bronchoalveolar lavage [5]. Some patients with suspected COVID-19 fluid samples and electron microscopy re- pneumonia may have the virus detected by 2Department of Radiology, Huadu District People’s Hospital of Guangzhou, Guangzhou, China. vealed the culprit to be a coronavirus, a virus means of reverse transcription–polymerase with a characteristic crownlike shape due to chain reaction (RT-PCR) testing of the respi- 3Department of Respiration, Guangzhou First People’s the presence of viral spike peplomers ema- ratory tract. However, RT-PCR is subject to Hospital, School of Medicine, South China University of nating from the viral envelope. On January false-negative results because it can easily be Technology, Guangzhou, China. 12, 2020, WHO temporarily named the virus affected by multiple factors, such as insuffi- 4 2019 novel coronavirus (2019-n-CoV) [1]. On cient cellular material for detection and im- Downloaded from www.ajronline.org by Jake Whitacre on 05/05/20 IP address 71.62.174.241. Copyright ARRS. For personal use only; all rights reserved Department of Radiology, Clifford Hospital, Guangzhou,China. February 10, 2020, the International Com- proper extraction of nucleic acids from clini- mittee on Taxonomy of Viruses and WHO cal materials. On February 8, 2020, the China AJR 2020; 215:1–5 officially named the new coronavirus and the National Health Commission released the ISSN-L 0361–803X/20/2155–1 resulting illness severe acute respiratory syn- guidance Diagnosis and Treatment of Pneu- drome coronavirus 2 (SARS-CoV-2) and monitis Caused by New Coronavirus (tri- © American Roentgen Ray Society coronavirus disease (COVID-19) [2, 3]. al version 5, revision) [6], which defined the AJR:215, November 2020 1 Chen et al. clinical diagnostic criteria for Hubei Prov- counts, C-reactive protein level, and erythrocyte short-axis dimension), pleural effusion, and pul- ince as imaging characteristics of pneumo- sedimentation rate. An epidemiologic history of monary fibrosis. nia. The commission also noted that high- being in Wuhan or exposure to a person with the resolution CT is an important element in the infection was also recorded. Statistical Analysis diagnosis of COVID-19 pneumonia. After Statistical analyses were performed with SPSS this guidance was instituted, the number of CT Image Data Acquisition software (version 21.0, IBM). The categoric vari- new cases in Hubei had increased by 14,840 All 21 patients underwent CT on the same day ables of CT characteristics were expressed as cases on February 13, 2020, which indicated that that the initial mouth swab tests were performed. and compared by Pearson chi-square test between CT had a higher detection rate in patients Chest CT was performed with the patients in the the group with negative initial RT-PCR results and with disease in the incubation period, espe- supine position during end-inspiration without IV the group with positive initial RT-PCR results. A cially for those with negative initial RT-PCR contrast administration. Nine patients were eval- value of p < 0.05 was considered significant. results. This finding showed that CT is help- uated with a Somatom Definition AS CT scan- ful for early diagnosis, timely isolation, and ner (Siemens Healthineers) at 1.5-mm slice thick- Results treatment of COVID-19 pneumonia. ness, 120-kV tube voltage, and 100- to 200-mAs Patient Characteristics The primary purpose of this study was to tube current–exposure time product. Four patients This study included 21 patients (nine men, describe CT in a group of 21 patients with underwent 16-MDCT (Somatom Emotion scan- 12 women; mean age, 49.7 ± 15.7 [SD] years; SARS-CoV-2 infection in Guangzhou, Chi- ner, Siemens Healthineers) at 1-mm slice thick- range, 26–90 years). Nineteen (90%) patients na, especially those with negative initial RT- ness, 120 kV, and 100–200 mAs. Four patients had a history of exposure to a person with PCR results with highly suspected COV- underwent CT with an Optima CT 520 Pro scan- SARS-CoV-2 infection or had been to Wu- ID-19 pneumonia. ner (GE Healthcare) at 1-mm slice thickness, 120 han. The mechanism of exposure of the oth- kV, and 200–300 mAs. Three patients under- er two patients was unknown. Blood counts Materials and Methods went 16-MDCT (Aquilion scanner, Toshiba) at at admission showed that 10 of the 21 (48%) Study Population 2-mm slice thickness, 120 kV, and 100–300 mAs. patients had leukopenia (WBC count, < 4 × This retrospective study received institutional The last patient underwent CT with a Brilliance 109/L) and four patients (19%) had lympho- review board approval, and the requirement for in- 64-MDCT scanner (Philips Healthcare) at 1-mm penia (lymphocyte count, < 1.0 × 109/L). C- formed consent was waived. To avert any potential slice thickness, 120 kV, and 100–200 mAs. reactive protein levels were above the normal breaches of confidentiality, no link between the range in 14 (67%) and erythrocyte sedimenta- patients and the researchers was made available. CT Image Evaluation tion rates were elevated in six (29%) patients. From January 19, 2020, to February 20, 2020, Two experienced thoracic radiologists (5 years Common symptoms were fever (13 patients the admission data of 21 patients with confirmed of experience) blinded to the clinical data and [62%]), cough (eight patients [38%]), and COVID-19 pneumonia from five nonspecialized RT-PCR results reviewed the CT images indepen- headache (five patients [24%]). infectious disease hospitals in Guangzhou, Chi- dently at a PACS workstation. The final decisions na, were obtained. The five hospitals are located were reached by consensus of the two radiolo- Chest CT Features in four districts of Guangzhou (13 cases in Hua- gists. If there was disagreement between them, a The 21 chest CT examinations showed that du, four cases in Baiyun, three cases in Yuexiu, third fellowship-trained thoracic radiologist with lesions were bilateral in 15 (71%) patients, in and one case in Nansha). All 21 patients had posi- 10 years of experience adjudicated the final deci- the left lung in three (14%) patients, and in the tive final RT-PCR results for SARS-CoV-2 in lab- sion. All of the unenhanced CT images were eval- right lung in three (14%) patients. Most of the oratory testing of respiratory secretions obtained uated in preset standard pulmonary (width, 1500– lesions (14 [67%]) were located in multiple by nasopharyngeal or oropharyngeal swab. On the 2000 HU; level, –450 to 600 HU) and mediastinal lobes, and the other seven (33%) in a single basis of the initial RT-PCR results, these patients (width, 400 HU; level, 60 HU) windows. The fol- lobe, with the lower lobe being involved most were divided into two groups: seven patients with lowing CT characteristics of the lesions were often (17 [81%]).
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