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Differential Diagnosis of Coronavirus Disease 2019 from Community

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Differential Diagnosis of Coronavirus Disease 2019 from Community Liu et al. Infectious Diseases of Poverty (2020) 9:118 https://doi.org/10.1186/s40249-020-00737-9 RESEARCH ARTICLE Open Access Differential diagnosis of coronavirus disease 2019 from community-acquired-pneumonia by computed tomography scan and follow- up Kai-Cai Liu1, Ping Xu2*, Wei-Fu Lv3* , Lei Chen4, Xiao-Hui Qiu5, Jin-Long Yao6, Jin-Feng Gu4,BoHu7 and Wei Wei3 Abstract Objective: Coronavirus disease 2019 (COVID-19) is currently the most serious infectious disease in the world. An accurate diagnosis of this disease in the clinic is very important. This study aims to improve the differential ability of computed tomography (CT) to diagnose COVID-19 and other community-acquired pneumonias (CAPs) and evaluate the short-term prognosis of these patients. Methods: The clinical and imaging data of 165 COVID-19 and 118 CAP patients diagnosed in seven hospitals in Anhui Province, China from January 21 to February 28, 2020 were retrospectively analysed. The CT manifestations of the two groups were recorded and compared. A correlation analysis was used to examine the relationship between COVID-19 and age, size of lung lesions, number of involved lobes, and CT findings of patients. The factors that were helpful in diagnosing the two groups of patients were identified based on specificity and sensitivity. Results: The typical CT findings of COVID-19 are simple ground-glass opacities (GGO), GGO with consolidation or grid-like changes. The sensitivity and specificity of the combination of age, white blood cell count, and ground- glass opacity in the diagnosis of COVID-19 were 92.7 and 66.1%, respectively. Pulmonary consolidation, fibrous cords, and bronchial wall thickening were used as indicators to exclude COVID-19. The sensitivity and specificity of the combination of these findings were 78.0 and 63.6%, respectively. The follow-up results showed that 67.8% (112/ 165) of COVID-19 patients had abnormal changes in their lung parameters, and the severity of the pulmonary sequelae of patients over 60 years of age worsened with age. Conclusions: Age, white blood cell count and ground-glass opacity have high accuracy in the early diagnosis of COVID-19 and the differential diagnosis from CAP. Patients aged over 60 years with COVID-19 have a poor prognosis. This result provides certain significant guidance for the diagnosis and treatment of new coronavirus pneumonia. Keywords: Coronavirus disease 2019, Pneumonia, Computed tomography, X-ray, Differential diagnosis Background * Correspondence: [email protected]; [email protected] Coronavirus disease-19 (COVID-19) is an acute infec- 2Department of Respiratory, Hefei Second People’s Hospital, Hefei Hospital Affiliated to Anhui Medical University, 1 Guangde Road, Hefei 230011, Anhui tious respiratory disease caused by severe acute respira- Province, China tory syndrome coronavirus 2 (SARS-CoV-2, also called 3 Department of Radiology, Anhui Provincial Hospital, the First Affiliated 2019-nCoV) [1]. As of June 22, 2020, in total, 8 708 008 Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, 4 Lujiang Road, Hefei 230001, Anhui cases have been diagnosed worldwide (http://www.chi- Province, China nanews.com/m/34/2020/0318/1388/globalfeiyan.html). Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Liu et al. Infectious Diseases of Poverty (2020) 9:118 Page 2 of 11 The common symptoms of SARS-CoV-2 infection in- CT examination clude fever, cough, shortness of breath, and dyspnoea CT scans were performed for all patients with 64-slice [2–4]. In more serious cases, infection can lead to pneu- multidetector row CT scanners. All images were dis- monia, severe acute respiratory syndrome, renal failure, played and stored in the picture archiving and commu- and even death. Antibodies against the new coronavirus nication systems (PACS) system. Information regarding are still being studied [5, 6], and there is no specific and the CT systems in the seven hospitals is provided in effective treatment [7]. Supplementary Table 1. The gold standard for diagnosing COVID-19 is a posi- tive result for the new coronavirus nucleic acid test [8, 9], CT image evaluation but due to delays in obtaining test results or “false-nega- The CT images of the patients in the COVID-19 and CAP tives” in some reports, some patients cannot be diagnosed groups were acquired by three experienced radiologists and treated in time. COVID-19 has certain imaging char- (who have been working in radiography for over 5 years). acteristics in the lungs. Chest computed tomography (CT) A double-blind method was used, and the images were examination is an important method for the clinical diag- read independently. The radiologists carefully observed nosis of COVID-19 [10]. The early detection of lesions is and recorded the location, shape, number, size, edge pat- very important for early isolation and treatment and pre- tern and extent of the lesion. If the diagnosis was incon- venting the spread of the disease. Previous studies have sistent, a consensus was reached by the three experts. mostly focused on the imaging manifestations and changes in COVID-19 [11–13]. The disease needs to be Statistical analysis distinguished from many diseases by imaging, especially The measurement data are expressed as the means ± community-acquired pneumonia (CAP). However, com- SDs, and the comparison of the groups was conducted parative studies based on imaging in this area remain by an independent-samples t-test; the count data are lacking. expressed as percentages (%), and the comparisons of The purpose of this study was to compare the clinical the groups were conducted by the χ2 test. A correlation features and CT imaging manifestations of COVID-19 analysis was used to examine the relationship between with those of community-acquired pneumonia, explore COVID-19 and the age, size of the lung lesions, number the value of CT in the diagnosis and differential diagno- of involved lobes, and CT findings of the patients. The sis of COVID-19 and evaluate the short-term prognosis statistical software SPSS version 22.0 (IBM Corporation, of patients with these two types of pneumonia. Armonk, NY, USA) was used for the statistical analysis. Results Methods Study population characteristics Patient cohort The baseline data and clinical manifestations of the two From January 21 to February 28, 2020, the clinical data groups are shown in Table 1. The differences in age, of 165 patients with COVID-19 from seven hospitals in white blood cell (WBC) count, lymphocyte proportion, Anhui Province, China, including 76 males and 89 fe- and presence or absence of underlying disease in the males aged 5 to 91 years with an average age of 45.1 ± lungs between the two groups of patients were signifi- 17.6 years, were reviewed. The diagnosis complied with cant (χ2 = 8.03, P < 0.001; χ2 = 5.58, P < 0.001; t = 4.62, 2 the Guidelines for the Diagnosis and Treatment of New P = 0.003; χ = 21.72, P < 0.001). Coronavirus Pneumonia (Seventh Edition) formulated by the National Health Committee of the People’s Republic CT imaging of China [14]. In total, 118 patients with CAP were se- The chest CT findings of the patients who had COVID- lected from the First Affiliated Hospital of the University 19 or CAP for 3–7 days are shown in Table 2. Ground- of Science and Technology of China for pneumonia dur- glass opacities (GGOs) on chest CT images were found ing the same period. The pathogens were confirmed in in 140 patients (84.8%) in COVID-19 group. The typical all patients by the RT-PCR detection of sputum throat early lesions in COVID-19 group appeared as single or swabs and blood or other pathogenic tests. The patients multiple small round lesions. In this group, 53 patients with CAP included 48 males and 70 females aged 1 to (32.1%) had small round lesions, and 87 patients (52.7%) 76 years with an average age of 15.6 ± 21.4 years. The CT had ground-glass-like density shadows with spots, large images and clinical data of all patients were collected. patches or areas of fusion (Fig. 1a). In CAP group, 47 pa- The inclusion and exclusion processes are shown in tients (39.8%) had ground-glass shadows in the lungs, 71 Fig. 1, and the results of the community-acquired pneu- patients (60.2%) showed consolidation, and the density monia respiratory pathogen panel (CAP-RPP) are shown differences between the two groups was significant (χ2 = in Fig. 2. 48.75, P < 0.001). In COVID-19 group, 54 cases (32.8%) Liu et al.
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