volume3-issue2

Journal of the Association of Pulmonologist of Tamil Nadu. Vol. 3, Issue 2, May – August 2020

EDITORIAL

B.COVID and A.COVID –The Paradigm Shift

Hola!
Respected Pulmonologists,

We can be sure that we are currently a part of an historical period that is going to renovate the importance of health care and its pillars in future.

I was a simple student in my undergraduate days and neither was I serious about the practical role of preventive health nor the people who worked towards its sustainability.

Now as a pulmologist , I firmly believe that we cannot empty the sink by only unblocking the drain when the faucet is open. This aptly applies to all budding pulmonologists.

We were always worried about the reach of respiratory hygiene amongst the general public despite the continual efforts by the government. Boon or bane, this pandemic has deep rooted the message in everyone’s sense.

Gone are the days when one strolls around wearing a mask and get a bewildered stare.

Gone are the days when one was considered obsessive for using sanitizers and maintained social distancing.

We will now enter into a golden period of superlative health aware social environment after the lockdown is complete.

Sure it is an ongoing process but it will ensure that fewer people will come to us for care and frankly we cannot be happier.

The happier side of this pandemic is that it taught many how to control respiratory diseases. I wonder if these principles of test, isolate and treat and supervise were strictly followed we would have controlled TB long back. But nature has a way of reminding and correcting things. If HIV pandemic increased the interests of western world with regards to TB COVID pandemic has increased people’s interest in respiratory hygiene. When HIV and TB became comrades in arms western world looked to India as we had many TB patients who did not have access to ethambutol, Isoniazid and Thiocetazone. Our golden period with short course therapy started then. Similarly peoples’s interest in respiratory hygiene and the field of pulmonology has grown enormously in A.COVID ( After COVID )

Hoping for fair winds,
Dr.R.Narasimhan
Dr. Amal Johnson

How to cite this article: Narasimhan.R, Editorial, JAPT 2020; 3(2):65

Pictorial CME

Radiology Quiz

R Sivanthi Sapna1, Narasimhan R2

¹Post Graduate, Department of Respiratory Medicine, Apollo Hospitals, Greams Road, Chennai
²Senior Consultant Pulmonologist, Department of Respiratory Medicine, Apollo Hospitals, Greams Road, Chennai

Corresponding Author: Dr. R Sivanthi Sapna, Post Graduate, Department of Respiratory Medicine, Apollo Hospitals, Greams
Road, India

Case History

This 67-year-old gentleman, with no co-morbidities, non-smoker, presented with history of fever and dry cough for past 8 days and sudden onset dyspnoea with desaturationSpO2 57% with room air, got admitted and tested COVID 19 RTPCR positive. He became severely hypoxic and required oxygen support.Chest x-ray done revealed bilateral diffuse infiltrates. CT CHEST done revealed Bilateral diffuse ground glass opacities with interstitial thickening in both lungs, along with patchy areas of consolidation.

1. What is the radiological description?
2. What is this characteristic pattern on CT CHEST known as?
3. What is the differential diagnosis of crazy paving pattern on CT CHEST?

Answers

A. CT CHEST demonstrated Bilateral diffuse ground glass opacities superimposed with interlobular and intralobular septal thickening in a geographical distribution resembling irregularly laid cobblestones on a pavement.

• These areas of crazy paving were bilateral and sharply demarcated from the normal lung parenchyma creating a geographic pattern.

B. This appearance is characteristically described as Crazy paving pattern.

How to cite this article: R Sivanthi Sapna, Narasimhan
R, Radiology Quiz, JAPT 2020; 3(2):106-107

• The reticular network in crazy paving pattern represent the thickened interlobular septa while the ground glass opacity reflects the alveolar filling
• The mechanisms thought to be responsible for this pattern include alveolar filling processes, interstitial fibrotic processes or a combination of both.

C. The lung insults associated with this crazy paving pattern can be related to infection, neoplasm, inhalation of toxins, fluid overload and can also be idiopathic.

(UIP– Usual interstitial pneumonia, COP Chronic organizing pneumonia, BOOP bronchiolitis obliterans organizing pneumonia,
GPS– Good pasture syndrome)

Discussion

• The diagnosis of COVID 19 PNEUMONIA was established on basis of characteristic imaging features on CT CHEST- bilateral peripheral and multilobar areas of ground glass opacities with septal thickening and patchy consolidation (pathological conversion from interstitial edemaor hyaline membrane injury early in disease to influx of exudates and frank alveolar involvement later in disease process) and substantiated by the positive COVID-19 RTPCR test.

• The crazy paving pattern found on CTCHEST is a non-specific radiologic sign named after the appearance of paths made with pieces of stone/concrete.
• It was first described in the late 1980s in patients with Pulmonary alveolar proteinosis, but has now been described in association with many pulmonary diseases.

References

1. Harrison X. Bai, Ben Hsieh, Zeng Xiong, Kasey Halsey, Ji Whae Choi, Thi My Linh Tran, Ian Pan, Lin-Bo Shi, Dong-Cui Wang, Ji Mei, Xiao-Long Jiang, Qiu-Hua Zeng, Thomas K. Egglin, Ping-Feng Hu, Saurabh Agarwal, Fangfang Xie, Sha Li, Terrance Healey, Michael K. Atalay, Wei-Hua Liao. Performance of radiologists in differentiating COVID-19 from viral pneumonia on chest CT. (2020) Radiology. doi:10.1148/radiol.2020200823 – Pubmed
2. Feng Pan, Tianhe Ye, Peng Sun, Shan Gui, Bo Liang, Lingli Li, Dandan Zheng, Jiazheng Wang, Richard L. Hesketh, Lian Yang, Chuansheng Zheng. Time Course of Lung Changes On Chest CT During Recovery From 2019 Novel Coronavirus (COVID-19) Pneumonia. (2020) Radiology. doi:10.1148/radiol.2020200370 -Pubmed
3. Zheng Ye, Yun Zhang, Yi Wang, Zixiang Huang, Bin Song. Chest CT manifestations of new coronavirus disease 2019 (COVID-19): a pictorial review. (2020) European Radiology. doi:10.1007/s00330-020-06801-0 -Pubmed
4. Shuchang Zhou, Yujin Wang, Tingting Zhu, Liming Xia. CT Features of Coronavirus Disease 2019 (COVID19) Pneumonia in 62 Patients in Wuhan, China. (2020) American Journal of Roentgenology. doi:10.2214/AJR.20.22975 – Pubmed

Letter to Editor

Covid-19 Pneumonia in Asymptomatic Patients -An Entity worth Noting

Rochita Venkataramanan¹, Anagha R Joshi²

¹Director Clinical Radiology, Apollo Hospitals Chennai
²Professor and Head Department of Radio-Diagnosis, Lokmanya Tilak Municipal Medical College and General Hospital, Sion,Mumbai.

Corresponding Author: Dr. Rochita Venkataramanan, Director Clinical Radiology, Apollo Hospitals Chennai.

Dear Editor,
An unprecedented outbreak of pneumonia of unknown aetiology in Wuhan City, Hubei province in China emerged in December 2019. A novel corona virus was identified as the causative agent and was subsequently termed COVID-19 by the World Health Organization (WHO). On 30th January 2020, the WHO declared the Chinese outbreak of COVID-19 to be a Public Health Emergency of International Concern.⁽¹⁾

At the time of writing this letter (21/5/2020) Covid-19 has infected 4891785 people across the globe and caused 324496 deaths. India is seeing rising number of infections (111687) though the number of deaths due to Covid-19 are low (3428) as compared to other countries like the UK, Italy, Spain and USA. It is now understood that the Quantitative SARS-CoV-2 viral loads are equal in all symptom groups namely those with typical symptoms, those with atypical symptoms, those who are pre-symptomatic, and those who remain asymptomatic highlighting the spread of the pandemic from the asymptomatic and pauci-symptomatic populations⁽²⁾.

These asymptomatic subjects are also known to have pneumonia changes on CT scans. Shi et al had 18.5 % asymptomatic patients in their cohort who were RTPCR positive and showed CT changes which were mild with involvement of less than 5 lung segments. More than 90% of these showed ground glass opacities (GGO) and the remaining showed consolidations.⁽³⁾Figure1

Figure 1 Axial High resolution plain CT scan through the lungs of a 45 year old man with fall from height and no history of fever, cough or breathlessness.He had no chest pain or bruising and no rib or any other fractures. His PaO2 was 98%. Panel A shows bilateral peripheral GGOs in the lungs. Panel B and C show magnified views of the GGOs at lower and upper sections respectively. RTPCR test was performed the next day and was positive.

Figure 2: Sagittal plain CT reconstruction through left lung of the same patient as Figure 1 shows multiple areas of GGOs in the left upper lobe.
In the cruise ship “Diamond Princess” 54% of the asymptomatic Covid-19 positive patients had changes of pneumonia on chest CT, 83% of which were GGO.⁽⁴⁾ Figure 2
Though GGOs are predominantly noted peripherally, some cases of central GGO have also been reported on CTs of asymptomatic subjects. These could represent early lesions when the patient is contagious or may represent resolving lesions when the patient is not contagious.⁽⁵⁾Figure 3

Figure 3: A axial contrast enhanced and B sagittal and C coronal reconstructions through the lungs of a 42-year-oldwoman who is a treated case of carcinoma left breast. She completed chemoradiation post mastectomy 6 months back and presented with a painful left axillary swelling without fever or cough. Curved arrows mark central and straight arrows peripheral GGOs suspicious of Covid-19 pneumonia. The RTPCR was done post CT and it was positive.

The real-time reverse transcription-polymerase chain reaction (RT-PCR) is considered the definitive diagnosis of COVID-19. However, the sensitivity of RT-PCR depends on factors like the quality of the sampling and the viral burden at the time of specimen collection with false negative results. In such cases CT findings typical of a viral pneumonia or Covid-19 should not be ignored. Since we are currently in the pandemic state of the disease, we can expect incidental detection of COVID-19 pneumonia on CT scans of the chest or abdomen or upper limbs done for other indications. This situation is of critical importance since COVID19 pneumonia on CT is associated with potential contagiousness. Therefore, while specific tracks for suspected or known COVID-19 patients have been established, the healthcare team should keep in mind that asymptomatic or paucisymptomatic carriers are potentially present in the non-COVID-19 pathway^(5). This would then help us direct the patient to proper Covid-19 care and isolation, isolate personnel unexpectedly exposed to Covid-19 and appropriately decontaminate the facility.

Since the SARS-CoV-2 pandemic will take several months to run its course, being alert to CT findings of Covid-19 pneumonia in asymptomatic subjects is important because these cases may be seen from time to time till the pandemic ends.

References

1. Sohrabi C, Alsafi Z, O’Neill N, Khan M, Kerwan A, AlJabir A, Iosifidis C, Agha R. World Health Organization declares global emergency: A review of the 2019 novel coronavirus (COVID-19). International Journal of Surgery. 2020 Feb 26.
2. Gandhi M, Yokoe DS, Havlir DV. Asymptomatic transmission, the Achilles’ heel of current strategies to control Covid-19. N Engl J Med 2020. doi:10.1056/NEJMe2009758.
3. Shi H, Han X, Jiang N, et al. Radiological findings from 81 patientswith COVID-19 pneumonia in Wuhan, China: a descriptive study.Lancet Infect Dis 2020;published online Feb 24. https://doi.org/10.1016/S1473-3099(20)30086-4
4. Inui S, Fujikawa A, Jitsu M, Kunishima N, Watanabe S, Suzuki Y, Umeda S, Uwabe Y. Chest CT findings in cases from the cruise ship “Diamond Princess” with coronavirus disease 2019 (COVID-19). Radiology: Cardiothoracic Imaging. 2020 Mar 17;2(2):e200110.
5. Pozzessere C, Rotzinger DC, Ghaye B, Lamoth F, Beigelman-Aubry C. Incidentally discovered COVID-19 pneumonia: the role of diagnostic imaging. European Radiology. 2020 May 4:1-3.

Case Report

COVID-19 Presenting as COVID – Clot Obstructing Vessels in Deep

Monisha Anandhan¹, Aishwarya KM², Mohammed Shafi Abdulsalam³, Balaji V⁴, Narasimhan R⁵

¹Post Graduate–Department of Respiratory Medicine, Apollo Hospitals, Greams Road, Chennai, India
²Post Graduate–Department of Medicine, Apollo Hospitals, Greams Road, Chennai, India
³Junior Consultant ,Department of Medicine/Hematolgy, Apollo Hospitals, Greams Road, Chennai, India
⁴Senior Consultant Vascular Surgeon, Apollo Hospitals, Greams Road, Chennai, India
⁵Senior Consultant Pulmonologist, Department of Respiratory Medicine, Apollo Hospitals, Greams Road, Chennai, India

Corresponding Author: Dr. Narasimhan R, Senior Consultant Pulmonologist, Department of Respiratory Medicine, Apollo Hospitals, Greams Road, Chennai, India Email: drrnarasimhan@gmail.com

Introduction

The novel CoronaVirus Disease 2019 (nCOVID-19), a viral infection caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2), was declared as a global health emergency by the World Health organisation (WHO). ¹ Similar to other respiratory viral illness, it manifests as dry cough, shortness of breath and fever, which can eventually progress to pneumonia, acute respiratory distress syndrome (ARDS) and endorgan failure.² There is an increased occurrenc

of thrombotic manifestations in COVID-19³. COVID-19 Associated Coagulopathy (CAC) is the term used for coagulation abnormalities associated with COVID-19, which is varied from DIC and thrombotic microangiopathy.^4,5 Studies showed increased levels of D-dimer were associated with high mortality.⁶

Case No. 1

A 65-year-old male presented with complaints of right lower limb pain with blackish discolouration of skin around toes for 10 days duration. COVID-19 RT- PCR was reported positive a week ago, which was done

How to cite this article: Monisha Anandhan, Aishwarya KM, Mohammed Shafi Abdulsalam, Balaji V, Narasimhan R, COVID-19 Presenting as COVID – Clot Obstructing Vessels in Deep, JAPT 2020; 3(2):98-102

elsewhere as a screening test for recent travel history. He denied any past medical illness, smoking or alcohol intake. On examination, he was afebrile, hemodynamically stable and Oxygen saturation (SpO2) was 98% in room air. He had bilateral infra-scapularcrepitation on auscultation. Right lowerlimb was cold associated with blackish discolouration over toes and calf muscle tenderness [Figure 1]. Right sided popliteal artery, dorsalis pedis artery and posterior tibial artery pulsations were slightly diminished in comparison with those on the left leg. Repeat RT-PCR COVID 19 done in our hospital was positive with cycle threshold(Ct) value of 30.Baseline investigations were within normal limits except for elevated D-Dimer levels (1.68 mcg/mL). PT, APTT were also within normal range. Lupus anti-coagulant, anticardiolipin antibody (IgM and IgG) and anti beta 2 glycoprotein antibody (IgM and IgG) were not detected. But interestingly he tested positive for anti-Phosphatidyl Serine Prothrombincomplex antibody (aPSPTIgM). HRCT chest showed bilateral peripheral and basal ground glass opacities with consolidation, interlobular septal thickening and traction bronchiectasis [Figure 2]. CT peripheral angiogram revealed thrombus at the level of aortic arch, soft plaque in Right Common Iliac Artery (CIA) narrowing its lumen by 50% [Figure 3], non-visualization of right profundafemoris artery beyond its proximal portion, total thrombotic occlusion of right Tibio Peroneal trunk (TP), right Posterior Tibial Artery (PTA) and right peroneal arteries, total occlusion of right anterior tibial artery just beyond its origin, thrombotic occlusion of left popliteal artery [Figure 4], non-visualization of left anterior tibial artery and peroneal arteries, and thrombus in proximal Inferior Venacava (IVC) at the level of L3, L4 vertebrae [Figure 5]. He was started on therapeutic dose of low molecular weight heparin. After adequate COVID-19 precautions, through trans popliteal approach, right Common Iliac Artery (CIA),popliteal and tibial thrombectomy with Fogarty catheter directed arterial embolectomy was performed as emergency procedure due to acute limb ischemia with threatening limb viability. He remained stable throughout his hospital stay and maintained oxygen saturation in room air. He was discharged on long term anti coagulation with Acenocumarol.

Figure 1 : Blackish discoloration over toes due to Acute Right Lower Limb Ischemia

Figure 2 : HRCT Chest showing bilateral peripheral and basal ground glass opacities with consolidation, interlobular septal thickening and traction bronchiectasis.

Figure 3: Soft plaque in Right Common Iliac Artery (CIA) narrowing its lumen by 50%

Figure 4: CT Peripheral Angiogram showing Non-visualization of right profundafemoris artery(PFA) beyond its proximal portion, total occlusion of right anterior tibial artery just beyond its origin, thrombotic occlusion of left popliteal artery and non-visualization of left anterior tibial artery and peroneal arteries.

Figure 5 : Thrombus in proximal Inferior Venacava (IVC)

Case No. 2

A 31-year-oldmale, a known asthmatic (on occasional inhalers use), presented with swelling of left leg and thigh gradually increasing in size associated with pain, intermittent fever and cough for 10 days duration. COVID-19 RT- PCR done elsewhere was reported negative. HRCT chest showed left lower lobe ground glass opacities. Venous Doppler of lower limb revealed deep vein thrombosis of distal anterior and posterior tibial veins, partial thrombosis of gastrocnemius and soleal veins of left lower leg. He was referred to our hospital for further management. In emergency room, his vitals were stable. Local examination revealed left lower limbs welling extending from groin to ankle associated with redness and calf muscle tenderness. His D-Dimer levels were elevated (14.6 mcg/mL). Repeat venous Doppler of lower limb revealed deep vein thrombosis extending to left common femoral vein, superficial femoral vein and popliteal vein [Figure 6]. Repeat RT-PCR COVID 19 of nasopharyngeal Swab was positive with cycle threshold (Ct) value of 35. He was started on therapeutic dose of low molecular weight heparin following which he was discharged on Rivaroxaban

Figure 6 : Venous Doppler of lower limb showing deep vein thrombosis extending to left common femoral vein.

Discussion

Coronavirus disease 2019 (COVID-19) is associated with systemic coagulation activation and thrombotic complications.⁷ In the above cases, thrombotic manifestations predominated Influenzalike Illness (ILI) and on initial presentation itself they had thrombotic event. Elevated levels of pro inflammatory cytokines are thought be the reason for coagulopathy in COVID-19.⁵

COVID-19 has features distinct from DIC or thrombotic microangiopathy. COVID-19 Associated Coagulopathy (CAC) is not typical DIC, as fibrinogen level and D dimer levels tends to be much higher where as prolongation of PT, APTT and thrombocytopenia are relatively uncommon on initial presentation^3. Prothrombotic state predominates in COVID-19 Associated Coagulopathy unlike the usual clinical coagulopathy where impaired ability to clot results in bleeding. ⁵ In very severe disease there can be sudden drop in platelets and fibrinogen like DIC.

Clinical diagnosis of Deep Venous Thrombosis (DVT) and Pulmonary embolism (PE) is particularly challenging in COVID-19.⁷ Symptoms like shortness of breath can be per se associated with COVID-19 as well as Pulmonary embolism.⁷ As the treating Physician’s primary concern is about the respiratory status of COVID-19 patients, systematic examination of extremities to pick up clinical signs and symptoms associated with Arterial/Venous thrombosis might also be overlooked.⁷

General screening ultrasound carries an increased risk of personnel exposure and resource utilization during the COVID-19 pandemic. [8] Taking into consideration of the risk factors for Venous Thromboembolism (VTE) such as immobilization, being confined to isolation rooms and the additional risk factor of VTE i.e. infectious diseases – which are present in all hospitalized patient’s with COVID-19 and the incidence of VTE in non-critically ill patients with COVID-19 being well above 1% even on anticoagulant thromboprophylaxis, its ideal to start anticoagulant thromboprophylaxis in all hospitalized patient with COVID-19 in absence of contraindications.[8] High index of clinical suspicion and early initiation of prophylactic or therapeutic dose of anti-coagulation is needed to prevent the occurrence of life threatening thrombosis.

Our first patient was positive for a PSPTIgM antibody. Though a PSPT antibody positivity is seen in many Sero Negative Anti-Phospholipid Syndrome (SNAPS), this antibody testing has to be repeated after 12 weeks for it to be diagnosed as Sero Negative Anti-Phospholipid Syndrome. [9] As of now, since the whole picture seems to be provoked thrombosis (secondary to covid-19 infection) and the thrombosis being atypical and extensive, it is ideal for the patient to be treated with long term anticoagulation. As our second patient has proximal DVT, it is essential to continue anti-coagulation therapy for a minimum duration of three months. [8]

Conclusion

COVID-19 has become a major life-threatening viral infection in recent times. Its major complication is thromboembolic event which can lead to death even before we diagnose it. Daily examination of peripheral pulses, looking for skin discolouration and other signs of Deep Venous Thrombosis is important for early identification of limb thrombosis. Anyone presenting with features of limb ischemia duringthis pandemic should be evaluated for COVID-19. Our case report portrays the importance and also the necessity for early initiation of anticoagulants to prevent life threatening complication like Pulmonary Embolism.

References

1. WHO Director-General’s opening remarks at the media briefing on COVID19 -March 2020
2. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus 133 in Wuhan, China. Lancet 2020;395(10223):497–506
3. Poggiali E, Bastoni D, Ioannilli E, Vercelli A, Magnacavallo A. Deep vein thrombosis and pulmonary embolism: two complication of COVID-19 pneumonia? EJCRIM 2020;7
4. Nahum J, Morichau-Beauchant T, Daviaud F,Echegut P, Fichet J, Maillet JM, et al. Venous Thrombosis Among Critically Ill Patients With Coronavirus Disease 2019 (COVID-19). JAMA Netw Open. 2020;3(5):e2010478.
5. Jean M. Connors, Jerrold H. Levy. COVID-19 and its implications for thrombosis and anticoagulation. Blood 2020; 135 (23): 2033–2040.
6. Tang N, Bai H, Chen X, Gong J, Li D, Sun Z. Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy. J ThrombHaemost. 2020;18(5):1094- 1099.
7. Middeldorp S, Coppens M, van Haaps TF, Foppen M, Vlaar AP, Müller MCA, et al. Incidence of venous thromboembolism in hospitalized patients with COVID-19. J ThrombHaemost. 2020 : 10
8. Moores LK, Tritschler T, Brosnahan S, Carrier M, Collen JF, Doerschug K, Holley AB, Jimenez D, LeGal G, Rali P, Wells P. Prevention, Diagnosis, and Treatment of VTE in Patients With COVID-19: CHEST Guideline and Expert Panel Report. Chest. 2020:S0012- 3692(20);31625-1.[Epub ahead of print]
9. Ganapati A, Goel R, Kabeerdoss J, Gowri M, Mathew J, Danda D. Study of clinical utility of antibodies to phosphatidylserine/prothrombin complex in Asian-Indian patients with suspected APS. ClinRheumatol. 2019;38(2):545-553.

Govindasaami et al.: A Typical Case of COVID – 19 Pneumonia with Two Consecutive Negative Nasopharyngeal Swab…

A Typical Case of COVID – 19 Pneumonia with Two Consecutive Negative Nasopharyngeal Swab RT-PCR for SARS CoV-2-Role of CT Thorax

Govindasaami¹, Vinod¹, Thangaswamy², Dhanasekar.T²

¹Assistant Professor, Department of Pulmonology, Sri Ramachandra Insititute of Higher Education and Research
²Professor, Department of Pulmonology, Sri Ramachandra Insititute of Higher Education and Research
Corresponding Author: Dr. Dhanasekar, Professor, Department of Pulmonology, Sri Ramachandra Institute of Higher Education and Research

Summary

Prompt diagnosis of COVID – 19 disease is of utmost importance as it will implicate both outcome of the patient and prevention of the spread of the disease. Current recommended diagnostic test for COVID – 19 is RT-PCR for SARS-CoV-2. But the test has a false negativity rate of around 30% causing diagnostic difficulties. Here we report a 50 years old female, who presented with typical clinical features and chest x-ray showed bilateral extensive opacities. But her initial RT-PCR for SARS-CoV-2 was negative. HRCT thorax done was highly suspicious of COVID – 19 with CORADS – 5 grading. Only the third swab for RT-PCR showed positive result. She was treated successfully with Remdesivir. So the important clinical lesson learnt was that the RT-PCR test is prone to yield false negative result and CT thorax should be done in patients with high clinical suspicion with a negative initial RT-PCR

Background

Covid – 19 or coronavirus disease 2019 is caused by novel corona virus, SARS CoV-2

Initially, in December 2019, a cluster of cases were noted with a diagnosis of “Pneumonia of unknown cause” notified from Huebei province of Wuhan City, China, which was later found to be the afore mentioned disease. It was declared by WHO as a pandemic on March 11 2020 (1). First case reported in India was on January 30, 2020 who was a student of Wuhan University returned to India^(2).

As the clinical presentation is non-specific, the diagnosis of the disease is essentially made by direct detection of SARS CoV-2 RNA by nucleic acid amplification test in practice. The commonly practiced testing is realtime reverse transcription polymerase chain reaction (rRT-PCR) either from nasal or oral pharyngeal swabs. But the testing has been reported to have a significant proportion of false-negative rates (around 30%) due to various factors⁽³⁾. In such instances, CT imaging can help in managing the patients. Though CT thorax is a non specific modality, limited by inability to differentiate the etiological agents based on its findings, it has been shown to have high sensitivity and low rate of missed diagnosis in COVID–19 scenario ^(4).

How to cite this article:Govindasaami, Vinod, Thangaswamy, Dhanasekar.T, A Typical Case of COVID– 19 Pneumonia with Two Consecutive Negative Nasopharyngeal Swab RT-PCR for SARS CoV-2-Role of CT Thorax, JAPT 2020; 3(2):93-97

Case Presentation

A 50-years-old Female, General medical practioner, who was treated for type II diabetes mellitus and hypertension, was referred to our emergency department for low grade fever with myalgia for four days and one day history of cough and breathlessness. She had no history of contact with a proven positive COVID – 19 patient though she admitted consulting outpatients with respiratory symptoms with precautions as mandated by the government. There was no recent history of travel.
On initial presentation, she was prostrated but not febrile, tachypnoeic, tachycardiac or hypotensive. Her room air saturation was 90% on arrival to Emergency. She was overweight with a BMI of 27.3 kg/m2. Physical examination was unremarkable. Respiratory examination revealed few scattered crepitations bilaterally.

Investigations

Laboratory findings showed mild anemia, mild leucocytosis with neutrophilia and mild thrombocytosis (leucocyte count: 12.6 X 109/L, normal: 4–11 X 109/L; Neutrophils: 85.4%, normal: 45 – 70%; haemoglobin: 113 g/L,

normal: 120–150 g/L; platelet count: 447 X109/L, normal: 150–450 X109/L).Liver function tests were normal (Total bilirubin : 0.46mg/dl, normal: 0.3 – 1.2 mg/dl aspartate aminotransferase: 30 U/L, normal: < 35 U/L; alanine aminotransferase: 16 U/L,normal: < 35 U/L) and mildly elevated renal parameters (BUN : 24mg/dl, normal 7.9 -20.1mg/dl; Creatinine : 1.2mg/dl, normal 0.7 –1.1mg/dl ).

NLR (Neutrophil / Lymphocyte ratio) was 9.9 and PLR (Platelet / Lymphocyte) was 413.

Serum Interleukin – 6 and ferritin were normal (4.84 pg/ml, normal: <6.4pg/ml; 216.5ng/ml, normal: 11 – 307 ng/ml, respectively), D-dimer level was elevated (>1.0 < 2.0 mg/L FEU, normal: < 0.55 mg/L FEU), serum LDH was elevated (528 U/L, normal: 208 – 378 U/L).

Arterial blood gas analysis revealed type I respiratory failure. Her baseline ECG was normal. Chest x-ray anteroposterior view showed bilateral diffuse infiltrates (Figure 1).

Fig 1: Anteroposterior view of a chest X-ray showing bilateral patchy pulmonary opacities

In view of the current pandemic situation and clinical presentation, she was suspected to have COVID-19 pneumonia and a nasopharyngeal swab for RT-PCR for SARS CoV-2 was sent and she was admitted in an isolation ward for COVID-19 and managed with contact and droplet precautions in view of high clinical suspicion.

She was started on supplemental oxygen,broad spectrum intravenous antibiotics (for probable secondary bacterial infection), oral hydroxychloroquine (with daily ECG monitoring), intravenous methyl prednisolone (40mg/day), lower molecular weight heparin in prophylactic dose (40mg/day), ulcer prophylaxis with intravenous pantoprazole and glycemic control was achieved with short acting insulin as and when needed according to CBG. Her RT-PCR for SARS CoV-2 came back as negative. Her blood and urine cultures were sterile. Sputum microbiology couldn’t be obtained as she couldn’t expectorate.

Fig 2: Axial section of computed tomography showing ground glass opacities in bilateral upper lobes.

At this juncture, a high resolution CT thorax (plain) was done which showed multiple areas of coalescing ground glass opacities in peripheral and peribronchovascular distribution involving all lobes bilaterally with lower lobe predominance(Figure 2 & Figure 3) – features highly consistent with severe COVID 19 pneumonia [CO-RADS 5 &Total CT severity score of 22/25]. The case was discussed with expert panel and was continued along the same line of management and a repeat nasopharyngeal swab for RTPCR was sent after 24 hours which again was negative. But the third nasopharyngeal swab for SARS CoV-2 RTPCR done on 4 th day of admission became positive.

Fig 3: CT Axial section through lower lobes showing multiple coalescing areas of ground glass opacities in peripheral and peribronchovascular distribution bilaterally

Treatment

Patient was transferred to dedicated COVID ICU and was treated with intravenous Remdesivir 200 mg on day 1 followed by 100 mg once daily for total of 5 days. She was continued on supplemental oxygen, methyl prednisolone (40mg/day) was continued for total of 10 days in view of extensive pulmonary involvement.Oral hydroxychloroquine was stopped in view of QT prolongation.

Outcome and Follow-UP

Patient improved clinically with the treatment given and her oxygen requirement gradually decreased over next 48 – 72 hours. She was weaned off oxygen and shifted to ward. As she was maintaining saturation on room air for the next around 48 hours in ward without any new symptoms, she was discharged and advised to follow home quarantine for 2 weeks.

Discussion

The Novel coronavirus is a single stranded, enveloped, positive sense RNA virus which is transmitted between humans mainly by airborne droplets, direct contact and feco-oral route (5, 6, 7). The symptom complex of COVID-19 is non-specific – most commonly presenting with fever, fatigue, dry cough, myalgia and dyspnea. Though the diagnosis can be suspected based on combination of detailed history (including contact, travel, geography etc.),symptomatology and radiology, the confirmation of the disease is reliably made by laboratory diagnosis (5).
Though a variety of immunological and serological laboratory tests are available for COVID 19, RT PCR is the gold standard test recommended for confirmation of SARS CoV-2 by WHO (7). Serological tests are not recommended for acute infection settings as it is less likely to yield a positive result during initial period of infection (8).

The COVID-19 RT-PCR is a real-time reverse transcription polymerase chain reaction test which detects nucleic acids of SARS CoV-2 qualitatively in recommended respiratory specimens, either upper or lower, collected appropriately from a suspected individual. But the test is plagued with documented false-negative results even in patient with typical clinical and radiological presentation (9) and it has been recommended that a single negative RT PCR should not be taken as a rule-out test for the diagnosis of COVID 19 in a strongly suspicious patient, as in our patient (10).

A Meta-analysis including five studies (957 patients) has reported upto 29% rate of initial false negative RT-PCR (11). The factors that can be causing such false-negativity were attributed to virus related factors such as RNA sequences variation , genomic mutations, viral load kinetics; host related factors such as early presentation, viral tropism to infect lower respiratory tract and procedure related factors such as inappropriate collection, transportation or laboratory facilities (12). There are case reports with multiple false-negative RT-PCR results in COVID – 19 patients (13, 14). Though,bronchoscopy with lavage has been recommended in suspcious cases with negative RT-PCR of nasopharyngeal sample, it has procedure related risk for patient with respiratory failure. The option was discussed with our patient but she was not willing for it and wanted to get repeat upper nasopharyngeal sampling.

The role of CT imaging of thorax in such situations of false negative NAAT has been emphasized by many investigators. In a study done by Xie et al, which included 167 laboratory confirmed COVID 19 patients, had high concordance of CT positivity with RT-PCR positivity – 93%. But significantly 5 patients(3%), had CT positivity with negative RT-PCR on initial testing who became positive on subsequent testing within 2 – 8 days (8).Another retrospective study of 34 patients with confirmed COVID 19, 10 symptomatic patients who had initial negative RT PCR had typical CT imaging findings suggesting the disease (15). Another study of 51 patients done in China showed CT imaging to have significantly superior sensitivity compared to RT-PCR test –98% to 71% (16). A study of 82 patients showed comparable sensitivity of CT chest (77%) and RT-PCR (79%) but a comprehensive strategy of combining the two modality improved sensitivity to 94% (17). Li et al (4) showed in a retrospective study of 53 patients, CT thorax has very low rate of missed diagnosis (3.8%).

Apart from the role in diagnosis of the disease, CT thorax has been shown to be helpful in screening asymptomatic individuals,assessing response to disease, prognosticate the disease (CT severity score) (18, 19). The CO-RADS (COVID-19 Reporting and Data System), a categorical reporting system which assesses the degree of pulmonary involvement by COVID-19 on chest CT in patients with moderate to severe symptoms with categories 1 to 5 according to increasing suspicion on CT (20). CT severity score, a scoring assigned out of 25 according to percentage of involvement of 5 lobes, correlates with severity of the disease and helps prognosticate (21).

WHO has provided important Infection prevention and control checklist to be followed for acquisition of CT in a suspected or confirmed patient (22).

The role of CT has been clearly proven to be beneficial in high clinical suspicion scenario with negative initial RT-PCR test and of those with CT findings typical of COVID 19, a repeat RT-PCR testing [as per local governmental /institutional policy (ideally between 1 – 7 days)]should be performed (13, 14).
Learning Points/Take Home Messages 3-5 bullet points

• RT-PCR for SARS CoV-2, the current Gold-Standard test, has sensitivity of around 70%and can yield false negative result even in a typical COVID – 19 pneumonia.
• RT – PCR can be taken as a good Rule-in test but it should not be considered as a single Rule-out test for the diagnosis of COVID -19.
• CT thorax, though non-specific, has good sensitivity and has very low rate of missed diagnosis of COVID – 19 pneumonia.
• CT thorax should be done in patients with high clinical suspicion but negative RT-PCR testing and among those who have typical CT features, repeat PCR testing should be done.

References

1. https://www.who.int/news-room/detail/29-06-2020-covidtimeline
2. https://www.indiatoday.in/india/story/kerala-reports-first-confirmed-novel-coronavirus-case-in-india-1641593-2020-01-30
3. Weissleder R, Lee H, Ko J, Pittet MJ. COVID-19 diagnostics in context. Science Translational Medicine. 2020;12(546).
4. Li Y, Xia L. Coronavirus Disease 2019 (COVID-19): Role of Chest CT in Diagnosis and Management. American Journal of Roentgenology. 2020;214(6):1280–6.
5. He, F, Deng, Y, Li, W. Coronavirus disease 2019: What we know? J Med Virol. 2020; 92: 719–725. https://doi.org/10.1002 /jmv.25766
6. Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al.Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus–Infected Pneumonia. New England Journal of Medicine. 2020;382(13):1199–207.
7. C. Li, C. Zhao, J. Bao, B. Tang, Y. Wang, B. Gu,Laboratory Diagnosis of Coronavirus Disease-2019 (COVID-19), Clinica Chimica Acta (2020), doi: https://doi.org/10.1016/j.cca.2020.06.045
8.https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19-diagnosis?topicRef=126981&source=related_link#H2813503854
9. Xie X, Zhong Z, Zhao W, et al. Chest CT for Typical 2019-nCoV Pneumonia: Relationship to Negative RTPCR Testing. Radiology. 2020 Feb 12. doi: 10.1148/radiol.2020200343
10. BMJ 2020;369:m1808
11. Arevalo-Rodriguez I, Buitrago-Garcia D, SimancasRacines D, et al. False-negative results of initial RT-PCR assays for COVID-19: a systematic review. April 21,2020
(https://www.medrxiv.org/content/10.1101/2020.04.1
6.20066787v1. opens in new tab). preprint.
12. Tahamtan, A., & Ardebili, A. (2020). Real-time RT-PCR in COVID-19 detection: issues affecting the results. Expert review of molecular diagnostics, 20(5),453–454.
https://doi.org/10.1080/14737159.2020.1757437
13. Feng H, Liu Y, Lv M, Zhong J. A case report of COVID19 with false negative RT-PCR test: necessity of chest CT. Japanese Journal of Radiology. 2020;38(5):409–10.
14. Lagziel T, Quiroga L, Ramos M, Hultman CS, Asif M. Two False Negative Test Results in a Symptomatic Patient with a Confirmed Case of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) and Suspected Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN). Cureus. 2020;
15. Chen, H. J., Qiu, J., Wu, B., Huang, T., Gao, Y., Wang, Z.P., Chen, Y., & Chen, F. (2020). Early chest CT features of patients with 2019 novel coronavirus (COVID-19) pneumonia: relationship to diagnosis and prognosis. European radiology, 1–8. Advance online publication. https://doi.org/10.1007/s00330-020- 06978-4
16. Fang Y, Zhang H, Xie J, Lin M, Ying L, Pang P, et al.Sensitivity of Chest CT for COVID-19: Comparison to RT-PCR. Radiology. 2020;:200432.
17. He, J. L., Luo, L., Luo, Z. D., Lyu, J. X., Ng, M. Y., Shen,X. P., & Wen, Z. (2020). Diagnostic performance between CT and initial real-time RT-PCR for clinically suspected 2019 coronavirus disease (COVID-19)patients outside Wuhan, China. Respiratory medicine, 168, 105980. https://doi.org/10.1016/j.rmed.2020.105980
18. Tenda ED, Yulianti M, Asaf MM, et al. The Importance of Chest CT Scan in COVID-19. Acta Med Indones.2020;52(1):68-73.
19. Tabatabaei SMH, Talari H, Moghaddas F, Rajebi H.Computed Tomographic Features and Short-term Prognosis of Coronavirus Disease 2019 (COVID-19) Pneumonia: A Single-Center Study from Kashan, Iran.Radiology: Cardiothoracic Imaging. 2020;2(2).
20. Prokop M, Everdingen WV, Vellinga TVR, Ufford JQV, Stöger L, Beenen L, et al. CO-RADS – A categorical CT assessment scheme for patients with suspected COVID19: definition and evaluation. Radiology. 2020;:201473.
21. https://japi.org/w2f4d464/clinico-radiologicalevaluation-and-correlation-of-ct-chest-images-withprogress-of-disease-in-covid-19-patients#abstract
22. World Health Organization. (2020). Use of chest imaging in COVID-19: a rapid advice guide, 11 June 2020 (No. WHO/2019-nCoV/

Abdul Majeed Arshad et al.: CT Manifestations of Novel Coronavirus Pneumonia: A Case Report and Review of Literature

Case Report

CT Manifestations of Novel Coronavirus Pneumonia: A Case Report and Review of Literature

Abdul Majeed Arshad¹, R. Anand1, Irfan Ismail Ayub¹, M.V.Jothikrishnan², A.Kumaresh³, T.Dhanasekar¹, C.Chandrasekar^1
1Department of Pulmonary Medicine – Sri Ramachandra Institute of Higher Educations Research, Chennai -600116
²Derpartment of Critical Care Medicine – Sri Ramachandra Institute of Higher Educations Research
³Department of Radiology – Sri Ramachandra Institute of Higher Educations Research

Abstract

Background: Till November 17 2020, Novel Corona virus outbreak has affected over 200 countries and territories and in India the COVID-19 has Risen up to 8, 912, 9007 (Near by 9 Million cases) and leading to 1, 31,031 deaths
Case Report: A Thirty three old male presented with complaints of fever for 3 days with myalgia and fatigue. Throat swab for RT PCR Positive. HRCT chest showed diffuse ill-defined ground glass opacities with coalescing consolidation noted in the bilateral lung fields with intralobular septal thickening suggestive of viral pneumonia – CORADS 6 – CTSS 20/25. The patient had severe Hypoxemia on Admission. The patient was started on HFNC and Steroids. The Patient’s Hypoxemia improved drastically throughout the course of treatment and was discharged with complete recovery from illness.
Conclusion:Chest computed tomography offers fast and convenient evaluation of patients with suspected 2019-novel coronavirus pneumonia and negative RT PCR reports
Keywords: Computed Tomography, diagnosis, novel coronavirus pneumonia, Bull’s eye Sign,GGO, Consolidation.

Corresponding Author: Dr. Abdul Majeed Arshad, Department of Pulmonary Medicine – Sri Ramachandra Institute of Higher Educations Research, Chennai -600116
Introduction
Coronavirus disease 2019 ( COVID-19 ) a highly infectious disease caused by severe acute respiratory Syndrome coronavirus 2 (SARS-COV – 2) was first reported in Wuhan, Hubei Province, China, and rapidly spread to other

domestic cities and other countries beyond China [2]. On January 30, 2020, the world health Organization (WHO) declared this ongoing outbreak as Global Pandemic [3]. In COVID – 19 diagnosis , real-time reverse chain reaction ( RTPCR) of viral nucleic acid is regarded as the Reference standard; however in patients with False negative RT PCR results, Computed

How to cite this article: Abdul Majeed Arshad, R. Anand, Irfan Ismail Ayub, M.V.Jothikrishnan, A.Kumaresh, T.Dhanasekar, C.Chandrasekar, CT Manifestations of Novel Coronavirus Pneumonia: A Case Report and Review of Literature, JAPT 2020; 3(2):88-92

tomography ( HRCT) plays an important role in diagnosing the COVID -19 Pneumonia and has a higher Sensitivity of 98% [4] when compared to RT PCR according to recent Studies.
The Aim of this article is to present a case with COVID 19 pneumonia and to provide an overview of Computed tomography findings in COVID patients

Case Report

On September 8, 2020, 33 year old male patient presented with chief complaints of fever for past 3 days. He was admitted in Sri Ramachandra Hospital- Porur, Chennai. On September 5, the patient had fever with a body temperature of 100.5°F, associated with myalgia and fatigue: The Results of Routine blood examinations were: Total Count – 11700/ dl; Neutrophil -86.6%, Lymphocyte – 25.6%, Eosinophil – 0.0, CRP – 7.7mg / dl; Throat Swab RT PCR for SARS COV2 was Positive: On Admission, Chest X-ray showed increased and thickened bilateral lower zone Opacities (left > Right) suggestive of interstitial pneumonia. His Oxygen saturation was 89 @ room air and 96 with 3 litres of oxygen via nasal prongs.

HRCT Chest on September 9 2020 – showed Diffuse ill Defined Ground glass opacities with coalescing Consolidation noted in the bilateral lung fields; intralobular septal thickening noted; healing signs in the form of organising pneumonia seen in both lungs – CORADS 6 – CT SEVERITY SCORE 20/25 (Severe). The patient desaturated in ward up to 80 in Room air. ABG taken Showed Hypoxemic Respiratory Failure,hence was shifted to intensive care unit and was started on High Flow nasal cannula. Chest X-ray done on 21 September 2020 showed increase in bilateral Diffuse Reticular nodular opacities in bilateral lung Fields

During the course of ICU Stay, the patient was treated with Methyl Prednisolone (60 mg intravenous once daily) and Injection Clexane (0.4cc Subcutaneous Twice daily). After Steroid introduction, the Oxygen Requirement decreased and the patient Improved and shifted once again to ward; Serial Chest X-rays showed Radiological improvement. In the ward the patient recovered completely and was discharged on 5/10/2020

Discussion

Here we will discuss various CT images and radiological patterns of above described COVID 19 (RT-PCR) Positive patient in our Hospital

Ground Glass Opacity:

GGO is defined as an area of increased attenuation in the lung on Computed tomography (CT) with Preserved Bronchial and Vascular markings. It can be unilateral or bilateral GGO with a peripheral lung and sub pleural distribution [5, 6, and 7]. Typical Presentation will be Multifocal, bilateral, peripheral and Basal GGO which Sub pleural in Distribution. GGO’s are usually accompanied by other radiological features including Reticular and/or Interlobular septal thickening and consolidation [9].

Consolidation

Consolidation is defined as inflammatory induration of a normally aerated lung due to the presence of cellular exudative in the alveoli. Multifocal, bilateral, peripheral and Basal consolidation is distributed in sub pleural areas or along Broncho vascular bundles [10, 11, and 12]. Usually consolidation was considered as an indication of disease progression. A recent Study shows that GGO could progress to or co-exist with consolidation within 1-3 weeks [16].
This pattern is highlighted by a Black Circle in the Below CT Scan.

Reticular Pattern and Crazy Paving Pattern

Reticular patternis the Second most common pattern next to GGO’s and Consolidation. It indicates lung infiltration with interstitial thickening or fibrosis [13, 14]and usually manifests as a collection of innumerable small linear opacities. This pattern is highlighted by a Black Box in the Below CT Scan.

Crazy paving Pattern refers to the appearance of Ground Glass opacity with superimposed interlobular septal and intralobular septal thickening resembling irregular pavement stones [13]. This is mainly due to alveolar Oedema and interstitial infiltrates in acute lung Injury [11, 15]. This sign Indicates Rapid Progression of disease or its Peak infective Stage. This pattern is highlighted by a Black Circle in the Below CT Scan.

Reversed Halo Sign or Bull’s Eye Sign

Reversed halo sign also known as atoll sign, is defined as a Central Ground glass opacity surrounded by Crescentic shaped denser consolidation [13]. This Sign was Reported in several COVID -19 cases, which may be attributed to disease progression due to a consolidation developed around GGO or a lesion absorption leaving a decreased intensity in the centre. The Bull’s eye sign is considered a variant of the reverse halo Sign and is likely to represent a Focus of Organizing Pneumonia. This pattern is highlighted by a Black Box in the Below CT Scan.

Vascular Enlargement

Pulmonary vessels is seen around and within the lesions of COVID 19 Patients and is attributed to the damage and swelling of the capillary wall caused by Pro inflammatory factors.

Subpleural Curvilinear Line

It is a Thin Curvilinear opacity with 1-3 mm thickness, lying less than 1cm from and parallel to the pleural surfaces [13]. Many Reports suggests that around 20% of patients with COVID -19 demonstrated this sign [12], which may relate to pulmonary oedema or fibrosis of COVID -19

Other Common Radiological Signs

Halo Sign

Halo Sign refers to a Ground glass opacity surrounding a pulmonary Nodule or mass. Halo Sign is associated with perilesional haemorrhage and seen in angio invasive fungal infections, hyper vascular metastases as well as viral infections or Organizing Pneumonia

Fibrosis

Fibrous lesions may form during the healing of pulmonary chronic inflammation or proliferative diseases, with gradual replacement of cellular components by scar tissues [13]. Some Researchers suggest that the presence of fibrosis indicates good prognosis in a COVID 19 patient leading to a Disease Stabilizing status [5]. However others suggested that fibrosis is associated with poor outcome and may progress to peak stage or result in Pulmonary Interstitial Fibrosis.

Pleural Changes

Pleural Changes mainly include Pleural thickening and pleural Effusion [16]. Among these two signs pleural thickening is more frequently encountered than the pleural effusion

Airway Changes

Airway changes include bronchiectasis and bronchial wall thickening. It is due to inflammatory damage of the bronchial wall and the bronchial obstruction, resulting in the destruction of bronchial wall structure leading to fibrosis, causing traction bronchiectasis [13].

Conclusion

Early Recognition and isolation of COVID-19 patients is of crucial importance in controlling the outbreak especially in patients who are with false negative RT PCR. Bilateral GGO and Consolidation were the predominant features in COVID 19 patients, CT chest imaging can vary from patients to another based on stage and immunity of the patients. In this Article we mainly discussed about the Typical and Atypical CT manifestations of COVID 19 Pneumonia with an Interesting Case Report with Review of Literature.

References

1. Chest CT manifestations of new coronavirus disease 2019 ; a pictorial review https://doi.org/10. 1007/s00330-020-06801-0
2. Zhu N, Zhang D, Wang Wet al (2020) A novel coronavirus from patients with pneumonia in China,2019. N Engl J Med. https://doi.org/10.1056/NEJMoa2001017
3. World Health Organization (2020) Coronavirus disease 2019 (COVID-19) situation report–39. World Health Organization, Geneva. Available via https://www.who.int/docs/default-source/coronaviruse/situationreports/20200228-sitrep39-covid-19.pdf?sfvrsn=5bbf3e7d_2
4. Fang Y, Zhang H, Xie J et al (2020) Sensitivity of chest CT for COVID-19: comparison to RT-PCR. Radiology. https://doi.org/10.1148/radiol.2020200432
5. Pan Y, Guan H, Zhou S et al (2020) 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.https://doi.org/10.1007/s00330-020-06731-x
6. Song F, Shi N, Shan F et al (2020) Emerging coronavirus 2019- nCoV pneumonia. Radiology. https://doi.org/10.1148/radiol.2020200274
7. Ng M-Y, Lee EY, Yang J et al (2020) Imaging profile of the COVID-19 infection: radiologic findings and literature review. Radiology: Cardiothoracic
   Imaging.https://doi.org/10.1148/ryct.2020200034
8. Xu Z, Shi L,Wang Yet al (2020) Pathological findings of COVID-19 associated with acute respiratory distress syndrome. Lancet Respire Med. https://doi.org/10.1016/S2213-2600(20)30076-X
9. Kanne JP (2020) Chest CT findings in 2019 novel coronavirus(2019-nCoV) infections from Wuhan, China: key points for the radiologist. Radiology. https://doi.org/10.1148/radiol.2020200241
10. Bernheim A, Mei X, Huang M et al (2020) Chest CT findings in coronavirus disease-19 (COVID-19): relationship to duration of infection. Radiology.
    https://doi.org/10.1148/radiol.2020200463
11. Wu J,Wu X, ZengWet al (2020) Chest CT findings in patients with corona virus disease 2019 and its relationship with clinical features. Invest Radiol.
    https://doi.org/10.1097/RLI.0000000000000670
12. Kunhua Li JW, Wu F, Guo D, Chen L, Zheng F, Li C (2020) The clinical and chest CT features associated with severe and critical COVID-19 pneumonia.
    https://doi.org/10.1097/RLI.0000000000000672
13. Hansell DM, Bankier AA,MacMahon H,McLoud TC, Muller NL, Remy J (2008) Fleischner Society: glossary of terms for thoracic imaging. Radiology 246:697–722
14. Ajlan AM, Ahyad RA, Jamjoom LG, Alharthy A, Madani TA (2014) Middle East respiratory syndrome coronavirus (MERSCoV) infection: chest CT findings.
    AJR Am J Roentgenol 203: 782–787
15. Wong K, Antonio GE, Hui DS et al (2003) Thin-section CT of severe acute respiratory syndrome: evaluation of 73 patients exposed to or with the disease. Radiology 228:395–400
16. Shi H, Han X, Jiang N et al (2020) Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China https://doi.org/10.1016/S1473 3099(20)30086-4

K. Anupama Murthy: COVID in Elderly

COVID in Elderly

K. Anupama Murthy

Professor, Head of Department, Dept. & Respiratory Medicine, PSG-IMSR, Coimbatore
The corona virus disease-19 (COVID-19)caused by Severe Acute Respiratory Syndrome Corona Virus 2 (SARSCoV-2) occurs in persons of all ages. Initial cases were reported in patients who were exposed to virus in seafood market in Wuhan, Hubei Province, China in December 2019(1).It has disseminated worldwide affecting more than 200 countries and declared as pandemic by WHO on 11 March 2020 Worldwide, there have been 14 million cases of COVID-19 and more than 5 lakh deaths by mid July 2020.(2)
In elderly due to multiple co-morbidities and complex health conditions, high case fatality and poor treatment outcomes have been observed. Physiological changes with age leads to decline in intrinsic capacity, manifested as malnutrition, cognitive decline, and depressive symptoms; those conditions should be managed comprehensively. Early detection of inappropriate medication prescriptions is recommended to prevent adverse drug events and drug interactions for those being treated for COVID-19.
Elderly patients have high probability of getting hospitalized, they might need intensive care or ventilator management and is associated with increased mortality. Consistently, age 65 and older is an independent risk factor for

death, cardiovascular events, and terminal events requiring IMV(invasive mechanical ventilation) and ICU admission (3) In one of the largest case series so far published, of 72,314 cases reported by the Chinese Centre for Disease Control and Prevention, case fatality was 8.0% (312 of 3,918) in patients aged 70–79 years and 14.8% in patients aged ≥80 years (4).The case fatality rate varies from 2.3 to 14.8% depending on the demographics of the nation or region,age, severity of the disease and co- morbidities

Clinical manifestations

Mild symptoms are seen in 80% of the patients more common amongst younger populations . Severe symptoms with shortness of breath and lung involvement are reported in 14% of the patients, and 5% develop critical illness, commonly seen in elderly patients. Elderly males with multiple comorbidities such as cardiovascular disease, diabetes mellitus, hypertension, chronic kidney disease, obesity, and chronic lung diseases are associated with the development of severe Covid infection.
COVID-19 diagnosis should be considered in any older adult who develops a new-onset fever or respiratory symptoms such as dry cough or breathing difficulty in the setting of community spread (5). The most common symptoms reported by patients with COVID-19 include fever, fatigue, and dry cough. Less common symptoms include headache, anosmia,

How to cite this article: K. Anupama Murthy, COVID in Elderly, JAPT 2020; 3(2):81-87

cough with sputum production, joint pains, chills, nausea, vomiting, and diarrhea. Covid infection can present with atypical symptoms in elderly. They may sleep more than usual or stop eating. They may seem unusually apathetic or confused, losing orientation to their surroundings. They may become dizzy and fall. Sometimes, seniors stop speaking or simply collapse. Underlying chronic illnesses can mask or interfere with signs of infection They may present with postural instability, diarhoea, delirium and unexplained hypoxia, tachycardia or tachypnea Older adults often present with atypical manifestations such as with sore throat,postural instability, diarhoea, delirium and unexplained hypoxia, tachycardia or tachypnea Most of the times COVID-19 gets detected in many elderly patients admitted for other complaints such as for falls or surgery.(6,7).

Critically ill patients develop significant complications such as acute respiratory distress syndrome (ARDS) requiring prolonged ventilatory support, cardiac injury, cardiac rhythm disorders, shock and death. The main complication of COVID-19 is acute respiratory distress syndrome (ARDS). This is reported to occur in between 15% and 23% of cases. Other complications include respiratory failure, acute kidney injury and liver dysfunction. Common causes of death include pneumonia, severe sepsis, multi-organ failure and severe acute respiratory syndrome .Guidance relating to the care of older people is emerging from the international community. This guidance spans ethical considerations to the clinical management of COVID-19 in different settings with a holistic assessment in their guidance of critical patients aged over 65 years. (3,8)

Diagnosis

Blood investigation : Typical findings on blood tests are lymphopenia, leucopenia and neutrophil/lymphocyte ratio >3.13 in critical illness.Raise in inflammatory markers like ESR and elevated C-reactive protein (CRP) are commonly seen.. In moderate-to-severe cases, increased procalcitonin levels has been observed (9) .D-Dimer may also be elevated in moderate to severe cases. Elevated troponin may indicate acute coronary syndrome or myocarditis Aging per se is a state of low grade inflammation therefore inflammatory markers may be raised like ESR and CRP in normal health in elderly. Patients with elevated D-dimer and severe lymphopenia have greater mortality [9].Underlying Chronic diseases like chronic renal failure, Copd, Diabetes, Cardiac Comorbidities can cause false negative results

Radiology

Chest X-ray findings

Most common features includes bilateral foci of illdefined opacification (10) opacities with predominant peripheral and lower zone distribution evolving into consolidation, and mostly seen in right lower lobe. Pleural effusion is rare.

Typical Manifestations

• Bilateral and posterior involvement.
• Peripheral distribution
• Ground glass densities
• Multilobar consolidation.
• Thickening of interlobular septa and
• peribronchial thickening
• Traction bronchiectasis

CT Scan Chest Findings⁽¹¹⁾

• Can be normal in the early stages of disease,
• a normal CT after a week suggests
• COVID-19 much less likely
• Lower lobe predominant, peripheral predominant, multiple, bilateral foci of ground glass opacity, Crazy paving, peripheral consolidation, air bronchograms, reverse halo/perilobular pattern

CO-Rads19

In March 2020, the “COVID-19 standardised reporting working group” of the Dutch Association for Radiology (NVvR) proposed a CT scoring system for COVID-19. They called it CO-RADS (COVID-19 Reporting and Data System ) to ensure CT reporting is uniform and replicable. This assigns a score of CO-RADS 1 to 5, dependant on the CT findings and if there is a confirmed positive RT-PCR test then it is CO-RADS 6.(12)

Samples used for diagnosis

Upper respiratory tract – Nasopharyngeal swab,oropharyngeal swab
Lower respiratory tract – Bronchoalveolar lavage(BAL),tracheal aspirate, sputum

Recommended test

The guideline recommend real time Reverse Transcriptase Polymerase chain reaction (RT-PCR) for diagnosis of COVID-19 (Pooled sensitivity – 70-98% and specificity of 95% in Nasopharyngeal swab) Positive tests after acute phase of infection are attributed to prolonged viral shedding that occurs in elderly and patients with co-morbidities. False negatives are attributed to low viral load in initial and late phases of infection Re-positive results are attributed to inactivated viral RNA being detected or viral reactivation. –(3,13,14)

Management in Elderly

• thorough understanding of the person’s life, values, priorities, and preferences for health management. Ensure multidisciplinary collaboration among physicians, nurses, pharmacists, and other health care professionals in the decision-making process to address multimorbidity and functional decline
• Currently, evidence for effective treatment for Covid-19 is rapidly evolving. Presently, treatment is supportive. All cases or suspected cases should be isolated until effective treatments or vaccines become available.
• NICE recommend that the Clinical Frailty Scale (CFS)should be used to provide a functional evaluation of people presenting with COVID-19 in those aged 65 years and over without long-term disability such as cerebral palsy, learning disability or autism.They advise that in patients with a CFS between 1 and 4, who would like to be treated intensively, critical care referral would be appropriate (3)
• Advanced care planning for those living with frailty, including sensitive consideration about the potential benefits of admission to hospital, is recommended. This is particularly relevant to people resident in care homes or with high clinical frailty scores where advanced care plans should be proactively revisited in the light of the current outbreak(2)
• Guidelines advocate stratifying people by disease severity however in older people, and those with co-morbidity, despite presenting with mild symptoms are at higher risk of severe COVID-19 and of unpredictable, rapid, deterioration
• Co-morbidities should be managed as standard, being careful of the non-specific presentation of disease in older patients to avoid attributing presenting symptoms solely to probable COVID-19 infection.
• Early medication review should occur to reduce the risks associated with polypharmacy and adverse reactions in the context of COVID infection .
• Medical management remains same in elderly patients as in adults but with due importance to drug–drug interactions, adequate control of Comorbidities and good supportive care.
• Loneliness and social distancing in elderly leads to depression, dementia and anxiety which need to be managed as well

Mild

Elderly patients need to be isolated to break the chain of transmission. even though disease is mild in view of co morbidities and high degree of mortality they will need hospital admission.(13,14)

• • Detailed clinical history regards co-morbidities and findings of Chest x-ray/CT chest, CBC, LFT and ECG noted. Daily vitals need to be monitored.
  • Strict contact precautions with symptomatic management (Paracetomol, IV fluids and good nutrition) advised.
  • Patients with risk factors for severe illness such as Hypertension, Diabetes mellitus, Chronic lung / kidney / liver disease, cerebrovascular disease, obesity and other immunosuppressive states to be monitored closely and can be preferably shifted to instituitional care as per advice of treating physician.
  • Patients with warning symptoms breathing difficulty, chest discomfort, and bluish discoloration of lips/face, decreased urine output should be immediately transferred to instituitional care

Moderate

(Pneumonia with no signs of severe disease, RR >=24/min, Spo2<94% on room air) (14)

• Moderate cases should be treated in an instituition with specialists to manage co morbidities as well.
• Detailed clinical history including co morbidities and findings of Chest x-ray/CT chest and blood investigations (CBC with neutrophil/lymphocyte ratio, CRP, Ddimer, Ferritin, LFT)
• Repeat CBC, LFT, ECG daily and CRP, Ddimer and Ferritin every 2-3 days.
• Oxygen support – Target Spo2:92-94% (88-92% in hypercapnic patients) through nasal prongs/ face mask with or without non rebreathing reservoir bag/ high flow nasal cannula (HFNC) depending on patient requirement (15)
• Awake rotation and self proning every 2 hours to be used as rescue therapy with care not to disrupt the flow of oxygen during change of position.(16)
• Dexamethasone 6 mg IV or PO for 10 days or equivalent dose if substituted by Methyl prednisolone or Prednisolone
• No routine antibiotics unless clinical suspicion of bacterial infection.
• Anticoagulation-LMWH (Enoxaparin) prophylactic dose
• Control of co-morbidities,
• Glycemic control to be optimised since patients on steroids
• Monitoring for thrombotic complications
• Drug to drug interactions to be taken care
• Adequate hydration and correction of dyselectrolenemia
• Psychological counselling and early identification of delirium, depression and anxiety disorders.

Severe

(Respiratory distress requiring Noninvasive ventilation (NIV)/Invasive mechanical ventilation (IMV), RR>=30/min, Spo2<90% on room air)
Detailed clinical history including co morbidities and findings of Chest x-ray/CT chest and blood investigations (CBC with neutrophil / lymphocyte ratio, LFT, RFT, PT/APTT/INR, D-DIMER, CRP, LDH, CPK, PCT, IL6, ECG, ECHO, NTPROBNP, Blood cultures) If work of breathing low, start a cautious trial of NIV /HFNC Dexamethasone 6mg IV or PO for 10 days or equivalent dose if substituted by Methyl prednisolone or Prednisolone.(17)
High prophylactic dose of LMWH (Enoxaparin) if no risk for bleeding If no evidence of shock, start conservative fluid management In management of shock,(8)

• • Measurement of dynamic parameters like skin temperature, capillary refilling time and or serum lactate measurement preferred over static parameters to assess fluid responsiveness
  • Fluid resuscitation with conservative strategy recommended with buffered crystalloids
  • Norepinephrine is used as 1st line vasoactive agent and Vasopression is used as 2nd line agent. In evidence of cardiac dysfunction, dobutamine suggested to add overincreasing norepinephrine dose. Target MAP of 60- 65 mm Hg.

Management of ARDS involving low tidal volume ventilation (4-8ml/kg of predicted body weight) and plateau pressure of (8).Use recruitment manoeuvre and prone positioning for 12-16 hours in patients with severe ARDS.
In mechanically ventilated patient with severe ARDS and hypoxemia despite optimizing ventilation, use of inhaled nitric oxide as a rescue therapy is suggested. In mechanically ventilated patient with severe ARDS and hypoxemia despite optimizing ventilation, recruitment manoeuvre, prone positioning and rescue therapy, use of venovenous ECMO is suggested. Empiric antibiotic with narrow spectrum activity based on local antibiogram.(18)

Investigations

– Repeat CBC, LFT, ECG daily and D- DIMER, PT/APTT/INR, CRP, LDH, CPK, PCT, IL6 every 2-3 days.
Control of co-morbidities
Stress ulcer prophylaxis
Older people are at greater risk of polypharmacy, as a result of newly prescribed medications, inadequate medication reconciliation, and a lack of coordination of care, all of which increases the risk of negative health consequences.

We need to involve caregivers and family members in decision-making and goal-setting,advanced care planning, throughout the management of older COVID (19)
Lots of clinical trials are going on world over to establish efficacy of various newer molecules but are not specific to elderly. Still a definitive therapy and preventive vaccine is awaited which, depends on outcomes of clinical trials. Many clinical trials are not done in elderly thereby clinical outcomes and drug interactions are unpredictable.

Post Covid Complications

Older adults are at greater risk of both severe disease and long time impairment

• • Prolonged hypoxia and widespread inflammation can also damage kidney, liver, heart, brain and other organs
  • Prolonged ventilator stay and acute respiratory distress syndrome (ARDS) can leads to fibrosis and scarring, long term breathing problems
  • Prolonged ICU stay make them prone to set of physical, cognitive and mental health problems known as post intensive care syndrome
  • Prolonged ventilator stay may leads to muscle atrophy and weakness so early physiotherapy, rehabilitation is beneficial.
  • Delirium due to prolonged hospital stays which can cause memory deficits and cognitive impairment are common. Polypharmacy and use of sedatives, steroids can worsen delirium.
  • Surge in mental health problems like anxiety, depression and post – traumatic stress disorder can follow psychological stress of severe disease.
  • Risk of thrombosis and clotting disorders is high which increases risk of cerebrovascular stroke and acute coronary syndrome
  • Risk of myocarditis is seen in mild to moderate patients in post covid period.
  • Many patients develop postural Hypotension and giddiness in post Covid period

Guidelines for prevention

Recommendations given to the general public to counteract the rapid spread of thevirus are

• Frequent hand washing, avoid touching eyes, nose, and mouth, social distancing (at least 6 ft, preferably > 13 ft), staying at home, and wearing a cloth face covering when going outside.
• Widespread use of face masks and social distancing have a vital role in decreasing the virus pace of spread.
• Telemedicine services should be encouraged by clinicians for residents to reduce direct contact between provider, staff and residents
• The visits of all nonessential visitors including family members should be stopped.
• Every person including all staff from cooks and housekeeping to nurses and administrators entering the facility should be screened for elevated temperature or presence of symptoms.
• In addition, staff should also be asked if they have had any contact with a COVID-19-positive (or suspected) person
• To avoid group dining, group therapies, and recreational activities involving large groups

To Summarize

Atypical clinical manifestation in elderly,multiple co-morbidities, drug-drug interactions, polypharmacy, low sensitivity of diagnostic tests, specific laboratory and radiological findings are important considerations during management of covid in elderly.
Older patients are mostly excluded from clinical trials and social distancing can have adverse effects on mental health in elderly. Further in sight is needed into how age, fraility, comorbidities and specific drug (ACE inhibitors, NSAIDS, immunosuppresents) can affect disease trajectory in elderly.
Post covid care and rehabilitation need to be initiated for elderly at the earliest Inclusion of elderly in clinical trials , early vaccination to high risk groups and further studies to assess consequences on mental health secondary to social isolation needs to be considered.

References

1. Amand Nanda et al Covid-19 in older adults. Aging clinical and experimental Research. 25 April 2020.
2. Centers for Disease Control and Prevention. 2019 Novel coronavirus, Wuhan, China. Information for Healthcare Professionals. https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index/html.
3. Fiona E. Lithander et al Covid-19 in older people : arapid clinical review Age and Aging 6 may 2020 :49:501-515.
4. Wu Z, McGoogan JM. Characteristics of and importantlessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72314 cases from the Chinese Center for Disease Control and Prevention.
5. The New York Times. Coronavirus Live Updates:W.H.O. Declares Pandemic as Number of Infected Countries Grows. The New York Times. Available at
   https://www.nytimes.com/2020/03/11/world/coron avir us-news.html
6. Wiersinga W, Rhodes A, Cheng A, Peacock S, Prescott H. Pathophysiology, Transmission, Diagnosis, and Treatment of Corona virus Disease 2019 (COVID-19).
   JAMA. 2020. doi:10.1001/jama.2020.12839
7. CDC. Symptoms of Coronavirus. Available at http://www.cdc.gov/coronavirus/2019ncov/ symptomstesting/ symptoms.html
8. Chinese Clinical Guidance for COVID-19 Pneumonia Diagnosis and Treatment (7th edition). Available at http://kjfy.meetingchina.org/msite/news/show/cn/3337.html.
9. Chen N, Zhou M, Dong X et al (2020) Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 395:507–513. https://doi.org/10.1016/S0140 -6736(20)30211 -7.
10. Clinical Management Protocol: COVID-19. Ministry of Health and Family Welfare, Government of India. Available at https://www.mohfw.gov.in/pdf/UpdatedClinicalManagementProtocolforCOVID19dated03072020.pdf
11. Wong HYF et al. Frequency and Distribution of Chest Radiographic Findings in COVID-19 Positive Patients.Radiology.2019.March 27. 201160.
12. Xun Ding, Jia Xu et al. Chest CT Findings of COVID-19 Pneumonia by Duration of Symptoms. Eur J Radiol.2020 Jun;127:109009
13. Prokop M, van Everdingen W, van Rees Vellinga T,Quarles van Ufford J, Stöger L, Beenen L, Geurts B,Gietema H, Krdzalic J, Schaefer-Prokop C, van Ginneken B, Brink M. CO-RADS – A categorical CT assessment scheme for patients with suspected COVID-19: definition and evaluation.2020. Radiology. doi:10.1148/radiol.2020201473 – Pubmed.
14. Bhimraj A, Morgan R, Shumaker A et al. Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients with COVID19. Clinical Infectious Diseases. 2020.doi:10.1093/cid/ciaa478.
15. Jie Li, James B Fink and Stephan Ehrmann. High-flow nasal cannula for COVID-19 patients. Eur Respir J. 2020 May; 55(5): 2000892.
16. Koeckerling D, Barker J,Mudalige NL, et al Awake prone positioning in COVID-19Thorax Published Online First: 16 June 2020. doi: 10.1136/thoraxjnl-2020-215133
17. Fadel R, Morrison AR et al. Early Short Course Corticosteroids in Hospitalised Patients with COVID-19. medRxiv. 2020 May 05.
18. Clinical guidelines, Overview and Evidence Based Guidelines for COVID-19: Endorsed by Association of Pulmonologist Tamilnadu, pg 8-10
19. Clinical management of severe acute respiratory infection when novel coronavirus (nCoV) infection is suspected. World Health Organisation. Available at https://www.who.int/publications-detail/clinicalmanagement-of-severe-respiratory-infection-whennovel-coronavirus-(ncov)-infection-is-suspected.

Kirubanandam Arularasan et al.: Clinical Profile and Outcome of COVID 19 Patients Admitted in Tertiary care Hospital, Tamilnadu

Clinical Profile and Outcome of COVID 19 Patients Admitted in Tertiary care Hospital, Tamilnadu

Kirubanandam Arularasan^1, Ria Lawrence^2, Sridhar R^3, Balasubramaniam Ramakrishnan^4, Ramanarasimhan R^5, Narasimhan R⁶

¹Post graduate resident, Department of Respiratory Medicine, Apollo Hospitals, Greams Road, Chennai, India
²Post graduate resident, Department of Respiratory Medicine, Apollo Hospitals, Greams Road, Chennai, India
³Junior Consultant, Department of Respiratory Medicine, Apollo Hospitals, Greams Road, Chennai, India
⁴Balasubramaniam Ramakrishnan M.S (Ph.D Biostatistics), Senior Biostatistician, Department of Biostatistics, DME Apollo Hospitals Chennai
⁵Senior Consultant, Department of General Medicine, Apollo Hospitals, Greams Road, Chennai
⁶Senior Consultant Pulmonologist, Department of Respiratory Medicine, Apollo Hospitals, Greams Road, Chennai

Abstract

Aim: to study the clinical, biochemical, radiological profile of symptomatic hospitalised COVID 19 patients at initial presentation and its outcome.
Background and Methods: Retrospective study was done on 50 hospitalised patients who were diagnosed with COVID- 19 pneumonia with gold standard RT PCR in Apollo Main hospital, Greams road, Chennai. The clinical, laboratory, radiological characteristics and treatment and outcomes were collected from electronic medical records. The information recorded included medical history, contact history, comorbidities, symptoms, signs, laboratory findings, radiological findings including chest X-ray and CT chest, treatment measures (antiviral, antibiotic, steroids, anticoagulant therapy and respiratory support), duration of hospital stay and outcomes of the patients.
Results: The study was done on 50 hospitalised patients with mean age of 59.8 years. Male(66%)patients were more compared to female patients. Fever (N=44)(88%)was the most common symptom present in our patients followed by breathlessness (N=27) (54%)Most of the patients were under category B 2(N=16)(32%). Most common comorbidity was Diabetes(N=25) (50%) followed by Hypertension (N=23) (46%). Only few patients had leucocytosis (N=16) (32%)but most of the patients had lymphocytopenia. LDH, PCT, and IL-6 were significantly elevated in majority of the patients. Chest x ray of the patients demonstrated bilateral(N=26) (52%)involvement with predilection for peripheries(N=34) (68%).. HRCT Chest of the patients demonstrated predilection for peripheral lung fields in the form of patchy ground glass opacities(100%). Most of the patients were treated with steroids(N=34%) (68%) and anticoagulants(N=46) (92%). 42 Patients were discharged(84%). Average length of stay in hospital is 8.92 days (2 to 42 days).

Discussion

Since the start of pandemic a higher percentage of cases and deaths have been identified in adult patients. This study included 50 laboratory confirmed patients by RT PCR. It is a observational study to describe the range of clinical presentation in our South Indian population. The mean age of the patients was 59.8 years which is similar to the studies conducted by Wang et al(56.0 years), Chen et al (55.5 years) and one decade older than studies done by Bhandari S et al (43.5 years) and Huang et al (49.0 years). Most of the patients requiring oxygen support were above 60 years of age, thus demonstrating that elder patients were more likely to have lung injury and require ventilator support.
Most of the patients having COVID 19 were male (66%) which was similar to studies conducted by Bhandari S et al (66.66%), Huang et al and Chen et al which show 73.0% male predominance but higher than that reported by Wang et al (54.3%). This male predominance may have happened due to increased travel for occupational purposes.
Fever was the most common complaint (88%) in our study followed by breathlessness (54%). Wang et al and Huang et al observed similar type of findings where fever was major clinical feature. But study done by Bhandari S et al reported Cough as the most common symptom. This variation between different studies may be explained by the fact that COVID 19 disease may present differently and varies country to country and region to region.
Diabetes was the most common comorbidity found in our study which was similar to Pande D et al study which included 27 patients. People with diabetes are inclined to get infections due to impaired phagocytic cell capabilities. A dysregulated immune response with increased ACE-2 receptors and furin expression may lead to a higher lung inflammation rate and lower insulin levels. The risk of ICU admissions is higher in patients with Diabetes.
Most patients had lymphocytopenia (64%) in this study. Whereas In study done by Saluja M et al lymphocytosis was found which is uncommon in viral infections. The inflammatory cytokine storm is a key factor for Lymphocytopenia in COVID 19 patients. Other possible mechanisms are exhaustion and infection of T cells by the SARS Cov-2 virus.
In this study LDH was significantly elevated in majority of the patients (93%) which is similar to results of the study done by Saluja M et al which included 406 patients.LDH is an enzyme involved in energy production by conversion of lactate to pyruvate. It is a general indicator of acute and chronic tissue damage. LDH has been described to be increased during acute and severe Lung damage and it is elaveted in Interstitial lung Infections.
Radiological investigations revealed predominant involvement of lower lobes (64%). Similar results were found in Pande D et al, Song et al Yang et al. This may be because of anatomical structure of trachea and bronchi- the bronchus of lower lobes is relatively straight, and the virus arrives more easily in the lower lobes. Ground glass opacities are the most common finding (100%) in our study which is suggestive of acute interstitial Pneumonia which is also be found in SARS and MERS.

Conclusion

This study shows the various range of COVID 19 presentation varying from mild to severe pneumonia. Lymphocytopenia and elevated biomarkers with peripheral opacities in CT chest will helpto assess the prognosis. Old age and patients with multiple comorbidities are associated with poorprognosis.

References

1. Bhandari S, Bhargava A, Sharma S, Keshwani P,Sharma R, Banerjee S. ‘Clinical profile of Covid-19 infected patinets Admitted in a Tertiary Care Hospital in North India. JAssoc Physicians India’. 2020;68(5):13-17
2. Sanyaolu, A., Okorie, C., Marinkovic, A. et al.‘Cpmorbidity and its Impact on Patients with COVID-19’. SN Compr. Clin. Med. 2, 1069-1076 (2020).
3. Wu, M, Yao, L., Wang, Y. et al. ‘Clinical evaluation of potential usefulmess of serum lactate dehydrogenase (LDH) in 2019 novel coronavirus (COVID 19) pneumonia’. Respir Res 21, 171(2020).
4. Haseli S, Khalili N, Bakhyeshwaram M, SaneiTaheri M, Moharramzad Y. ‘Lobar Distribution of COVID 19 Pneumonia Based on Chest Computed Tomography Findings; A Retrospective Study’. Arch AcadEmerg Med. 2020 Apr 18;8(1): e55. PMID: 32440666; PMCID:PMC7212068.
5. Huang C, Wang Y, Li Xingwang et al. ‘ Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China’. The lancet Volume 395, Issue 10223, 15-21 February 2020, Pages 497-506.
6. Wang D., Yin , Y., Hu, C. et al. ‘Clinical course and outcome of 107 patients infected with the novel coronavirus, SARS-Cov-2, discharged from two hospitals in Wuhan, China’. Crit Care 24, 188 (2020).
7. Pande D, Kochhar A, Saini S, Ganapathy U, Gogia AR.‘An update on initial epidemiological profile, clinical course, and outcome of COVID-19 patients at a tertiary care centre in India’. Indian J Palliat Care 2020;26:S36-9.
8. Saluja M, Pillai D, Jeliya S., et al. ‘COVID 19- Clinical Profile, Radiological Presentation, Prognostic Predictors, Complications and Outcome: A perspective from Indian Subcontinent’. J Assoc Physicians India :68(7): 13-18, 2020.
9. Asghar M, Haiderkazmi S, Ahmed Khan N, et al. ‘Clinical Profiles, Characteristics, and Outcomes of the First 100 Admitted COVID-19 Patients in Pakistan: A Single-Center Retrospective Study in a Tertiary Care Hospital of Karachi’. Cureus 12(6): e8712.
10. Gupta, Nitesh & Agarwal, Sumita&Ish, Pranav&Gaind, Rajini & Aroroa, Balvinder & Sen, Manas & Chakrabarti, Shibdas & Yadav, Siddharthraj & Gupta, Neeraj& Das, Rojaleen. ‘Clinical and epidemiologic profile of the initial COVID 19 patients at a tertiary care centre in India’. Monald archives for chest disease 90.193-96. 10.4081/monaldi.2020.1294

Monisha Anandhan et al.: Correlation between CT Severity Score and Clinical Severity of COVID-19 Pneumonia in Hospitalised ..

Correlation between CT Severity Score and Clinical Severity of COVID-19 Pneumonia in Hospitalised Patients in a Tertiary Care Hospital, Tamilnadu

Monisha Anandhan¹, Aishwarya KM² ,Sridhar R³, Ajith⁴, Balasubramaniam Ramakrishnan⁵ ,Narasimhan R⁶

¹Post Graduate Resident, Department of Respiratory Medicine, Apollo Hospitals, Greams Road, Chennai, India
²Post Graduate Resident, Department of Internal Medicine, Apollo Hospitals, Greams Road, Chennai, India
³Associate Consultant, Department of Respiratory Medicine, Apollo Hospitals, Greams Road, Chennai, India
⁴Post Graduate Resident, Department of Radiology, Apollo Hospitals, Greams Road, Chennai, India
⁵Balasubramaniam Ramakrishnan, M.S (Ph.D Biostatistics), Senior Biostatistician, Dept of Biostatistics, DME Apollo Hospitals Chennai
⁶Senior Consultant Pulmonologist, Department of Respiratory Medicine, Apollo Hospitals, Greams Road, Chennai, India

Abstract

Aim:To study the correlation between CT severity score in COVID pneumonia patients with oxygen supplementation and diseases outcome.
Background and Methods: Retrospective study was done on 56 hospitalied patients who were diagnosed with COVID-19 Pneumonia with gold standard RT PCR in Apollo Main Hospital, Greams road, Chennai. We retrospectively collected epidemiological data, clinical manifestation, co-morbidities, oxygen requirement as well as CT chest findings and CT severity score of all patients. Meticulous study of HRCT chest for pattern and distribution of the disease was done along with the calculation of CT severity score for all patients according to American journal of radiology recent guidelines. CT severity score was then compared with the clinical severity of the diseases as determined by the oxygen supplement and patient outcome.
Results:The study was done on 56hospitalized patients with mean age of 58.7 ± 14.3 with age group of 40 to 59 years(48.21%) and above 60 years(46.43%). Male(71.4%) patients were more compared to female(28.6%) patients .Typical COVID-19 findings like peripheral GGO’s were present in all patients, crazy paving in 96.4% patients and consolidation in 16.1% patients. There is a significant difference in CT severity score between those who required (N=39) (19.2±7.2) and not required oxygen (N=17) (10.7±5.7) (P value = 0.0001). Even though there was increasing trend in CT severity score across different modes of oxygen requirements but it was not statistically significant (0.183).

Corresponding Author: Dr. Narasimhan R, Senior Consultant Pulmonologist, Department of Respiratory Medicine, Apollo Hospitals, Greams Road, Chennai, India @gmail.com
Introduction
The emergence of similar clinical manifestation of unknown pneumonia since December 2019 in a large proportion of people in Wuhan City, Hubei Province, China, lead to the isolation of a new type of coronavirus from the lower respiratory tract samples. Subsequently it was named as Severe Acute Respiratory Syndrome Coronavirus-2 (SARSCoV-2) by the International Virus Classification Commission and the disease caused by it was named as Coronavirus Disease 2019 (COVID-19)by WHO in February 11, 2020.
Currently, as we are in the trial phase of discovering specific drug and vaccine against COVID-19, strategies for prompt diagnosis is the need of the hour to ensure appropriate patient management. Also, rapid patient isolation is crucial for containment of this communicable disease from a public health perspective. Realtime reverse transcriptase polymerase chain reaction (RT PCR) assay is being used as the gold standard for diagnosing COVID-19.However, RT PCR is suboptimal for rapid diagnosis as it takes several hours before results become available and sensitivity of the test is also insufficient to reliably exclude COVID-19.Another drawback is running a PCR machine is expensive and labs generally test large batches at once to reduce costs.
In this current scenario clinico-radiological diagnosis of COVID-19 has become very crucial. Thin-section Chest CT is more sensitive than chest x-ray, in picking up abnormal changes in the lung parenchyma in early stages of the disease. It acts as a valuable screening tool.Hence Chest CT has become a vital component in the diagnostic algorithm for patients suspected of having COVID-19 infection as it is not only less time consuming but also as it helps us in monitoring the response to therapy during the course of the disease.
The purpose of this study is to understand the correlation between the CT severity score and Clinical severity of COVID-19 pneumonia.And also infer on the prognosis of the patient based on the CT Severity Score which would enable the treating physician to plan the management the disease accordingly.

Series of data of COVID-19 pneumonia patients were collected and correlation of the CT Chest Severity Score with clinical severity was done to understand the importance of diagnosis and prognosis of the patient based of CT Chest findings. A total of 56 laboratory confirmed COVID-19 patients by RT-PCR and clinically as well as radiologically suggestive of COVID-19 admitted at Apollo Main Hospital, Greams Road, Chennai in the month May 2020, were assessed retrospectively.
Study Design
Retrospective observational study was done on 56 hospitalized patients who were diagnosed with COVID-19 Pneumonia in Apollo Main Hospital, Greams road, Chennai, after obtaining consent. The privacy and confidentiality of patients was observed as pernorms. To ensure the quality and integrity of clinical and imaging data, here we included 56 patients with COVID-19 who had been admitted to our institution.
Data Collection
We retrospectively collected the clinical, COVID-19 RT PCR and chest imaging data. This included epidemiological data, clinical manifestation, co-morbidities of patients, CT chest findings, CT severity score. After collection of all required data and careful medical chart review, the clinical data of laboratory-confirmed patients was compiled and tabulated.
Diagnosis of COVID-19 Pneumonia was confirmed by RT PCR on nasopharyngeal swab andclinico-radiologically. The data collected included epidemiological data (age, sex), a detailed history, inclusive of co-morbidities,clinical symptoms and signs. According to our hospital protocol, clinically patients were classified as mild (Category A and Category B1),moderate (Category B2) and severe (Category C)as follows^1,2,3,4,5:
1. Mild cases
Category A – Patients with age<60 years with underlying co-Morbidities
Category B1 – Patients with age >=60 years with underlying co-Morbidities.
2. Moderate cases
Category B2 – Patients with Respiratory Rate >24/min or SpO2 90-93% in Room Air.
3. Severe cases
Category C – Patients with SpO2 < 90% in Room Air or BP<90/60 or ARDS or with end organ damage.
All 56 patients underwent initial CT Chest scan within an average of 4 days of hospitalization. CT Chest scanning of the patient was done after taking adequate COVID-19 precautions. Data pertaining to clinical progress of the patient and final outcome was also collected and correlated with the CT Severity Score. Repeat imaging was done in a few patients if they had clinical worsening and also to look for response to therapy.
CT Chest Review
The CT Chest images of all the 56 patients were reviewed. For every patient, the chest CT scan was evaluated for the following characteristics: (a) presence of ground-glass opacities (GGO’s); (b) extent of distribution of the GGO’s in each of the 5 lobes namely, Right upper lobe (RUL), Right middle lobe (RML), Right lower lobe (RLL), Left upper lobe (LUL) and Left lower lobe (LLL); (c) presence of crazy paving or consolidation; (d) presence of atypical findings like nodules, pleural effusion, lymphadenopathy, cavitating consolidation; (e) other findings like pulmonary embolism, cardiomegaly, pneumothorax etc^4,5,6,7

CT Chest severity score
The base CT score was assigned according to the extent of GGO involvement in the lobes (with a maximum score of 5 possible for each of the five lobes), with scores defined as follows:
0 – denoting no involvement;
1 – denoting less than 5% involvement;
2 – denoting 5–25% involvement;
3 – denoting 26–49% involvement;
4 – denoting 50–75% involvement; and
5 – denoting more than 75% involvement.
Weight assignments were different for the three categories of CT findings (i.e., GGO, crazypaving pattern, and consolidation).
If the crazy-paving pattern appeared in one lobe, the base CT score was increased by 1, and if consolidation appeared (either with or without the crazy- paving pattern), the base CT score was increased by 2.
Therefore, a maximum CT score of 7 was possible for each lobe. The total CT score was defined as the sum of the scores for each of the five lobes and ranged from 0 to 35, with the highest possible CT score indicating consolidation in all five lobes.
Statistical Analysis Plan

All continuous variables will be represented by mean ±SD. Normality of the data will be assessed through Shapiro-Wilk’s test. Normally distributed variables will be expressed as mean ±SD, otherwise median (Interquartile range). Categorical variables will be represented by percentage. Comparison of normally distributed continuous variables will be done by independent sample t test if there are two categories. ANOVA will be used to compare normally distributed continuous variables between three groups. Mann-Whitney U test or Kruskal Wallis H test will be used if the distribution is not normal. Comparison of categorical variables will be done by Chi square test or Fisher’s Exact test based on the number of observations. Pearson correlation coefficient will be computed to know the association between binary continuous variables. Data entry will be done in Microsoft Excel 2007. Data analysis will be carried out by IBM SPSS statistics for Windows Version 25.0, Armonk, NY: IBM Corp. All ‘p’ values < 0.05 will be considered as statistically significant.
Results
In our study we included fifty six COVID-19 RT PCR nucleic acid test positive patients in which most of the patients were in age group of 40 to 59 years (48.21%) and above 60 years (46.43%) with mean ageof 58.7 ± 14.342. Male (71.4%) patients were more compared to female(28.6%) patients. Fever (66.1%) was the most common symptom followed by shortness of breath (41.1%) and cough (39.3%) while a few patients (12.82%) also had other symptoms like headache, chest pain, pain abdomen, altered sensorium. Patients in sample population had some or other underlying co-morbid condition. The most common present co-morbidity in our study population was Diabetes mellitus present in 67.9% of patients followed by Hypertension in 50% and Coronary artery disease (CAD) in 32.1%. Among 38 patients who had Diabetes five (13.2%) were died which was statistically significant (P value =0.652) .Similarly there was no difference in mortality among patients who had hypertension and CAD with P value 1.00 and 0.374 respectively.

There were 6 patients (10.7%) patients in Category A, 16 patients (28.6%) in category B1, 15 (26.8%) patients in Category B2 and 19 patients (33.9% ) in Category C with mean CT severity score of 8.7 ± 4.4, 13.8 ± 6 , 15.5 ± 5.9 and 22.5±7.6 respectively which was statistically significant (P value 0.0001). We did Post Hoc analysis using LSD which reveals that there was significance difference between category A and B2 (P value 0.036), category A and C (P value 0.0001), Category B1 and C (P value 0.0001) and category B2 and C (P value 0.0003) in CT severity score.
In this study percentage of lung involvement in each of the 5 lobes of lungs were assessed. Typical COVID-19 findings like peripheral GGO’s were present in all patients, crazy paving in 96.4% patients and consolidation in 16.1% patients. A typical findings like nodules (n=2, 3.6%), pleural effusion (n=3, 5.4%), cavitating consolidation (n=1,1.8%), pulmonary thromboembolism (n=3,5.4%), cardiomegaly (n=7,12.5%), (n=1, 1.8%), pneumothorax and pneumomediastinum were present in (n=3, 5.4%)

Figure 1 showing the histogram of CT severity score
COVID-19 patients with CT severity score in percentage were described as follows:

The commonly involved lobes in decreasing order were LLL (98.2%), RLL (98.2%)RUL (94.6%), LUL (94.6%) and RML (87.5%).More than 75% of GGOs were noticed in RUL (7.1%), RML (8.9%), RLL (12.5%), LUL (7.1%), LLL (14.3%). 50-75% of GGOs were noticed in RUL (14.3%), RML (8.9%), RLL (30.4%), LUL (14.3%), LLL (23.2%). 26-49% of GGOs were noticed in RUL (8.9%), RML (8.9%), RLL(19.6%), LUL (17.9%), LLL (23.2%). 5-25% of GGOs were noticed in RUL (28.6%), RML (23.2%), RLL (19.6%), LUL(25%), LLL (21.4%). Less than 5% of GGOs were noticed in RUL (35.7%), RML(37.5%), RLL (16.1%), LUL (30.4%), LLL (16.1%)

Mean CT severity score among those who required oxygen and not required oxygen table 1

Table 1: There is a significant difference in CT severity score between those who required (N=39) (19.2±7.2) and not required oxygen (N=17)(10.7 ±5.7) (P value = 0.0001). Even though there was increasing trend in CT severity score across different modes of oxygen requirements but it was not statistically significant (0.183).
Among 39 patients who needed Oxygen supplementation through different modes, nasal prongs (NP) (N=12) (30.8%), face mask (FM) (N=6) (15.4 %), Non rebreathing face mask (NRBM) (N=8) (20.5 %), High Flow Nasal Canula (HFNC) (N=2) (5.1%), Non Invasive Ventilation (NIV)(N=6) (15.4%) 5 patients were intubated (12.8% _ with respective mean CT severity score of 16.50 ± 4.1 , 16.67 ± 5.5, 19.13 ±6.2, 17 ± 16 , 23.7 ± 8.8 and 24 ± 8.9 which was not statistically significant [P value (0.183)].
Outcome Primary-Out of the 56 patients, 50 patients were discharged alive and 6 patients succumbed to illness. There was increased CT severity score in those patients who died which was not statistically significant when compared to the patients who were alive (P value = 0.120).
Outcome Secondary – Out of the 50 discharged patients, 43 patients were discharged off Oxygen support with mean CT severity score of 15.09 ± 7.1, 5 patients were discharged on minimal home oxygen support with mean CT severity score of 21.4 ± 10. We couldn’t comment on two patients who were discharged against medical advice.
Discussion
The present study included 56 laboratory confirmed COVID-19 patients by RT-PCR who underwent CT scan chest. The main goal of our study was to evaluate correlation between the CT severity score and clinical severity of COVID-19 pneumonia and its therapeutic utility in terms of treatment modification and clinical improvement based on the CT Severity Score.This is the first kind of study done at our tertiary care hospital. The purpose of doing the study is to reduce the time consumption in diagnosing COVID 19 and to be able to decide early shifting to isolation while the patients are in the emergency ward. With better CT screening at the very beginning, we can start empirically with multiple potent antiviral drugs, DVT prophylaxis and steroids before testing for COVID 19 by RT-PCR. Because of this early empirical treatment approach, there is decreased economic burden in view of hospital stay. This study highlights the role of CT severity score indetermining the prognosis in COVID 19 pneumonia patients. Patients were also followed up during their stay in the hospital to look for clinical progression.
The mean age of the patients was 58.7±14.342 ranging in the age group of 40 to 59 years (48.21%) and above 60 years (46.43%). Out of 56 patients included in the study, 71.4% were male and 28.6%were females with an average sex ratio of Female: Malebeing 1: 2.5. Similar observations were also made by Behznezmoradi et al in his study on one hundred and fifteen confirmed cases of COVID-19 with thoracic CTscans in which he concluded that the lung infiltrates on COVID inflicted chest CT in males are higher than females and the former have increased risk of disease severity and death.⁸ In another study by Jin et al, males are more susceptible to higher severity and mortality regardless of age.⁹ There is a proposed theory that due to the higher expression of Angiotensin-Converting Enzyme 2 (ACE2) gene on the X chromosome in men, they are more susceptible to COVID 19.¹⁰
Fever was one of the most common presentations, being the only symptom in 66.1% of the patients, followed by respiratory symptoms like shortness of breath in 41.1% and cough in 39.3% patients. 12.82% had other symptoms like headache, chest pain, pain abdomen and altered sensorium. Joseph R.Larsen et al. observed similar findings wherein patients with COVID 19 first develop fever, then upper respiratory symptoms followed by gastrointestinal (GI) tract symptoms¹¹.
67.9 % of the patients had Type II Diabetes Mellitus, 50% had Hypertension and Coronary artery disease (CAD) was seen in 32.1%. Guan WJ et al analysed data from 1590 laboratory confirmed hospitalised patients and found that the most prevalent comorbidity was hypertension (16.9%), followed by diabetes (8.2%)^12. In a meta-analysis of eight studies, patients with COVID-19 with diabetes had an increased risk of ICU admission^13. The reason for high CT severity score in diabetes is because they produce proinflammatory cells and alter homeostatic immune response, skewed towards helper T cell 1 (Th1) and T17 cells and a concomitant decrease in regulatory T cells (Treg)^14.
Crazy paving was the predominant pattern seen in 96.4% of patients, followed by consolidation in 16.1%, nodules in 3.6%, pleural effusion in 5.4%, cavitating consolidation in1.8%, pulmonary thromboembolism in 5.4%, cardiomegaly in 12.5%, pneumothorax and pneumomediastinum in 5.4%. As post COVID sequelae pulmonary embolism and pneumothorax were found to be the most common complications.
Lower lobe involvement was most common with 98.2% followed by upper lobe with 94.6% and middle lobe with 87.5%. Focal involvement (single lobe) was more common with left lower lobe. A systematic review of chest CT findings by Ojha V et al. found a similar result that ground glass opacities (GGO) in isolation in 50.2% or coexisting with consolidations in 44.2% of the patients were the most common lesions^16.These results are in accordance with several other published studies.^15,16,17,18 .The distribution of pattern in other studies were similar to our study. Most commonly, the distributions of GGOs have been found subpleurally which is probably because of the small size of the COVID virus being around 120nm due to which it can lodge into the deeper
structures.
Serious complications of COVID19 pneumonia in our study were only minor which include pulmonary embolism in 5.4% of the patients, pneumothorax and pneumomediastinum in 5.4%. Pneumothorax occurred probably because of advanced nature of the disease which required ICD insertion. The patients who developed pneumothoraces were on mechanical ventilation with optimal PEEP.The COVID lung has poor compliance which can lead to spontaneous pneumothorax as evident in our case. This implies that CT aids in early diagnosis of the complications and hence it can help in early management of the same.Those patients in whom pulmonary embolism was diagnosed were promptly started on therapeutic anticoagulants. The overall treatment modification could be done based on these atypical CT findings.
Interestingly, one of the patients had cavitating consolidation and found to have sputum positive tuberculosis with CT severity score of 3. The patient was started on antitubercular therapy, but deteriorated suddenly with worsening hypoxia, possibly due to pulmonary embolism secondary to COVID.
CT severity score and oxygen correlation in accordance to the former findings was reported in our study. It was found that it had positive correlation with significant P value.
Oxygen is a drug which has to be chosen carefully. Oxygen therapy is more effective for hypoxemic hypoxia. Oxygen delivery depends on oxygen source, delivery device and patient demand, hence choosing the appropriate mode of oxygen delivery is essential. In COVID pneumonia, people experience “happy hypoxia”. There is a major mismatch between how the patient looks and what the pulse oxymeters reveal. In the latest study, the researchers at Loyola University took a poll from about 58 hospitals and healthcare practitioners to see if they have seen any patients with happy hypoxia. They found that 16 patients had PaO2 less than 60 mm Hg but were not experiencing any discomfort. Before even the pulse oxymeter detects the severity of hypoxemia, a CT chest can help us in detecting the severity of hypoxemia at the initial presentation itself, based on the CT severity score. Hence this study is done to understand better about the correlation of oxygen demand of patients and CT severity score.
The patients with mean CT severity score of 10.71were able to maintain adequate oxygen saturation (sPO2) in room air. The patient with mean CT severity score of 16.50 needed oxygen supplementation via nasal prongs (NP), those having a score of 16.67 needed oxygen to be delivered via face mask, those with 19.13 had to be put on Non Rebreathing face mask (NRBM) and those having a score of 17.00 required oxygen through High Flow Nasal Cannula (HFNC). Non Invasive Ventilation was needed by those with a mean CT severity score were 23.67. The mean CT severity score ofintubated patients were 24.40. This implies that as severity score increases, the oxygen demand increases as well. CT severity scores therefore can aid in predicting the oxygen demand appropriately.
In our study, we also compared the category outcome of all COVID patients and correlated them with CT severity score .In the mild Category, with CT severity score between 1 to 10, the patients did not require any oxygen support. However, patients with CT severity score between 11 to 15 required minimal oxygen support via nasal prongs. In the moderate category with CT severity score between 11 to 15 and between 16-20, the patients required NRMB,whereas those with CT severity score between 26-35 got intubated. In the severe category, all patients required oxygen support and their CT severity score was between 16 to 35. Those with higher CT severity score got intubated.
There are many clinical and laboratory available data which help in predicting the mortality of COVID 19 patients. Here is the first study in which CT severity score helps in predicting the morbidity and mortality. Majority of patients with high CT severity scores were found to have succumbed to COVID.
Conclusion
Significant correlation between CT Severity Score and the comparable need for appropriate mode of oxygen delivery suggests the high predictive value of HRCT chest in the disease outcome. Hence, HRCT chest is one the best tools for early rapid identification as well as to predict the severity of disease.It also helps the physician in making important treatment modifications at crucial points during the progression and course of the disease.
Limitataion of the Study Smaller number noticed in each different mode of requirement of oxygen.
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