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FIGURE 1. A–C, Chest CT of a 38-year-old man. The clinical manifestations were fever (38 C), cough, expectoration, muscle pain, and dyspnea.
C-reactive protein and procalcitonin levels were increased. Ground glass opacity (GGO) (white triangle), consolidation (white thick arrow), and
interlobular septal thickening (white thin arrow) distributed under the pleura were seen. Nine lung segments including the lateral basal segment, posterior
basal segment, posterior basal segment, anterior basal segment of the both lower lobe, and the dorsal segment of the left inferior lobe were involved. In
3 segments, the lesions occupied more than 50% of the total volume. PII = (9 + 3)/40 100% = 30%.
(including systemic hypertension, diabetes mellitus, tobacco smoke, RESULTS
asthma, heart disease, chronic obstructive pulmonary disease [COPD],
immunodeficiency, and others). Information regarding the physical ex- Characteristics and Clinical Manifestations
amination at admission was also evaluated, including the heart rate, This study included 80 patients diagnosed as COVID-19, of
body temperature, oxygen saturation, and blood pressure (BP). Moreover, which 42 were male (52%) and 38 were female (48%). All the patients
the laboratory data obtained at admission, which included the leukocyte, aged 15 to 79 years with an average age of 44 ± 11 years. Twenty-six
lymphocyte, neutrophil, monocyte, procalcitonin, and C-reactive protein, (33%) of 80 patients were smokers. Sixty-one (76%) of 80 patients
were assessed as well. Blood gas analyses were performed in 40 patients
whose PH value, PaCO2, and PaO2 were also assessed. All the blood gas
analysis was conducted from arterial blood samples. TABLE 1. Characteristics and Clinical Manifestations of the 80
Patients With COVID-19
CT Scans and Review
The CT examinations were carried out with an 16-row multide- Characteristics Patients (n = 80)
tector CT scanner (Siemens Somatom Sensation; Siemens, Erlangen, Age, y 44 (11)
Germany) using the following parameters: 120 kVp, 150 mA, Sex
1.5 mm collimation, 1.35:1 pitch, sharp kernel (B80f ), reconstruction Female 38 (48%)
matrix of 512 512, slice thickness of 1.0 mm, and high spatial reso- Male 42 (52%)
lution algorithm. All the patients were scanned in a supine position dur-
Smokers 26 (33%)
ing breath-holding at full inspiration. All CT images were evaluated
using a lung window, with a window level of −500 HU and window Days from illness onset 7 (4)
width of 1500 HU. Two certificated chest radiologists with 10 and 8 Comorbidity 15 (18%)
years' experience independently reviewed the CT images while they Hypertension 4 (5%)
were blinded to the names and clinical data of the patients. The CT im- Diabetes 4 (5%)
aging features were fully assessed, and the following findings were COPD 3 (4%)
highlighted: ground glass opacity (GGO), consolidation, interlobular Immunosuppression 3 (3%)
septal thickening, bronchial wall thickening, subpleural line, lymph Heart disease 1 (1%)
node enlargement, pleural effusion, and pericardial effusion in accor- Asthma 0 (0%)
dance with the standard morphologic descriptors based on the Signs and symptoms
Fleischner Society Nomenclature Committee recommendations and
Fever 61 (76%)
similar studies.7,8 As a rule, a consensus had to be reached between
the 2 radiologists about the abnormalities, and discrepancies were rec- Highest temperature 37.80°C (37.30°C–38.20°C)
onciled and tackled via discussion. Specifically, the evaluation of the <37.30°C 19 (24%)
size and extent of lung involvement was based on the segments of the 37.30–38.00°C 38 (47%)
lung anatomy: 10 segments in the right lung and 10 segments in the left 38.10–39.00°C 20 (25%)
lung (2 segments were considered in the apicoposterior segment of the >39.00°C 3 (4%)
left upper lobe and 2 segments were considered in the inferior front seg- Cough 58 (73%)
ment of the left lower lobe). According to the evaluation criterion estab- Expectoration 11 (14%)
lished by Chongqing Radiologist Association of China, the pulmonary Chest pain 5 (6%)
inflammation index (PII) was obtained from each patient. PII = (distribu- Muscle ache 13 (16%)
tion score + size score)/40 100% (Fig. 1). Distribution score: scored
Dyspnea 7 (9%)
according to the lesion distribution, one score for each lung segment,
and 20 scores for left and right lung. Lesion size was scored according Abdominal pain and diarrhea 7 (9%)
to whether the lesion occupied more than 50% of the lung segment vol- Pharyngeal discomfort 9 (11%)
ume, one score for ≥50%, and zero score for <50%. Spearman correla- Dizziness and headache 8 (10%)
tions were performed to evaluate the relationships between the PII value Blood in sputum 3 (4%)
and the clinical symptom and laboratory results of the patients. All sta-
Data are n (%), n/N (%), and mean (SD), where N is the total number of pa-
tistical analyses were conducted using Statistical Package for Social tients with available data. COVID-19, corona virus disease 2019. COPD, chronic
Sciences software version 23.0 (SPSS Inc, Chicago, IL). P values less obstructive pulmonary disease.
than 0.05 were considered statistically significant.
258 www.investigativeradiology.com © 2020 Wolters Kluwer Health, Inc. All rights reserved.
FIGURE 2. A–C, Chest CT of a 60-year-old man. The clinical manifestations were fever (37.8°C), cough, expectoration, and dyspnea. Neutrophil count,
lymphocyte count, and C-reactive protein levels were increased. “Crazy paving signs” (white thin arrow) were seen.
© 2020 Wolters Kluwer Health, Inc. All rights reserved. www.investigativeradiology.com 259
FIGURE 3. A–C, Chest CT of a 44-year-old man. The clinical manifestations were fever (38.5°C), cough, dizziness, and headache. C-reactive protein level
was increased. “Spider web signs” (white thin arrow) were seen.
temperature (continuous variable) (P < 0.05). The correlation coeffi- thickened like a net. The adjacent pleura were pulled and formed a
cient values were −0.260, −0.258, 0.373, 0.273, 0.287, and 0.544, re- spider web–like shape in the corner. Thus, we named it “spider
spectively. The chest CT findings of the patients were shown in Table 3. web sign.” However, the pathological basis needs further pathologi-
cal confirmation. It is a specific sign for COVID-19, which has not
been reported in other diseases in the literature. At present, it is
DISCUSSION not clear whether it has clinical value in evaluating the prognosis
COVID-19, which is primarily transmitted by contact between of patients. Recently, Pan et al have analyzed the time course of lung
people and droplets, turns out to be a new disease of human beings. changes in 21 mild patients with confirmed COVID-19. They found
Whether the novel coronavirus can spread in other ways is unclear, that the initial lung manifestation was subpleural GGO, which
although it could be detected in nasopharyngeal swabs, sputum, lower turned to consolidation 2 weeks after the onset of the disease, and
respiratory secretions, blood, feces, and other samples. Early identifica- then the lesions were gradually absorbed, leaving a wide range of
tion and early intervention are vital to reduce the incidence and mortal- GGO and subpleural parenchymal bands.17 In another article, the au-
ity of severe cases. In this study, most patients were adults, and there thors found that after 7 days of treatment for the mild patients, there
was no significant difference between the numbers of either male or fe- was a significant reduction in GGO on chest CT. On the 13th day after
male. Cough and fever were the most common clinical symptoms. The admission, most of the ground glass disappeared. Our patients constituted
incidence of expectoration, chest pain, muscle ache, abdominal pain or
diarrhea, pharyngeal discomfort, headache or dizziness, and dyspnea
were less common. This is similar to other types of coronavirus infec- TABLE 3. Chest CT Findings of the 80 Patients With COVID-19
tions such as the SARS and Middle East respiratory syndrome
(MERS).11–13 This implies that they can presumably be classified as Patients (n = 80)
the same kind of infection and the target cells of SARS-CoV-2 may also
be located in the lower respiratory tract. CT features
For chest CT, 76 cases (95%) had abnormalities indicating the GGO 73 (91%)
pneumonia. On the whole, in comparison with other types of pneu- Consolidation 50 (63%)
monia, COVID-19 seemed to cause milder symptoms and severer Interlobular septal thickening 47 (59%)
pulmonary changes on CT. Most of the patients had mild symptoms Crazy paving pattern 23 (29%)
and mild temperature rise, but their lung manifestations were seri- Spider web sign 20 (25%)
ous. Multiple lesions were found in multiple segments and lobes of Subpleural line 16 (20%)
both lungs, which was different from the bacterial pneumonia. In Bronchial wall thickening 9 (11%)
other words, multiple and large lesions of 2 lungs involved simulta- Lymph node enlargement 3 (4%)
neously is not generally spotted in the typical bacterial pneumo-
Pericardial effusion 4 (5%)
nia.14,15 The most common involved lung segments were the
dorsal segment of the right lower lobe, the posterior basal segment Pleural effusion 5 (6%)
of the right lower lobe, the lateral basal segment of the right lower Lung segment involved
lobe, the dorsal segment of the left lower lobe, and the posterior Average lung segments involved 12 (6)
basal segment of the left lower lobe. There were significant correla- Dorsal segment of the right lower lobe 69 (86%)
tions among the degree of pulmonary inflammation and the main Lateral basal segment of the right lower lobe 64 (80%)
clinical symptoms and laboratory results. Our results suggested that Posterior basal segment of the right lower lobe 68 (85%)
chest CT could be used to evaluate the severity of the disease and Dorsal segment of the left lower lobe 61 (76%)
played an important role in clinical practice. For CT features, GGO Posterior basal segment of the left lower lobe 65 (81%)
was the most common of all the abnormalities, followed by consol- PII value 34% (20%)
idation and interlobular septal thickening. This is consistent with the
Distribution 76 (95%)
results of the recently published studies.16–18 Occasionally, the
subpleural line and bronchial wall thickening could be seen, whereas Subpleural distribution 42 (53%)
pleura effusion, pericardial effusion, or lymph node enlargement Diffuse distribution 7 (9%)
were rare to identify. Some of the GGO was characterized by the re- Peribronchial distribution 3 (4%)
ticular interlobular septa thickening, which was called “crazy paving Mixed distribution 24 (30%)
pattern.” It resulted from the alveolar edema and interstitial inflam-
Data are n (%), n/N (%), or mean (SD), where N is the total number of patients
matory of acute lung injury, which had been reported in SARS.9,10 with available data. CT, computed tomography; COVID-19, corona virus disease
In another situation, some of the GGO showed a triangular or angu- 2019; GGO, ground glass opacity; PII, pulmonary inflammation index.
lar shape under the pleura with the internal interlobular septa
260 www.investigativeradiology.com © 2020 Wolters Kluwer Health, Inc. All rights reserved.
a complete group with mild, severe, and critical types.19 All patients 4. World Health Organization. Novel coronavirus - Japan (ex-China). 2020. Available at:
completed CT examination within 2 days after admission, which was http://www.who.int/csr/don/17-january-2020-novel-coronavirusjapan-ex-china/en/.
7 ± 4 days from the onset of the disease. 5. World Health Organization. Novel coronavirus - Republic of Korea (ex-China).
2020. Available at: http://www.who.int/csr/don/21-january-2020-novelcoronavirus-
At present, to our knowledge, all patients have not been exam- republic-of-korea-ex-china/en/.
ined by pathology in the world, so it is impossible to know the exact 6. CDC. First travel-related case of 2019 novel coronavirus detected in United States.
pathological manifestations of COVID-19. However, according to the 2020. Available at: https://www.cdc.gov/media/releases/2020/p0121-novel-
morphological changes of the CT features, pathological manifestations coronavirus-travel-case.html.
could be speculated although there was no direct evidence. The ground 7. Hansell DM, Bankier AA, MacMahon H, et al. Fleischner society: glossary of
glass density lesions could be caused by the exudation of alveoli. The terms for thoracic imaging. Radiology. 2008;246:697–722.
appearance of consolidation indicated that the alveoli were completely 8. Schoen K, Horvat N, Guerreiro NFC, et al. Spectrum of clinical and radiographic
filled by inflammatory exudation. The thickening of interlobular sep- findings in patients with diagnosis of H1N1 and correlation with clinical severity.
BMC Infect Dis. 2019;19:964.
tum indicated that the pulmonary interstitium has been involved. In 9. Ketai L, Paul NS, Wong KT. Radiology of severe acute respiratory syndrome
the late stage of acute respiratory distress syndrome, diffuse alveolar, (SARS): the emerging pathologic-radiologic correlates of an emerging disease.
and interstitium damage may occur. J Thorac Imaging. 2006;21:276–283.
The COVID-19 needs to be differentiated from other diseases, 10. Wong KT, Antonio GE, Hui DS, et al. Thin-section CT of severe acute respiratory
such as SARS and MERS. They all showed multiple ground glass syndrome: evaluation of 73 patients exposed to or with the disease. Radiology.
shadows and solid lesions in both lungs, mainly distributed under the 2003;228:395–400.
pleura, which were difficult to distinguish.20–22 However, SARS and 11. Lee N, Hui D, Wu A, et al. A major outbreak of severe acute respiratory syndrome
in Hong Kong. N Engl J Med. 2003;348:1986–1994.
MERS had faster disease progress and heavier lung damages than
12. Assiri A, Al-Tawfiq JA, Al-Rabeeah AA, et al. Epidemiological, demographic,
COVID-19 infection did. Likewise, COVID-19 should be distinguished and clinical characteristics of 47 cases of Middle East respiratory syndrome
from other kinds of viral pneumonia such as influenza virus, coronavirus disease from Saudi Arabia: a descriptive study. Lancet Infect
parainfluenza virus, adenovirus, respiratory syncytial virus, rhinovirus, Dis. 2013;13:752–761.
human metapneumovirus, and mycoplasma pneumonia. 13. Muller NL, Ooi GC, Khong PL, et al. High-resolution CT findings of severe acute
In conclusion, in this study, we found that common chest CT respiratory syndrome at presentation and after admission. Am J Roentgenol. 2004;
182:39–44.
findings in COVID-19 include multiple GGO, consolidation, and inter-
14. Gharib AM, Stern EJ. Radiology of pneumonia. Med Clin North Am. 2001;85:
lobular septal thickening in both lungs, with mostly subpleural distribu- 1461–1491, x.
tion. There were significant correlations among the degree of pulmonary 15. Koo HJ, Lim S, Choe J, et al. Radiographic and CT features of viral pneumonia.
inflammation and the main clinical symptoms and laboratory results. Radiographics. 2018;38:719–739.
Computed tomography played an important role in the diagnosis and 16. Song FX, Shi NN, Zhang ZY, et al. Emerging coronavirus 2019-nCoV pneumonia.
evaluation of this emerging global health emergency. Nevertheless, this Radiology. 2020;200274:200274.
study has 3 limitations. First of all, this was a retrospective study involv- 17. Pan F, Yan TH, Sun P, et al. Time course of lung changes on Chest CT during
ing a small number of patients with proven SARS-CoV-2 infection. Sec- recovery from 2019 novel coronavirus (COVID-19) pneumonia. Radiology.
2020;200370. doi:10.1148/radiol.2020200370.
ond, none of the patients had a lung biopsy or autopsy to reflect the
18. Jeffrey K. Chest CT findings in 2019 novel coronavirus (2019-nCoV) infections
histopathological changes. Third, this study was a cross-sectional study, from Wuhan, China: key points for the radiologist. Radiology. 2020;200241.
and we could not analyze the dynamic CT changes in different stages. doi:10.1148/radiol.2020200241.
In the future work, we will investigate the chest CT features of differential 19. Duan YN, Qin J. Pre- and posttreatment chest CT findings: 2019 novel coro-
stages of COVID-19 by using larger, more diverse samples. navirus (2019-ncov) pneumonia. Radiology. 2020;200323. doi:10.1148/
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© 2020 Wolters Kluwer Health, Inc. All rights reserved. www.investigativeradiology.com 261