PICTORIAL ESSAY
COVID-19 and its Mimics
What the Radiologist Needs to Know
Sameer H. Hanfi, MBBS, Tasneem K. Lalani, MD, Amina Saghir, MD,
Lacey J. McIntosh, DO, MPH, Hao S. Lo, MD, and Hemang M. Kotecha, DO
Abstract: Severe acute respiratory syndrome coronavirus 2 (SARS-
CoV-2) is responsible for the current outbreak of Coronavirus disease
2019 (COVID-19). Although imaging should not be used for first-line
screening or diagnosis, radiologists need to be aware of its imaging
features, and those of common conditions that may mimic COVID-19
pneumonia. In this Pictorial Essay, we review frequently encountered
conditions with imaging features that overlap with those that are
typical of COVID-19 (including other viral pneumonias, chronic
eosinophilic pneumonia, and organizing pneumonia), and those
with features that are indeterminate for COVID-19 (including
hypersensitivity pneumonitis, pneumocystis pneumonia, diffuse
alveolar hemorrhage, pulmonary edema, and pulmonary alveolar
proteinosis).
Key Words: COVID-19, coronavirus, pneumonia, mimics
(J Thorac Imaging 2021;36:W1–W10)
S evere acute respiratory syndrome coronavirus 2 (SARS-
CoV-2)1 belongs to the family of Coronaviridae and is
responsible for the current outbreak of Coronavirus disease
2019 (COVID-19).2 COVID-19 cases were first reported as
pneumonia of unknown cause in Wuhan, China.3 With
increasing spread across the world, it was declared as a pan-
demic by the World Health Organization in March 2020.
Similar to other respiratory viral illnesses, COVID-19
most commonly presents with symptoms of fever, fatigue,
cough, and dyspnea.4,5 Severe COVID-19 with high mortality
mostly, but not exclusively, occurs in elderly patients and
individuals with comorbidities such as hypertension, diabetes,
cardiovascular disease, cancer, or obesity.4–6 The most fre-
quently reported complications of COVID-19 include acute
respiratory distress syndrome (ARDS), acute cardiac injury,
arrhythmia, septic shock, acute kidney injury, and secondary
infections.4,5,7,8
As COVID-19 continues to spread globally, health care
professionals are increasingly being urged to utilize computed
tomography (CT) and chest radiographs as screening and/or
diagnostic tools. Data from China emerged in late February
2020, which concluded that “CT imaging has a high sensitivity
for the diagnosis of COVID-19,”9 but data outside of China
during early stages of the outbreak have been less convincing,
considering significant overlap in imaging features that might
be seen during an influenza epidemic and, in particular, with
From the University of Massachusetts Medical School, UMass
Memorial Medical Center, Worcester, MA.
The authors declare no conflicts of interest.
Correspondence to: Sameer H. Hanfi, MBBS, Department of Radiology,
University of Massachusetts Medical School, 55 North Lake Ave,
Worcester, MA 01655 (e-mail: sameer.hanfi@umassmemorial.org).
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DOI: 10.1097/RTI.0000000000000554
J Thorac Imaging  Volume 36, Number 1, January 2021
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many false-negative tests.10 Current thinking is that the pos-
itive predictive value of CT will be low unless the disease
prevalence is high, as it was in Wuhan.10 Viral testing remains
the only specific method of diagnosis to date,11 but has its own
challenges with imperfect sensitivity.9,12,13
The American College of Radiology recommends that
CT not be used as a first-line tool for screening or diag-
nosing COVID-19, and should be reserved only for hospi-
talized symptomatic patients with specific indications for
chest CT.11 Portable radiography may be considered in
patients if deemed medically necessary.11 The Fleischner
Society recently issued a consensus statement on the role of
chest imaging in patient management during the COVID-19
pandemic, which states that imaging is indicated in patients
with COVID-19 and worsening respiratory status. Imaging
is also indicated as a triage tool for patients with suspected
COVID-19 who present with moderate-severe clinical fea-
tures and a high pre-test probability of disease in a resource-
constrained environment.14 Although imaging should not be
used for first-line screening or diagnosis, if a patient imaged
for other reasons has findings suggestive of COVID-19 and
negative testing, this should prompt repeat testing. In all
scenarios, radiologists should be familiar with the typical
imaging findings seen in COVID-19 along with mimics that
could potentially confound the diagnosis.
IMAGING FINDINGS OF COVID-19
Numerous studies have shown a wide variety of
imaging findings seen in COVID-19, most commonly
including ground-glass, consolidative, or nodular opacities;
with the distribution pattern being peripheral, bilateral, and
multi-lobar.15 Additional findings include crazy paving
pattern, interlobular septal thickening, bronchiectasis, or
subpleural involvement15 along with other unclear dis-
tribution patterns.16 “Crazy paving” is used to describe the
pattern of thickened interlobular and intralobular lines
superimposed on a background of ground-glass opacities
(GGO), resembling irregularly shaped paving stones.17 The
Radiological Society of North America (RSNA) recently
published an expert consensus statement in an attempt to
reduce report variability among radiologists and to better
aid in the management of these patients.18 In this consensus
statement, imaging findings are divided into 4 main cate-
gories: typical, indeterminate, atypical, and negative, to
convey a relative likelihood that these findings are attrib-
utable to COVID-19 pneumonia.
The “negative for pneumonia” category has imaging
features that lack any parenchymal abnormality to suggest
an infectious process, such as GGO or consolidation.18 It is
vital to understand that imaging may be negative in the
early stages of COVID-19, and that many conditions may
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Hanfi et al J Thorac Imaging  Volume 36, Number 1, January 2021

FIGURE 1. Typical findings of COVID-19. Axial (A) and coronal MinIP (B) CT images in a 58-year-old male patient with COVID-19
demonstrate peripheral GGO and consolidation (white arrows) and right lower lobe consolidation (black arrow). Axial CT images (C)
and (D) in a 62-year-old male patient with COVID-19 show multifocal peripheral GGO and consolidation of rounded morphology
(white arrows).

present with imaging findings similar to those that have been
described to occur in COVID-19 pneumonia.
“Typical” features of COVID-19 pneumonia (Fig. 1)
are those that are more frequently and specifically reported
in the current literature. These include GGO in a peripheral,
bilateral distribution, with or without consolidation or
visible intralobular lines (crazy paving pattern).18 GGO can
also be multifocal with a rounded morphology in a similar
distribution.18
Although radiographic changes may be absent or mild
in early disease, findings may change over the course of the
disease. Later stage infections (6 to 12 d) are usually char-
acterized by greater total (often bilateral) lung involvement,
coalescence of GGO into dense consolidations that can
progress to ARDS.16,19 Findings that have been described to
occur more commonly in later stages of disease include
GGO with a reticular pattern, vacuolar sign (lucency within
GGO), fibrotic streaks, air bronchogram, bronchus dis-
tortion, a subpleural line, a subpleural transparent line, and
pleural effusion (Figs. 2, 3).20 As patients recover, this is
followed by progressive organization into more linear
opacities and sometimes resolution of all abnormalities.16,19
MIMICS OF COVID-19: TYPICAL FINDINGS
Frequently encountered conditions with overlapping
imaging features with those that are typical of COVID-19
include other viral pneumonias, chronic eosinophilic pneu-
monia (CEP), and disease processes that result in an
organizing pneumonia pattern of lung injury.
Viral Pneumonia
Several RNA and DNA viruses can cause respiratory
illnesses in humans. RNA viruses that typically present from
late autumn to early spring include Influenza A and B,
Human Metapneumovirus (HMPV), and Coronavirus. DNA
viruses such as Adenovirus tend to manifest in late winter,
spring, and early summer. Other DNA viruses including
Herpes Simplex Virus, Cytomegalovirus, and Varicella occur
more often in immunocompromised patients.21 Symptoms
reported include high fever, dry cough, runny nose and/or
congestion, lethargy, and myalgias.22
RNA viruses, specifically Influenza A and B, are
responsible for annual outbreaks of pneumonia during the
winter months.21,22 HMPV causes about 4% of the commun-
ity-acquired pneumonias in adults and in those with chronic
obstructive pulmonary disease exacerbation, and can account
for 9% of infections in patients with hematologic
malignancy.23 Coronaviruses initially appeared with the
SARS-CoV epidemic in autumn 2002 and Middle East respi-
ratory syndrome-related coronavirus (MERS-CoV) in autumn
2012, and more recently COVID-19.3,22,24,25 Most patients
with Coronavirus pneumonias (SARS-CoV, MERS-CoV, and

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J Thorac Imaging  Volume 36, Number 1, January 2021 COVID-19 and its Mimics

FIGURE 2. Temporal progression of COVID-19. Axial CT images (A, B) in a 51-year-old male with COVID-19 performed on day 5 of
symptoms shows multifocal bilateral peripheral and peribronchial consolidation and GGO. Axial CT images (C, D) performed 21 days
later show improving consolidation with residual GGO and reticular pattern in the upper lobes, coalescence of consolidation in both
lower lobes (rectangle), and development of linear fibrotic streaks (arrows) and a small left pleural effusion (rectangle).

COVID-19) will have imaging findings similar to the afore- to peripheral consolidation with air bronchograms
mentioned findings typical of COVID-19.3 (Fig. 4).21–23 Influenza pneumonia presents with centrilobular
Imaging patterns of viral pneumonias range from poorly nodules and branching linear opacities, with or without con-
defined centrilobular nodules and patchy peribronchial GGO solidation on radiographs. Patchy areas of consolidation

FIGURE 3. Recovery from COVID-19. Axial (A) and coronal (B) images from CT performed on day 6 of symptoms in a 62-year-old man
with COVID-19 show multifocal GGO and consolidation of rounded morphology in the right lung (arrows). Axial (C) and coronal (D)
images from CT performed 16 days later show resolution of these opacities and the presence of a thin subpleural line in the right upper
lobe (arrows).

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Hanfi et al J Thorac Imaging  Volume 36, Number 1, January 2021

avian subtype (H5N1, H7N9) pneumonias can undergo

FIGURE 4. Respiratory syncytial virus pneumonia. Axial CT image
shows peripheral and peribronchial GGO (white arrows) with air
bronchograms (black arrow) in a 55-year-old female patient with
RSV pneumonia.
rapidly coalesce over days.21,22 On CT, bilateral peri-
bronchovascular and subpleural GGO with or without septal
thickening (crazy paving) can be seen (Fig. 5).23 Influenza A
pseudocavitation and pneumatocele formation and may be
associated with lymphadenopathy.26
HMPV pneumonia shows multifocal consolidation on
chest radiographs. On CT, HMPV pneumonia manifests as
GGO, small centrilobular nodules, and multifocal areas of
consolidation in a bilateral asymmetric distribution.21–23
Many patients with HMPV do not undergo imaging due to
mild symptoms; those that do are typically patients who are
either immunocompromised or who may have chronic
obstructive pulmonary disease exacerbation, cystic fibrosis,
or asthma.23
Adenovirus is more prevalent in children and only
accounts for 1% of respiratory infections in adults.21 On
imaging, adenovirus pneumonia manifests as patchy GGO,
centrilobular nodules, and peribronchial consolidation.21,22
Sequelae of adenovirus can include bronchial wall thicken-
ing, bronchiectasis, and postinfectious bronchiolitis
obliterans. The latter is most often seen in children after
adenovirus infection.21
Although most viral pneumonias resolve without com-
plication, some viral pneumonias may result in significant lung
injury with a pattern of diffuse alveolar damage (DAD)
resulting in fibrosis.22 Influenza A has been shown to have
fibrotic interstitial changes after the initial infection.3

FIGURE 5. Influenza pneumonia. Axial CT images (A) and (B) show bilateral peripheral and peribronchial GGO with septal lines (arrow) in
a 40-year-old male patient with Influenza A pneumonia. Axial CT images (C) and (D) show bilateral peribronchial and peripheral GGO in
a 64-year-old woman with Influenza B pneumonia.

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J Thorac Imaging  Volume 36, Number 1, January 2021
FIGURE 6. Chronic eosinophilic pneumonia. Axial CT image shows
multifocal bilateral peripheral GGO (arrows) in a 72-year-old
woman with chronic eosinophilic pneumonia.
Coronavirus pneumonias can result in fibrotic changes after
pneumonia, likely due to lung injury and DAD.22,24 Adeno-
virus in solid organ and stem cell transplant patients has an
incidence of 3% to 47%, with increased risk for developing
ARDS as a complication of adenovirus pneumonia.21
CEP
CEP is one of a heterogenous group of eosinophilic lung
diseases and can result in an imaging appearance similar to that
of COVID-19. CEP is an idiopathic condition with gradual onset
of clinical symptoms of restrictive lung disease. It most com-
monly affects middle-aged patients, approximately half of whom
have a history of asthma.27 Histologically, CEP is characterized
by accumulation of eosinophils and lymphocytes in the alveoli
and interstitium, with interstitial fibrosis. The percentage of
eosinophils in bronchoalveolar lavage fluid is very high.27
The typical CT finding in CEP is nonsegmental
peripheral airspace consolidation, with an upper lobe pre-
dominance (Fig. 6). Less commonly encountered findings
that predominate in later stages of disease include GGO,
FIGURE 7. Organizing pneumonia. Axial CT images (A) and (B) show multifocal bilateral peripheral GGO (white arrows) and
consolidation (black arrows) in a 49-year-old woman with organizing pneumonia secondary to systemic lupus erythematosus.
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COVID-19 and its Mimics
reticulation, and nodules. Pleural effusion is uncommon. CT
performed at least 2 months after symptom onset may show
linear bands parallel to the pleural surface.27
Treatment consists of systemic corticosteroids, with
patients experiencing complete recovery in a matter of days.
Long-term prognosis is considered excellent, although most
patients require maintenance therapy with low-dose oral
corticosteroids to prevent relapses.28
Organizing Pneumonia
Organizing pneumonia is a pattern of lung injury
resulting from a spectrum of causes, such as infection
(including COVID-19), inflammatory disease, radiation
therapy, drugs, toxins, or autoimmune disease.29 Idiopathic
forms are referred to as cryptogenic organizing pneumonia.
Lung injury in organizing pneumonia can be either
focal or diffuse. Injury to alveolar epithelium leads to
fibroblast migration, starting the process of “organization.”
If the inciting factor is removed and the basement mem-
brane is intact, there is remodeling of the fibroblastic tissue
into normal pulmonary parenchyma. On the contrary, if the
culprit stimulus persists and there is prolonged distortion of
basement membranes, eventually, organized fibroblastic
tissue leads to irreversible fibrosis.30
Patients present with shortness of breath, non-
productive cough, lethargy, low-grade fever, and weight
loss.31 The diagnosis is made on the basis of a combination
of clinical presentation, lack of response to multiple anti-
biotic regimens, negative cultures, and imaging findings. It is
imperative to note that some etiologies of organizing
pneumonia may clinically overlap with COVID-19. These
include infections such as pneumococcus, influenza, and
pneumocystis carinii, and respiratory involvement in sys-
temic lupus erythematous and rheumatic fever.32,33
The accuracy of CT has been described to be up to 79%
for the diagnosis of organizing pneumonia.29 In 62% to 90%
cases of organizing pneumonia, pulmonary involvement is
diffuse and bilateral. There is generally a lower lobe predi-
lection with peripheral consolidations and GGO in a peri-
bronchial distribution (Fig. 7).31 Unilateral pulmonary
involvement, although less common (10% to 38%), is man-
ifested by a solitary pulmonary nodule, single consolidation,
and/or GGO in a peribronchial location, with associated
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Hanfi et al J Thorac Imaging  Volume 36, Number 1, January 2021

bronchiectasis and architectural distortion. In addition to
consolidation, peribronchial nodules of varying sizes can be
seen in both diffuse and unilateral lung involvement.30
Although descriptors such as reverse halo sign and atoll
sign were initially reported to be specific for organizing
pneumonias,29,34,35 it is now known that these can also be seen
in a host of infectious, noninfectious, and granulomatous
processes. The “reverse halo” sign is described as ring of
consolidation around a central GGO. If this ring is inter-
rupted at one location, it is referred to as an “Atoll sign.”30
Treatment consists of removal of the inciting stimulus
and corticosteroid therapy for 6 to 12 months, and the
prognosis is generally favorable.31 Nevertheless, if the initial
lung injury is severe, irreversible fibrosis can ensue.
MIMICS OF COVID-19: INDETERMINATE
FINDINGS
As per the RSNA consensus statement, “atypical” imaging
findings of COVID-19 (Fig. 8) pneumonia are those that are not
commonly reported with this disease and more indicative of
other disease processes. They lack the typical and indeterminate
features. Atypical CT findings include isolated lobar or seg-
mental consolidation without GGO, lung cavitation, discrete
nodules (tree-in-bud opacities and centrilobular nodules), and
pleural effusion.18 These are more commonly seen in bacterial
pneumonia, a variety of community-acquired pneumonias, and
aspiration. Such findings are unlikely to create a diagnostic
dilemma and should suggest alternative diagnoses other than
COVID-19 pneumonia.
Imaging findings that have been reported in COVID-19,
but are nonspecific, fall into the “indeterminate” category,
including diffuse, multifocal, perihilar or unilateral GGO,
with or without consolidation, and lacking a specific dis-
tribution pattern. Few very small nonrounded and non-
peripheral GGO are also included in this category.18 Similar
findings have also been described in pneumocystis pneumo-
nia, hypersensitivity pneumonitis, diffuse alveolar hemor-
rhage (DAH), pulmonary edema, and pulmonary alveolar
proteinosis (PAP), which may present a diagnostic challenge.
Pneumocystis Jirovecii Pneumonia (PJP)
PJP is a fungus that causes pneumonia in immunocom-
promised hosts and is the most common opportunistic infection
among individuals with AIDS. Since the introduction of highly
active anti-retroviral therapy and PJP chemoprophylaxis in HIV-
infected patients, patients without HIV infection account for a
majority of PJP cases in industrialized countries.36 This includes
patients with primary immunodeficiency or hematologic malig-
nancies, solid organ and bone marrow transplant recipients,
collagen vascular disorders, and those undergoing treatment with
corticosteroids or chemotherapy.36 HIV-infected patients typi-
cally present with insidious onset of respiratory symptoms,

FIGURE 8. Findings atypical of COVID-19. Axial contrast-enhanced CT images in lung (A) and soft tissue (B) windows show lobar
consolidation (white arrows) without GGO in the left lower lobe of an 80-year-old female patient with community-acquired streptococcal
pneumonia. Axial CT image (C) demonstrates clustered centrilobular micronodules (black arrow) in the right lower lobe in a 77-year-old
female patient with human metapneumovirus infection. Axial CT image (D) shows right upper lobe consolidation with areas of cavitation
(arrow) in an 81-year-old male patient with methicillin-sensitive Staphylococcus aureus pneumonia. Axial CT image (E) shows smooth
interlobular septal thickening (white arrow) and small bilateral pleural effusions (black arrows) in a 55-year-old male patient with
congestive heart failure exacerbation.

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J Thorac Imaging  Volume 36, Number 1, January 2021
FIGURE 9. Pneumocystis jirovecii pneumonia. Axial CT images
shows perihilar predominant GGO in a 61-year-old female patient
on long-term high-dose steroids for dermatomyositis, diagnosed
with Pneumocystis jirovecii pneumonia by bronchoalveolar lavage.
whereas PJP infection in patients without HIV infection presents
acutely with severe hypoxia and rapid deterioration of respira-
tory function requiring mechanical ventilation, overlapping with
the clinical presentation of patients with COVID-19.37
On CT, PJP is characterized by extensive GGO, which is
most commonly in a central distribution with peripheral sparing
but may also be diffuse (Fig. 9). In more advanced disease,
consolidation and crazy paving may develop. Pulmonary cysts
develop in up to one third of cases and are associated with an
increased risk of spontaneous pneumothorax.36
First-line therapy for PJP is oral trimethoprim-sulfa-
methoxazole (TMP-SMX), with the addition of cortico-
steroids for patients with HIV infection. Mortality rates of
PJP remain high despite treatment, with survival rates of
86% to 92% in HIV-infected patients, and 51% to 80% in
those without HIV infection.37
Hypersensitivity Pneumonitis (HP)
HP is an inflammatory reaction in the lungs caused by
repeated inhalation of triggering particles. Chronic and severe
FIGURE 10. Hypersensitivity pneumonitis. Axial CT image (A) demonstrates multifocal bilateral GGOs in both lungs (white arrows), with
areas of crazy paving (black arrow), in an 86-year-old man with subacute hypersensitivity pneumonitis. Coronal image (B) shows the
same findings with sparing of the lung apices.
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COVID-19 and its Mimics
cases can lead to pulmonary fibrosis. The offending particles
are small enough to reach the lung parenchyma (1 to 5 μm)
and elicit an immune response.38 Numerous types of expo-
sures can cause this entity, often related to occupation, but
also seen with recreational activities or contaminated air
systems. Many antigens have been described as triggers,
including plant and animal products, chemicals, chemo-
therapies, and aerosolized microorganisms. Development of
this disease is multifactorial, and likely related to the levels
and duration of exposure, type of antigen, and inherent host
characteristics.39 Smokers are less likely to develop HP as
their lungs are frequently and repeatedly exposed to antigens.
The diagnosis is made by combining clinical and radio-
graphic features: exposure to triggering antigen, classic signs
and symptoms, abnormal pulmonary function tests, and
abnormal chest imaging. The sensitivity of chest radiography
for the detection of HP is low and radiographs may be normal.
If abnormal, findings depend on the phase of acuity. Early
disease can manifest as numerous poorly defined small nodular
opacities throughout both lungs and may spare apices and
bases. Pulmonary edema pattern of patchy or diffuse GGO
can also be seen. Later stages of disease are characterized by
irreversible lung damage or fibrosis with reticulation and
honeycombing and upper lobe predominant volume loss.
Cardiomegaly can be seen as a result of cor pulmonale.40
CT has superior sensitivity, with abnormal findings in
90% of patients with clinical features of HP. Findings that
can be seen by CT (Fig. 10) include GGO, which can be
bilateral and symmetric, or patchy in the mid to lower lungs
or in a bronchovascular pattern; numerous often poorly
defined centrilobular nodules; mosaic attenuation; and a
combination of patchy GGO, normal lung, and air trap-
ping, known as the “head cheese sign.” Later stage disease
may show a spectrum of fibrosis from reticulation to hon-
eycombing, mediastinal lymphadenopathy, pulmonary
arterial enlargement, midlung predominant, or diffuse cen-
trilobular emphysema sparing the extreme apices and bases,
and traction bronchiectasis and bronchiolectasis.38
Treatment entails removal of the offending antigen and
steroids, if indicated. Prognosis is generally worse if fibrosis
or severe respiratory impairment is present.41
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Hanfi et al
FIGURE 11. Diffuse alveolar hemorrhage. Axial CT image shows
bilateral perihilar GGO (white arrow) and consolidation
(black arrow) in a 77-year-old female patient with diffuse alveolar
hemorrhage secondary to granulomatosis with polyangiitis.
DAH
DAH is an uncommon condition describing bleeding
into pulmonary alveoli, caused by injury to the alveolar
microcirculation. Clinical symptoms often include severe
hemoptysis, anemia, and hypoxemic respiratory failure.42
DAH is associated with various disease entities, reflecting
several histologic subtypes. The most common subtype is
small-vessel vasculitis (ie, pulmonary capillaritis), typically
resulting from seropositive systemic vasculitides or connective
tissue disorders. Other subtypes are bland pulmonary hemor-
rhage and DAD.42
In one case review of DAH, capillaritis occurred in 88%
of cases. The most common clinical cause was granulomatosis
with polyangiitis (formerly Wegener’s granulomatosis) (32%),
followed by Goodpasture syndrome (13%), idiopathic
FIGURE 12. Pulmonary edema. Axial CT image in the lung window (A) shows bilateral lower lobe GGO with superimposed interlobular
septal thickening (arrow) in a 68-year-old woman with pulmonary edema. Axial CT image in the soft tissue window (B) demonstrates
small bilateral pleural effusions (arrows).
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J Thorac Imaging  Volume 36, Number 1, January 2021
pulmonary hemosiderosis (13%), collagen vascular diseases
(13%), and microscopic polyangiitis (9%).43
The imaging findings of DAH can vary with underlying
disease etiology and chronicity. In up to 50% of cases,
imaging of the lungs appears normal during the acute phase.
Radiographic findings of acute alveolar hemorrhage include
central and basilar predominant airspace opacities, with
sparing of the costophrenic angles. The corresponding find-
ings on CT are patchy GGO without significant interlobular
septal thickening. CT findings in the subacute phase (within
48 h) include interlobular and intralobular interstitial thick-
ening. If septal thickening occurs in the setting of pre-existing
GGO, a crazy paving pattern is seen. Airspace opacities and
septal thickening typically resolve within 2 weeks. If hemor-
rhagic episodes are chronic or recurrent, pulmonary fibrosis
may develop. Chronic CT findings include regional archi-
tectural distortion with lobular sparing, on a background of
coarse septal thickening and interstitial fibrosis.44
Granulomatosis with polyangiitis (formerly Wegener’s
granulomatosis) is the most common cause of DAH on imaging
(Fig. 11). It is a multisystemic necrotizing vasculitis associated
with the presence of c-ANCA serum antibody. The classic
imaging appearance is bilateral peribronchovascular nodules
and masses, which may cavitate, surrounded by a halo of
ground-glass opacity. GGO and consolidation, when they
occur, indicate underlying DAH. Associated arteriolar vasculitis
may cause a mosaic perfusion pattern. Focal or diffuse airway
stenosis is an uncommon late-stage complication.44
On the basis of imaging findings seen in DAH, the
differential diagnosis commonly overlaps with pulmonary
edema and infection, including COVID-19. Cardiogenic
pulmonary edema is often accompanied by cardiomegaly
and rapidly changing radiologic findings, over the course of
hours. The airspace opacities of DAH typically improve
over the course of days. Pleural effusions are commonly seen
in acute pulmonary edema, but they are uncommon in
DAH. Also, unlike in pulmonary edema, radiographic
findings in DAH are generally not gravity dependent.
To differentiate from infectious etiologies, the presence of
fever, cough, and leukocytosis are important.44
J Thorac Imaging  Volume 36, Number 1, January 2021
FIGURE 13. Pulmonary alveolar proteinosis. Axial (A) and coronal (B) CT images show diffuse bilateral GGO and septal thickening
(crazy paving), with geographic sparing in the left lower lobe, in a 28-year-old man with autoimmune PAP.
Bronchoalveolar lavage confirms the diagnosis of DAH.
However, lung biopsy is often required to elucidate under-
lying histologic subtype. DAH treatment aims to directly
address the underlying etiology and usually includes corti-
costeroids, immunosuppressive agents, and plasmapheresis.42
Pulmonary Edema
Pulmonary edema is defined as abnormally increased
fluid within the extravascular spaces of the lung. In terms of
pathophysiology, pulmonary edema may be classified as
increased hydrostatic pressure (ie, cardiogenic), permeability
with DAD (ie, ARDS), permeability without DAD, and
mixed edema with increased hydrostatic pressure and per-
meability changes.45 The 2 most common clinical pre-
sentations resulting in pulmonary edema are congestive heart
failure and fluid overload. The numerous other causes of
pulmonary edema include postobstructive, acute asthma
exacerbation, acute/chronic pulmonary embolism, veno-
occlusive disease, near drowning, drug reaction, high-altitude
sickness, inhalational injury, neurogenic, and reperfusion.45
Generally, pulmonary edema develops in 2 phases:
interstitial and alveolar. These correspond with imaging find-
ings on radiograph and CT (Fig. 12). Interstitial pulmonary
edema manifests as distended pulmonary arteries and veins,
interlobular septal thickening, and peribronchovascular inter-
stitial thickening. Alveolar pulmonary edema is seen as air-
space GGO or consolidation.46 The combination of septal
thickening and GGO can result in a crazy paving pattern on
CT, which may mimic the findings of COVID-19. Classically,
cardiogenic pulmonary edema demonstrates central dis-
tribution of acute pulmonary opacities (ie, bat’s wing appear-
ance), whereas permeability edema shows dependent
distribution of opacities. In most cases of cardiogenic pulmo-
nary edema, associated extrapulmonary imaging findings
include cardiomegaly and pleural effusions.46
PAP
PAP is a rare condition that leads to abnormal intra-
alveolar accumulation of surfactant due to altered surfac-
tant homeostasis. This accumulation of surfactant can be
either due to overproduction of phospholipids by pneumo-
cytes, impaired clearance of surfactant by macrophages, or a
combination of both.47
Adult patients with PAP may be asymptomatic or
present with nonspecific symptoms of dyspnea, dry cough,
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COVID-19 and its Mimics
fatigue, and weight loss, which may overlap with the clinical
presentation of COVID-19.47,48 The most common elevated
serologic marker in PAP is lactate dehydrogenase. Cases of
idiopathic PAP also tend to have antibodies against gran-
ulocyte-macrophage colony-stimulating factor.47
Classically, imaging findings appear more severe than clin-
ical presentation. Chest radiographs in patients with PAP most
commonly demonstrate symmetric bilateral central lung opacities
(GGO, reticular, or nodular) with relative sparing of the lung
apices and costophrenic angles.47 Unilateral involvement or
extensive diffuse consolidation are less common manifestations.
Chest CT characteristically demonstrates widespread crazy pav-
ing with wide areas of regional or zonal predominance, and
sharply marginated areas of geographic or lobular sparing
(Fig. 13).47,48 Although these CT findings are characteristic of
PAP, they are nonspecific and can be seen with several infectious,
hemorrhagic, and idiopathic conditions, including COVID-19.
Treatment for PAP depends on the particular subtype of the
disease. Idiopathic PAP requires sequential therapeutic whole-
lung lavage, secondary PAP requires removing the offending
agent, and congenital PAP typically requires lung transplant.47
CONCLUSION
As global rates of COVID-19 continue to rise, radiol-
ogists need to be aware of its imaging features, and those of
common conditions that may mimic COVID-19 pneumonia.
Although imaging is not currently recommended to play a
diagnostic role, recognition of this entity as an incidental
finding or in the setting of negative testing has diagnostic and
management implications, and public health importance for
managing staff exposures, patient isolation, and appropriate
facility decontamination. At the very least, detection of
imaging features that are typical of COVID-19 should prompt
confirmation of the diagnosis with laboratory testing and
further clinical evaluation.
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