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Nematollahi N, Mohammadi M R, Vakili M A, Baniaghil A S, Ghelichli M, Najafi M J, et al . Chest CT Findings (COVID-19), Analysis of 200 Cases (Postmortem). J Adv Med Biomed Res 2022; 30 (140) :241-248
URL: http://journal.zums.ac.ir/article-1-6503-en.html
Chest CT Findings (COVID-19), Analysis of 200 Cases (Postmortem)
Nematollah Nematollahi1 , Mohammad Reza Mohammadi 2, Mohammad Ali Vakili3 , Asieh Sadat Baniaghil4 , Maryam Ghelichli5 , Mohammad Javad Najafi6 , Atousa Mortazavi Milani6 , Amir Hossein Ghadirian6 , Fatemeh Shahrokhi6 , Hasan Khorshah7 , Sepide Sadat Hosseini8
1- Dept. of Radiology, School of Medicine, 5Azar Hospital, Golestan University of Medical Sciences, Gorgan, Iran
2- Dept. of Neurosurgery, School of Medicine, 5Azar Hospital, Golestan University of Medical Sciences, Gorgan, Iran , dr.mmohamadi@goums.ac.ir
3- Dept. of Biostatistics and Epidemiology, School of Medicine, Golestan University of Medical Sciences, Gorgan, Iran
4- Dept. of Midwifery, School of Nursing and Midwifery, Golestan University of Medical Sciences, Gorgan, Iran
5- Dept. of Oral and Maxillofacial Pathology, School of Dentistry, Golestan University of Medical Sciences, Gorgan, Iran
6- School of Medicine, 5Azar Hospital, Golestan University of Medical Sciences, Gorgan, Iran
7- Dept.of Statistics, 5Azar Hospital, Golestan University of Medical Sciences, Gorgan, Iran
8- Dept.of Education, 5Azar Hospital, Golestan University of Medical Sciences, Gorgan, Iran
Keywords: Ground Glass Opacity, Cardiomegaly, CT Findings, COVID-19
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✅ Based on this study, hypertension as an underlying disease was significantly related to Highly Suggestive CT scans. No relation was found between cardiomegaly and death under 48 hours. Our findings Showed Ground Glass Opacity (GGO) in 192 (96%), consolidation  in 88 (44%), crazy paving in 30 (15%), cardiomegaly in 30 (15%), and pleural effusion in 53 (26.5%) cases.


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Introduction
 

December 2019 was the beginning point in time of a very contagious viral disease (–entitled COVID-19 by WHO) in Wuhan, China. An infection that causes acute lower pulmonary tract involvement leading to superimposed septicity. There are many cases with subtle clinical symptoms and milder manifestations but can spread via airborne droplets to others and eventually kill them (1, 2). After the COVID-19 outbreak declaration in Golestan-Iran with a population near 1900000,  onJanuary 20, 2020, many patients were referred to the Emergency Departments of 22 hospitals in Golestan Province, Iran.
Unfortunately, some were in bad condition and died with the consequences of acute viral respiratory syndrome. Because of the limitation of access to rRT-PCR kits) due to sanctions, clinical diagnosis was made as per WHO and Ministry of Health guidelines (2).

 

Materials and Methods

All cases in this study underwent CT scans, and some had rRT-PCR documents and other paraclinical data. PCR samples were gathered and sent to the Virology Department of Golestan University of Medical Sciences (GOUMS). We collected all chest CT scans of 200 cases diagnosed as COVID-19 who  had died in 22 hospitals of Golestan Province and stored them in a separate PACS system. All CT scans were stored  in a specific PACS system. A radiologist reported all scans regardless of their initial reports for confirming the diagnosis and transferring data to the checklist provided previously. All scans were reported by a second radiologist again for confirming the diagnosis. Performing CT scans as a valid test even before RT-PCR beccomes positive is time-saving and necessary for admission and starting medical care (3, 4).
This study is derived from a research study (Recording Mortality COVID-19 in Golestan-Iran) approved by the deputy Research of GOUMS and the Medical Ethics Committee (Code: IR.GOUMS.REC.1398.390). A cross-sectional study was carried out on 200 cases who died with COVID-19 acute respiratory syndrome in Golestan (North of Iran). All cases had undergone lung CT scans performed through the standard technique with 3 mm thickness and without a gap in supine and no contrast use. Underlying diseases and medical history were obtained from hospital records HIS (Hospital Information System), and PACS (Picture Archiving and Communication System). Statistical evaluation was made using descriptive analysis and the Chi-Square test. The data analysis  was performed using SPSS version 16 (SPSS Inc., IL, USA). The significance level was less than 0.05.
 

 
Results

Our cases had mean and standard deviation (SD) age of 64.5±13.57 years, and median of 65, (minimum age 25, maximum 94). After admission 23.6% died before 48 hours, 51.5%in 3-7 days, and 24.9% after 7 days.
In our study 52.5% of the cases were male, and 47.5% female; the mean age was 64.5± 13.57 years. No difference was observed  between those who were under 70 years of age and those who were over 70. 23.6% of cases died in the first 48 hours after admission, which could be due to advanced disease or late reference.
Acute symptoms of cases referred to Emergency room were dyspnea (38%), fever (15%), dry cough (13%), myalgia (9%), nausea and vomiting (3.5%), runny nose (1%). Initial symptoms are presened in Table 1.


Table 1. Initial Symptoms

  Male Female Total
Count % Count % Count %
Runny Nose Yes 2 1.90 0 0.00 2 1.00
No 103 98.10 95 100.00 198 99.00
Body Pain Yes 10 9.52 8 8.42 18 9.00
No 95 90.48 87 91.58 182 91.00
Cough Yes 12 11.43 14 14.74 26 13.00
No 93 88.57 81 85.26 174 87.00
Dyspnea Yes 36 34.29 41 43.16 77 38.50
No 69 65.71 54 56.84 123 61.50
Nausea and Vomiting Yes 4 3.81 3 3.16 7 3.50
No 101 96.19 92 96.84 193 96.50
Diarrhea Yes 0 0.00 0 0.00 0 0.00
No 105 100.00 95 100.00 200 100.00
Hemoptysis Yes 0 0.00 0 0.00 0 0.00
No 105 100.00 95 100.00 200 100.00
Fever Yes 15 14.29 15 15.79 30 15.00
No 90 85.71 80 84.21 170 85.00
Sore Throat Yes 0 0.00 0 0.00 0 0.00
No 105 100.00 95 100.00 200 100.00
Other No 100 95.24 90 94.74 190 95.00
Yes 5 4.76 5 5.26 10 5.00

One hundred cases had no specific symptoms, 25.5%had only one symptom, 19.5% had two, 4.5% had three and 0.5% had four of above symptoms. We had no gastrointestinal and hemoptysis complaints.
Severity of involvement of lung lobes was scored 0-4, (no lobar involvement=0, <25%=1, 25%-50%=2, 50% -75%=3, >75%=4). Right lower lobe (RLL) was involved in 69%, Left lower lobe (LLL) in 64%, left upper lobe (LUL) in 50%,and Right upper lobe (RUL)in 47.5%. 13.5% of cases had no Right middle lobe (RML) involvement. (Table 2).

 
Table 2. The severity of Lobar Involvement

  Male Female Total
Count % Count % Count %
RUL Score 0 6 5.71 6 6.32 12 6.00
Score 1&2 41 39.05 52 54.74 93 46.50
Score 3&4 58 55.24 37 38.95 95 47.50
RML Score 0 14 13.33 13 13.68 27 13.50
Score 1&2 56 53.33 60 63.16 116 58.00
Score 3&4 35 33.33 22 23.16 57 28.50
RLL Score 0 4 3.81 4 4.21 8 4.00
Score 1&2 22 20.95 32 33.68 54 27.00
Score 3&4 79 75.24 59 62.11 138 69.00
LUL Score 0 5 4.76 5 5.26 10 5.00
Score 1&2 43 40.95 47 49.47 90 45.00
Score 3&4 57 54.29 43 45.26 100 50.00
LLL Score 0 2 1.90 4 4.21 6 3.00
Score 1&2 31 29.52 35 36.84 66 33.00
Score 3&4 72 68.57 56 58.95 128 64.00

RUL: Right upper lobe
RML; Right middle lobe
RLL: Right lower lobe
LUL: left upper lobe
LLL: Left lower lobe.
 

Underlying diseases found were hypertension in 45 (22.5%), history of heart problem in 39 (18.5%), diabetes  in 30 (15%), renal disease or on dialysis  in 10 (5%), malignancy or on chemotherapy in 8(4%), lung disease, asthma and COPD in 6 (3%), nervous disease and seizure in 5 (2.8%), Body Mass Index (BMI) > 40 in1 (0.5%), no liver disease, other diseases in 10(5%) cases. 110 (55%) Patients had no underlying disease ,and 90(45%) had at least one underlying disease.
Underlying diseases are presented in Table 3.


 Table 3. Underlying Diseases

  Male Female Total
Count % Count % Count %
History of hypertension No 83 79.05 72 75.79 155 77.50
Yes 22 20.95 23 24.21 45 22.50
History of heart disease No 90 85.71 73 76.84 163 81.50
Yes 15 14.29 22 23.16 37 18.50
History of diabetes No 97 92.38 73 76.84 170 85.00
Yes 8 7.62 22 23.16 30 15.00
History of kidney  disease or dialysis No 99 94.29 91 95.79 190 95.00
Yes 6 5.71 4 4.21 10 5.00
History of Malignancy or Chemotherapy No 102 97.14 90 94.74 192 96.00
Yes 3 2.86 5 5.26 8 4.00
History of lung disease , asthma ,or COPD No 104 99.05 90 94.74 194 97.00
Yes 1 0.95 5 5.26 6 3.00
History of nervous disease/seizure No 102 97.14 93 97.89 195 97.50
Yes 3 2.86 2 2.11 5 2.50
BMI > 40 No 105 100.00 94 98.95 199 99.50
Yes 0 0.00 1 1.05 1 0.50
History of liver disease No 105 100.00 95 100.00 200 100.00
Yes 0 0.00 0 0.00 0 0.00
Other No 100 95.24 90 94.74 190 95.00
Yes 5 4.76 5 5.26 10 5.00

BMI: Body Mass Index.
 

All CT scans had been collected from 22 hospitals in a separate database PACS; Reports were transferred to the checklist. CT scans were categorized as Highly Suggestive  in 171 (85%), Indeterminate  in 20 (10%), and Inconsistent in 9 (4.5%) cases. (Figure 1).
Lungs were involved bilaterally in 196 (98%), and unilaterally in 4 (2%) cases. The other results were as follows: Ground Glass Opacity (GGO) 192 (96%), consolidation 88 (44%), crazy paving 30 (15%), cardiomegaly 30 (15%), pleural effusion 53 (26.5%), pericardial effusion 7 (3.5%), significant lymphadenopathy (LAP) (>1 cm diameter) 7 (3.5%), bronchiectasis 7 (3.5%), emphysema 5 (2.5%), intrathoracic mass 5 (2.5%), fibrosis 4 (2%), cavity formation 3 (1.5%), and pneumothorax 3 (1.5%). No reverse halo was seen. GGO and consolidation together was seen in 83 (41.5%) cases. (Table 4)


Figure 1. Chest radiography and CT imaging:  
Figure 1. Chest radiography and CT imaging:
A) Multiple bilateral ground-glass densities. B) Bilateral patchy consolidations. C) Patchy consolidations on the left lung and ground glass densities on the right side. D) Cardiomegaly and pleural effusion. E) Cardiomegaly and pericardial effusion associated with pulmonary infiltrations.

 
Table 4. CT scan findings

  Count % Count % Count %
CT Finding Highly Suggestive 90 85.71 81 85.26 171 85.50
Indeterminate 10 9.52 10 10.53 20 10.00
Inconsistent 5 4.76 4 4.21 9 4.50
Lung involvement Unilateral 2 1.90 2 2.11 4 2.00
Bilateral 103 98.10 93 97.89 196 98.00
GGO Yes 101 96.19 91 95.79 192 96.00
No 4 3.81 4 4.21 8 4.00
Consolidation Yes 46 43.81 42 44.21 88 44.00
No 59 56.19 53 55.79 112 56.00
Pleural effusion Yes 25 23.81 28 29.47 53 26.50
No 80 76.19 67 70.53 147 73.50
Crazy Paving Yes 18 17.14 12 12.63 30 15.00
No 87 82.86 83 87.37 170 85.00
Cardiomegaly Yes 14 13.33 17 17.89 31 15.50
No 91 86.67 78 82.11 169 84.50
Pericardial effusion Yes 1 0.95 6 6.32 7 3.50
No 104 99.05 89 93.68 193 96.50
LAP Yes 3 2.86 4 4.21 7 3.50
No 102 97.14 91 95.79 193 96.50
Bronchiectasis Yes 1 0.95 6 6.32 7 3.50
No 104 99.05 89 93.68 193 96.50
Emphysema Yes 3 2.86 2 2.11 5 2.50
No 102 97.14 93 97.89 195 97.50
Intra Thoracic Mass Yes 2 1.90 3 3.16 5 2.50
No 103 98.10 92 96.84 195 97.50
Fibrosis Yes 1 0.95 3 3.16 4 2.00
No 104 99.05 92 96.84 196 98.00
Cavity formation Yes 2 1.90 1 1.05 3 1.50
No 103 98.10 94 98.95 197 98.50
Pneumothorax Yes 3 2.86 0 0.00 3 1.50
No 102 97.14 95 100.00 197 98.50
Reverse halo Yes 0 0.00 0 0.00 0 0.00
No 105 100.00 95 100.00 200 100.00
 


 

Discussion

After the statement of the COVID-19 pandemic by the World Health Organization (WHO) on  January 30, 2020, many people died from this new unseen disaster all over the world.  In an unequal combat,  on one side therewere the organizations responsible for saving the lives of humans, and on the other side humanity suffered from disease and its complications with no adequate information (2).
Based on our results, comorbid diseases were hypertension in 45 (22.5%), heart problems  in 37 (18.5%), diabetes in 30 (15%), renal diseases in 10 (5%), malignancy or on chemotherapy 8 (4%) cases. Similar to to our results, Shi et al., reported accompanying diseases as hypertension in 12 (15%), diabetes in 10 (12%), chronic pulmonary disease in 9 (11%), and cardiovascular disease in 8 (10%) cases (5).
Prominent symptoms with which patients referred to ER were dyspnea 77 (38.5%), fever 30 (15%), and dry cough 26 (13%). Half of the patients (50%) had no significant complaints, but deterioration occurred later.. These symptoms also were observed in the results of Zhou et al., (4), Shi et al., (5), Han et al., (6), Pan et al., (7), Chung et al., (8), and Li et al., (9).
In the first 48 hours after admission 23.6% of  the cases died, which could be due to advanced disease or late reference because of low knowledge of the novel disease (5, 6).
The majority (98%) of  the cases had involved pulmonary tissue bilaterally, GGO (96%), consolidation (44%), crazy paving (15%), and cardiomegaly (15.5%)  which were our prominent findings. InWei et al., report CT showed rapidly growing ground-glass opacities and progressing peripheral consolidations in both lungs (10).
Fluid leakage to alveoli space leads to non-complete filling of spaces, sparing bronchial tree, seen in X-rays, and CT scan as white areas (GGO). Continuing the process leads to the hardening of alveolar walls and disability in expanding enough, seen as consolidation. Severe changes in pulmonary tissue media by inflammatory cytokines predispose injured tissue to super-imposed infections. In most  reported studies GGO+ consolidation is the best hallmark for treatment initiation and following the progression of medical care (9-11). In other studies, the sensitivity of pulmonary CT scans was evaluated as 97% (12- 14).
Cardiomegaly in  31 (15.5%) and Pericardial effusion in  7 (3.5%) cases were also seen. In this group (cardiomegaly and pericardial) hypertension in 35 (17.5%), heart disease in 31.9%, and DM in 22.9% of the cases were reported as the underlying diseases. Patients with hypertension and heart disease  do not seem to be more prone to show cardiovascular symptoms. There was no significant relevance between these groups and death under 48 hours (11).
There may be earlyonset or nondiagnosed cardiac problems exacerbated by a virus attack. Viremia causes high temperature, cytokine storm, and inflammatory response of the immune system that may impose more pressure on the myocardium. On the other hand, increasing demand for oxygen will not be responded adequately by disturbed alveolar O2 change. Viral myocarditis has been reported with other viruses,  which is also seen in COVID-19 (15).
A comparison between patients with HTN in a highly suggestive group and an indeterminate group showed no significant relation. Diabetes had no significant association.
We had only 7(3.5%) cases with more than 10 mm diameter lymph nodes. When LAP is seen it can be the sign of advanced disease and superimposed bacterial infection. Yet, LAP is rarely seen in most reports.
The tendency of viruses to invade basilar lobes and posterior parts of lungs  was seen in our study, with RLL suffering higher than others (69%) followed by LLL (64%). The right middle lobe has the lowest rate of involvement (28%) in the scores 3and 4. RML was not involved in 13.5%. These findings could be due to the gravity effect, resting position, and anatomical location of bronchi (7, 10, 11).

 

Conclusion

The pulmonary CT scan is a rapid investigation for screening patients with vague symptoms and helps to initiate treatment decisions earlier before deterioration. In the presence of positive signs in a CT scan, a quick reaction to starting treatment occurs. Our findings showed Ground Glass Opacity (GGO) in 192 (96%), consolidation in 88 (44%), crazy paving in 30 (15%), cardiomegaly  in 30 (15%), and pleural effusion  in 53 (26.5%) cases. More public information about symptoms is essential for an ontime visit. The presence of subtle symptoms does not mean mild involvement; a complete medical assessment should be made for older people and people with risk factors. Hypertension as an underlying disease was significantly related to Highly Suggestive CT scans. Also, cardiomegaly in our study could be a warning sign, although no significant relevance between cardiomegaly and death under 48 hours’ post-admission was found. We think more studies are needed to determine the role of cardiomegaly in acute viral respiratory syndrome.

 

Acknowledgements

The authors would like to acknowledge Dr. Alijan Tabarraei, Ph.D., Professor of Medical Virology, and Golestan University of Medical Sciences for their cooperation and giving useful consultations to our team. And also, we thank Mohsen Mansouri, M.Sc., and Mohammad Gholamrezaei, M.Sc., Statistics and Information Technology Management Unit of Golestan University of Medical Sciences, for making PACS system data available for the current study.

 

Ethical considerations 

Ethical issues (Including plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc.) have been completely observed by the authors. This study is derived from a research study (Recording Mortality COVID-19 in Golestan-Iran) approved by the deputy Research of GOUMS and the Medical Ethics Committee (Code: IR.GOUMS.REC.1398.390).

 

Conflicts of Interest

The authors declare no conflict of interest.

 

Type of Study: Original Article | Subject: Clinical medicine
Received: 2021/04/13 | Accepted: 2021/10/25 | Published: 2022/04/1
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