Mediastinal lymphadenopathy in patients with severe COVID-19

Presence of mediastinal lymphadenopathy in hospitalized Covid-19 patients in a tertiary care hospital in Pakistan-A cross-sectional study

BACKGROUND

The aim of this study was to investigate the presence of mediastinal lymphadenopathy in hospitalized Covid-19 patients in a tertiary care hospital in the metropolitan city of Lahore, Pakistan from September 2020 till July 2021.

METHODS

We retrospectively collected data of Covid-19 patients hospitalized from September 2020 till July 2021. Only those patients who tested PCR positive through a nasopharyngeal swab, were enrolled in the study. Patients' whose data were missing were excluded from this study. Our exclusion criteria included patients who tested negative on Covid-19 PCR, patients with comorbidities that may cause enlarged mediastinal lymphadenopathies such as haemophagocytic lymphohistiocytosis, neoplasia, tuberculosis, sarcoidosis or a systemic disease. The extent of lung involvement in Covid-19 patients was quantified by using a 25-point visual quantitative assessment called the Chest Computed Tomography Score. This score was then correlated with the presence of mediastinal lymphadenopathy.

FINDINGS

Of the 210 hospitalized patients included in the study, 131 (62.4%) had mediastinal lymphadenopathy. The mean and median Severity Score of Covid-19 patients with mediastinal lymphadenopathy (mean: 17.1, SD:5.7; median: 17, IQR: 13-23) were higher as compared to those without mediastinal lymphadenopathy (mean: 12.3, SD:5.4; median: 12, IQR:9-16).

INTERPRETATION

Our study documents a high prevalence of mediastinal lymphadenopathy in hospitalized patients with Covid-19 with the severity score being higher in its presence representing a more severe course of disease.

[18F]FDG-PET/CT in mechanically ventilated critically ill patients with COVID-19 ARDS and persistent inflammation

Purpose

We report the findings of four critically ill patients who underwent an [18F]FDG-PET/CT because of persistent inflammation during the late phase of their COVID-19.

Methods

Four mechanically ventilated patients with COVID-19 were retrospectively discussed in a research group to evaluate the added value of [18F]FDG-PET/CT.

Results

Although pulmonary PET/CT findings differed, bilateral lung anomalies could explain the increased CRP and leukocytes in all patients. This underscores the limited ability of the routine laboratory to discriminate inflammation from secondary infections. Based on PET/CT findings, a secondary infection/inflammatory focus was suspected in two patients (pancreatitis and gastritis). Lymphadenopathy was present in patients with a detectable SARS-CoV-2 viral load. Muscle uptake around the hips or shoulders was observed in all patients, possibly due to the process of heterotopic ossification.

Conclusion

This case series illustrates the diagnostic potential of [18F]FDG-PET/CT imaging in critically ill patients with persistent COVID-19 for the identification of other causes of inflammation and demonstrates that this technique can be performed safely in mechanically ventilated critically ill patients.

Two in one: Overlapping CT findings of COVID-19 and underlying lung diseases

Coronavirus disease 2019 (COVID-19) is associated with pneumonia and has various pulmonary manifestations on computed tomography (CT). Although COVID-19 pneumonia is usually seen as bilateral predominantly peripheral ground-glass opacities with or without consolidation, it can present with atypical radiological findings and resemble the imaging findings of other lung diseases. Diagnosis of COVID-19 pneumonia is much more challenging for both clinicians and radiologists in the presence of pre-existing lung disease. The imaging features of COVID-19 and underlying lung disease can overlap and obscure the findings of each other. Knowledge of the radiological findings of both diseases and possible complications, correct diagnosis, and multidisciplinary consensus play key roles in the appropriate management of diseases. In this pictorial review, the chest CT findings are presented of patients with underlying lung diseases and overlapping COVID-19 pneumonia and the various reasons for radiological lung abnormalities in these patients are discussed.

Impact of Mediastinal Lymphadenopathy on the Severity of COVID-19 Pneumonia: A Nationwide Multicenter Cohort Study

BACKGROUND

We analyzed the differences between clinical characteristics and computed tomography (CT) findings in patients with coronavirus disease 2019 (COVID-19) to establish potential relationships with mediastinal lymphadenopathy and clinical outcomes.

METHODS

We compared the clinical characteristics and CT findings of COVID-19 patients from a nationwide multicenter cohort who were grouped based on the presence or absence of mediastinal lymphadenopathy. Differences between clinical characteristics and CT findings in these groups were analyzed. Univariate and multivariate analyses were performed to determine the impact of mediastinal lymphadenopathy on clinical outcomes.

RESULTS

Of the 344 patients included in this study, 53 (15.4%) presented with mediastinal lymphadenopathy. The rate of diffuse alveolar damage pattern pneumonia and the visual CT scores were significantly higher in patients with mediastinal lymphadenopathy than in those without (P < 0.05). A positive correlation between the number of enlarged mediastinal lymph nodes and visual CT scores was noted in patients with mediastinal lymphadenopathy (Spearman's ρ = 0.334, P < 0.001). Multivariate analysis showed that mediastinal lymphadenopathy was independently associated with a higher risk of intensive care unit (ICU) admission (odds ratio, 95% confidence interval; 3.25, 1.06-9.95) but was not significantly associated with an increased risk of in-hospital death in patients with COVID-19.

CONCLUSION

COVID-19 patients with mediastinal lymphadenopathy had a larger extent of pneumonia than those without. Multivariate analysis adjusted for clinical characteristics and CT findings revealed that the presence of mediastinal lymphadenopathy was significantly associated with ICU admission.

Decidual stromal cell therapy for generalized lymphadenopathy as a special clinical manifestation of COVID‐19 infection: A case report

We are going through the greatest global health crisis of the last decades, the coronavirus disease 2019 (COVID‐19) pandemic. It may cause morbidity and mortality in some cases, and there is no therapeutic approach with reproducible and favorable outcomes. As clinical manifestations differ from patient to patient, any report regarding clinical symptoms has been beneficial for early detection and treatment. Due to the immunomodulatory effect of mesenchymal stem cells (MSCs), MSCs‐based therapy has been approved to be one of the therapeutic strategies for COVID‐19 management. For the first time in the literature, we reported generalized lymphadenopathy with fever and no sign of respiratory distress in a 16‐year‐old patient with confirmed COVID‐19 infection as the main clinical signs. We also introduce decidual stromal cells as a potential immunomodulatory treatment for COVID‐19–infected patients.

COVID-19: A systematic review and update on prevention, diagnosis, and treatment

Since the rapid onset of the COVID-19 or SARS-CoV-2 pandemic in the world in 2019, extensive studies have been conducted to unveil the behavior and emission pattern of the virus in order to determine the best ways to diagnosis of virus and thereof formulate effective drugs or vaccines to combat the disease. The emergence of novel diagnostic and therapeutic techniques considering the multiplicity of reports from one side and contradictions in assessments from the other side necessitates instantaneous updates on the progress of clinical investigations. There is also growing public anxiety from time to time mutation of COVID-19, as reflected in considerable mortality and transmission, respectively, from delta and Omicron variants. We comprehensively review and summarize different aspects of prevention, diagnosis, and treatment of COVID-19. First, biological characteristics of COVID-19 were explained from diagnosis standpoint. Thereafter, the preclinical animal models of COVID-19 were discussed to frame the symptoms and clinical effects of COVID-19 from patient to patient with treatment strategies and in-silico/computational biology. Finally, the opportunities and challenges of nanoscience/nanotechnology in identification, diagnosis, and treatment of COVID-19 were discussed. This review covers almost all SARS-CoV-2-related topics extensively to deepen the understanding of the latest achievements (last updated on January 11, 2022).

Potentials of post-mortem CT investigations during SARS-COV-2 pandemic: a narrative review

In December 2019, a new coronavirus, SARS-COV-2, caused a cluster of cases of pneumonia in China, and rapidly spread across the globe. It was declared a pandemic by the World Health Organization on March 11th, 2020. Virtual autopsy by post-mortem CT (PMCT) and its ancillary techniques are currently applied in post-mortem examinations as minimally or non-invasive techniques with promising results. In this narrative review, we speculate on the potentials of PMCT and its ancillary techniques, as a viable investigation technique for analysis of suspected or confirmed SARS-COV-2 deaths. An online literature search was performed by using three prefix search terms (postmortem, post-mortem, post mortem) individually combined with the suffix radiology, imaging, computed tomography, CT and with the search terms ‘SARS-CoV-2’ and ‘COVID-19’ to identify papers about PMCT and its ancillary techniques in SARS-COV-2 positive cadavers. PMCT findings suggestive for pulmonary COVID-19 in deceased positive SARS-COV-2 infection are reported in the literature. PMCT ancillary techniques were never applied in such cases. PMCT imaging of the lungs has been proposed as a pre-autopsy screening method for SARS-COV-2 infection. Further studies are needed to ascertain the value of PMCT in determining COVID-19 as the cause of death without autopsy histopathological confirmation. We advocate the application of PMCT techniques in the study of ascertained or suspected SARS-COV-2 infected deceased individuals as a screening technique and as a method of post-mortem investigation, to augment the numbers of case examined and significantly reducing infection risk for the operators.

Cervical and preauricular lymphadenopathies as atypical manifestations in the setting of COVID-19: a case report

Besides the common symptoms in COVID-19, it has been thought to be a more imperative measure to identify the extraordinary manifestations of the illness, which would be more helpful to improve clinical management. In the current report, a 39-year-old woman and a 44-year-old man showed reactive cervical and preauricular lymphadenopathies, respectively, upon a range of the common symptoms of the disease. Interestingly, none of them showed the symptoms of lower respiratory tract infection as well. Notably, a herpes-like skin lesion was also observed on the right lower eyelid in one of the positive patients.

Para-aortic lymphadenopathy associated with adult COVID-19 multisystem inflammatory syndrome

A 21-year-old woman arrived at the emergency department with dyspnoea, arterial hypotension and abdominal pain after 5 days with a influenza-like syndrome. SARS-CoV-2 was detected by reverse transcription PCR in a nasopharyngeal swab specimen. CT of the chest and abdomen with contrast demonstrated a minimal amount of free intraperitoneal fluid, gallbladder with wall oedema, multiple para-aortic lymph node and interlobular septal thickening with ground glass opacities on the lungs. No pleural effusion or thromboembolism. Early broad-spectrum antibiotics, high-flow nasal cannula and norepinephrine were started. She was successfully treated with intravenous immunoglobulin and pulse corticosteroid therapy with methylprednisolone. The patient was discharged home with complete resolution of her symptoms and returned to her previous health status.

Diffuse Lymphadenopathy Syndrome as a Flare-Up Manifestation in Lupus and Mixed Connective Tissue Disease Following Mild COVID-19

BACKGROUND Manifestations of Coronavirus disease 2019 (COVID-19), caused by the SARS-CoV-2 virus, are highly variable among healthy populations. In connective tissue disease patients, the spectrum of clinical manifestations is even broader. In mild COVID-19 patients, diffuse lymphadenopathy (DL) has not been described as a late manifestation, and only severe COVID-19 has been associated with lupus flare-ups. Herein, we report 3 cases of connective tissue disease patients that presented with DL after diagnosis and complete resolution of mild COVID-19 disease. CASE REPORT Case 1. A 28-year-old man with inactive lupus, mixed connective tissue disease (MCTD), and a history of lung and cutaneous involvement. He presented with fever, polyarthralgia, and multiple lymphadenopathies 3 weeks after COVID-19 disease resolution. After evaluation, immunosuppressive treatment was initiated, with rapid response. Case 2. A 25-year-old woman with inactive lupus with a history of articular, hematologic, and cutaneous involvement. Four weeks after resolution of COVID-19 disease, she presented with malaise and cervical lymphadenopathies. After laboratory testing and imaging, she was treated for lupus flare-up, with rapid response. Case 3. A 68-year-old woman with inactive lupus with a history of articular and cutaneous involvement. Four weeks after COVID-19 resolution, she presented with malaise and cervical and axillary lymphadenopathies. After extensive evaluation, immunosuppressive treatment resulted in a rapid response. CONCLUSIONS After 3 to 4 weeks of mild, outpatient-treated COVID-19 and complete resolution of symptoms, 3 patients with connective tissue disease presented diffuse lymphadenopathy associated with inflammatory and constitutional symptoms. Infectious and neoplastic causes were thoroughly ruled out. All patients responded to reintroduction of or an increase in immunosuppressive therapy. We recommend considering the diffuse lymphadenopathy as a possible post-acute COVID-19 syndrome (PACS) manifestation in these patients, mainly when they are in the inactive phase.

Modeling a deep transfer learning framework for the classification of COVID-19 radiology dataset

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-Coronavirus-2 or SARS-CoV-2), which came into existence in 2019, is a viral pandemic that caused coronavirus disease 2019 (COVID-19) illnesses and death. Research showed that relentless efforts had been made to improve key performance indicators for detection, isolation, and early treatment. This paper used Deep Transfer Learning Model (DTL) for the classification of a real-life COVID-19 dataset of chest X-ray images in both binary (COVID-19 or Normal) and three-class (COVID-19, Viral-Pneumonia or Normal) classification scenarios. Four experiments were performed where fine-tuned VGG-16 and VGG-19 Convolutional Neural Networks (CNNs) with DTL were trained on both binary and three-class datasets that contain X-ray images. The system was trained with an X-ray image dataset for the detection of COVID-19. The fine-tuned VGG-16 and VGG-19 DTL were modelled by employing a batch size of 10 in 40 epochs, Adam optimizer for weight updates, and categorical cross-entropy loss function. The results showed that the fine-tuned VGG-16 and VGG-19 models produced an accuracy of 99.23% and 98.00%, respectively, in the binary task. In contrast, in the multiclass (three-class) task, the fine-tuned VGG-16 and VGG-19 DTL models produced an accuracy of 93.85% and 92.92%, respectively. Moreover, the fine-tuned VGG-16 and VGG-19 models have MCC of 0.98 and 0.96 respectively in the binary classification, and 0.91 and 0.89 for multiclass classification. These results showed strong positive correlations between the models' predictions and the true labels. In the two classification tasks (binary and three-class), it was observed that the fine-tuned VGG-16 DTL model had stronger positive correlations in the MCC metric than the fine-tuned VGG-19 DTL model. The VGG-16 DTL model has a Kappa value of 0.98 as against 0.96 for the VGG-19 DTL model in the binary classification task, while in the three-class classification problem, the VGG-16 DTL model has a Kappa value of 0.91 as against 0.89 for the VGG-19 DTL model. This result is in agreement with the trend observed in the MCC metric. Hence, it was discovered that the VGG-16 based DTL model classified COVID-19 better than the VGG-19 based DTL model. Using the best performing fine-tuned VGG-16 DTL model, tests were carried out on 470 unlabeled image dataset, which was not used in the model training and validation processes. The test accuracy obtained for the model was 98%. The proposed models provided accurate diagnostics for both the binary and multiclass classifications, outperforming other existing models in the literature in terms of accuracy, as shown in this work.

Viral Load and Patterns of SARS-CoV-2 Dissemination to the Lungs, Mediastinal Lymph Nodes, and Spleen of Patients with COVID-19 Associated Lymphopenia

Lymphopenia is a frequent hematological manifestation, associated with a severe course of COVID-19, with an insufficiently understood pathogenesis. We present molecular genetic immunohistochemical, and electron microscopic data on SARS-CoV-2 dissemination and viral load (VL) in lungs, mediastinum lymph nodes, and the spleen of 36 patients who died from COVID-19. Lymphopenia <1 × 109/L was observed in 23 of 36 (63.8%) patients. In 12 of 36 cases (33%) SARS-CoV-2 was found in lung tissues only with a median VL of 239 copies (range 18-1952) SARS-CoV-2 cDNA per 100 copies of ABL1. Histomorphological changes corresponding to bronchopneumonia and the proliferative phase of DAD were observed in these cases. SARS-CoV-2 dissemination into the lungs, lymph nodes, and spleen was detected in 23 of 36 patients (58.4%) and was associated with the exudative phase of DAD in most of these cases. The median VL in the lungs was 12,116 copies (range 810-250281), lymph nodes-832 copies (range 96-11586), and spleen-71.5 copies (range 0-2899). SARS-CoV-2 in all cases belonged to the 19A strain. A immunohistochemical study revealed SARS-CoV-2 proteins in pneumocytes, alveolar macrophages, and bronchiolar epithelial cells in lung tissue, sinus histiocytes of lymph nodes, as well as cells of the Billroth pulp cords and spleen capsule. SARS-CoV-2 particles were detected by transmission electron microscopy in the cytoplasm of the endothelial cell, macrophages, and lymphocytes. The infection of lymphocytes with SARS-CoV-2 that we discovered for the first time may indicate a possible link between lymphopenia and SARS-CoV-2-mediated cytotoxic effect.

Positron emission tomography in the COVID-19 pandemic era

Coronavirus disease 2019 (COVID-19) has become a major public health problem worldwide since its outbreak in 2019. Currently, the spread of COVID-19 is far from over, and various complications have roused increasing awareness of the public, calling for novel techniques to aid at diagnosis and treatment. Based on the principle of molecular imaging, positron emission tomography (PET) is expected to offer pathophysiological alternations of COVID-19 in the molecular/cellular perspectives and facilitate the clinical management of patients. A number of PET-related cases and research have been reported on COVID-19 over the past one year. This article reviews the current studies of PET in the diagnosis and treatment of COVID-19, and discusses potential applications of PET in the development of management strategy for COVID-19 patients in the pandemic era.

COVID-19 pneumonia: current evidence of chest imaging features, evolution and prognosis

COVID-19 pneumonia represents a global threatening disease, especially in severe cases. Chest imaging, with X-ray and high-resolution computed tomography (HRCT), plays an important role in the initial evaluation and follow-up of patients with COVID-19 pneumonia. Chest imaging can also help in assessing disease severity and in predicting patient’s outcome, either as an independent factor or in combination with clinical and laboratory features. This review highlights the current knowledge of imaging features of COVID-19 pneumonia and their temporal evolution over time, and provides recent evidences on the role of chest imaging in the prognostic assessment of the disease.

Mediastinal lymphadenopathy in COVID-19: A review of literature

A novel coronavirus disease 2019 (COVID-19) is a progressive viral disease that affected people around the world with widespread morbidity and mortality. Patients with COVID-19 infection typically had pulmonary manifestation but can also present with gastrointestinal, cardiac, or neurological system dysfunction. Chest imaging in patients with COVID-19 commonly show bilateral lung involvement with bilateral ground-glass opacity and consolidation. Mediastinal lymphadenopathy can be found due to infectious or non-infectious etiologies. It is commonly found to be associated with malignant diseases, sarcoidosis, and heart failure. Mediastinal lymph node enlargement is not a typical computer tomography of the chest finding of patients with COVID-19 infection. We summarized the literature which suggested or investigated the mediastinal lymph node enlargement in patients with COVID-19 infection. Further studies are needed to better characterize the importance of mediastinal lymphadenopathy in patients with COVID-19 infection.

Clinical Application of Chest Computed Tomography (CT) in Detection and Characterization of Coronavirus (Covid-19) Pneumonia in Adults

To analyze diagnostic accuracy of chest computed tomography (CT) and RT-PCR (real-time polymerase chain reaction) for COVID-19 (coronavirus disease 19) pneumonia in early and progressive stages. To evaluate if combination of chest CT with RT-PCR can supplement the shortage of RT-PCR in diagnosis of COVID-19 pneumonia. We conducted a prospective study on 103 male patients. The study population were divided into two groups; early COVID-19 stage (number = 50 patients, with positive RT-PCR but mild symptoms) and progressive COVID-19 stage (number = 53, positive RT-PCR and sever symptoms including fever > 37.5 °C, cough, and shortness of breath). All patients underwent CT imaging. The early stage included typical category; 34% (17 out of 50 cases), 6% indeterminate category (3 cases), 10% atypical category (5 cases) and 50% (25 cases) were normal CT imaging. The progressive stage included typical category that was further divided to five subgroups; (i) peripheral bilateral lower lobe ground-glass opacity (GGO) in (37.7%), (ii) peripheral bilateral lower lobes GGO with peribronchovascular consolidation and bronchiolar dilatation in (18.8%), (iii) peripheral bilateral lower lobes GGO with crazy paving appearance in (15%), (iv) bilateral diffuse GGO in (18.8%), and (v) peripheral bilateral GGO with mediastinal lymph node enlargement (9.4%). Chest CT imaging could aid to supplement the shortages of PCR for clinically suspected patients of COVID-19 in the epidemic area as CT was positive in 50% of patients. Chest CT is very effective in detecting pulmonary parenchymal abnormalities in the progressive stage of COVID-19 patients in 100%.

From Neck Pain to Sarcoidosis: The Interesting Association

We report the case of a 31-year-old male patient, presenting to the emergency department (ED) with a 6-week history of left-sided lateral neck pain, along with a minor localized swelling. A few weeks after the beginning of his complaints, he contracted a mild coronavirus disease 2019 (COVID-19). Upon examination, his aches were defined as carotidynia; thus, proper radiologic evaluation was carried out. While ultrasound (US) and magnetic resonance imaging (MRI) scans showed evident signs of left common carotid (LCC) vasculitis, computed tomography angiography (CTA) and positron emission tomography-CT (PET-CT) scans revealed no vascular findings. Unexpected hypermetabolic hilar and mediastinal lymphadenopathy was found on PET-CT, necessitating lymph node biopsy. Pathology results displayed noncaseating granulomas. Besides, angiotensin-converting enzyme (ACE) levels in blood were high. Sarcoidosis, with concurrent LCC vasculitis, was diagnosed, and corticosteroid therapy was started. Shortly thereafter, remarkable recovery ensued.

Spectrum of atypical pulmonary manifestations of COVID-19 on computed tomography

Background

The typical CT manifestations of COVID-19 pneumonia include ground-glass opacity (GGO) with or without consolidation and superimposed interlobular septal thickening. These are often rounded in morphology and frequently bilateral, multilobar, posterior, peripheral, and basilar in distribution. The various atypical CT features of COVID-19 are seldom described in the literature. The study aims to enumerate the atypical pulmonary CT features in patients with COVID-19 pneumonia in correlation with the disease severity.

Results

A total of 298 confirmed cases of COVID-19 pneumonia with positive reverse transcription polymerase chain reaction (RT-PCR) who underwent chest CT scans were retrospectively evaluated. The cohort included 234 (78.5%) men and 64 (21.5%) women and the mean age was 53.48 ± 15.74 years. The most common presenting symptoms were fever [n = 197 (66.1%)] and cough [n = 139 (46.6%)]. Out of 298 cases of COVID-19 pneumonia, 218 cases (73.1%) showed typical CT features while 63 cases (21.1%) showed atypical CT features with concurrent classical findings and the remaining 17 cases (5.8%) were normal. Among the atypical CT features, the most common was pulmonary cysts [n = 27 (9%)]. The other features in the order of frequency included pleural effusion [n = 17 (5.7%)], nodules [n = 13 (4.3%)], bull’s eye/target sign[n = 4 (1.3%)], cavitation [n = 3 (1.0%)], spontaneous pneumothorax [n = 2 (0.6%)], hilar lymphadenopathy [n = 2 (0.6%)], spontaneous pneumo-mediastinum with subcutaneous emphysema [n = 1 (0.3%)], Halo sign [n = 1 (0.3%)], empyema [n = 1 (0.3%)] and necrotizing pneumonia with abscess [n = 1 (0.3%)].

Conclusion

CT imaging features of COVID-19 pneumonia while in a vast majority of cases is classical, atypical diverse patterns are also encountered. A comprehensive knowledge of various atypical presentations on imaging plays an important role in the early diagnosis and management of COVID-19.

Case Report: Mediastinal Mass in SARS-COV-2 Pandemic: A Word of Caution

Background: SARS-CoV-2 is a new disease with some manifestations not yet well-known. Sharing experiences in this topic is crucial for the optimal management of the patients.

Case Presentation: Left upper extremity deep vein thrombosis (UEDVT) due to a mediastinal mass strongly suspected of lymphoproliferative disease in a patient affected by SARS-CoV-2, disappearing at the resolution of the viral infection.

Conclusion: Before proceeding to surgical biopsy, mediastinal mass in SARS-CoV-2 patients must be revaluated after the resolution of the infection.

Mediastinal lymphadenopathy may predict 30-day mortality in patients with COVID-19

PURPOSE

There is scarce data on the impact of the presence of mediastinal lymphadenopathy on the prognosis of coronavirus-disease 2019 (COVID-19). We aimed to investigate whether its presence is associated with increased risk for 30-day mortality in a large group of patients with COVID-19.

METHOD

In this retrospective cross-sectional study, 650 adult laboratory-confirmed hospitalized COVID-19 patients were included. Patients with comorbidities that may cause enlarged mediastinal lymphadenopathy were excluded. Demographics, clinical characteristics, vital and laboratory findings, and outcome were obtained from electronic medical records. Computed tomography scans were evaluated by two blinded radiologists. Univariate and multivariate logistic regression analyses were performed to determine independent predictive factors of 30-day mortality.

RESULTS

Patients with enlarged mediastinal lymphadenopathy (n = 60, 9.2%) were older and more likely to have at least one comorbidity than patients without enlarged mediastinal lymphadenopathy (p = 0.03, p = 0.003). There were more deaths in patients with enlarged mediastinal lymphadenopathy than in those without (11/60 vs 45/590, p = 0.01). Older age (OR:3.74, 95% CI: 2.06-6.79; p < 0.001), presence of consolidation pattern (OR:1.93, 95% CI: 1.09-3.40; p = 0.02) and enlarged mediastinal lymphadenopathy (OR:2.38, 95% CI:1.13-4.98; p = 0.02) were independently associated with 30-day mortality.

CONCLUSION

In this large group of hospitalized patients with COVID-19, we found that in addition to older age and consolidation pattern on CT scan, enlarged mediastinal lymphadenopathy were independently associated with increased mortality. Mediastinal evaluation should be performed in all patients with COVID-19.

Peritonsillar Phlegmon: An Addition to the Spectrum of COVID-19

The coronavirus disease 2019 (COVID-19) epidemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first reported in December 2019 in Wuhan, China, then declared to be a pandemic associated with substantial morbidity and mortality. It has shown to exhibit a vast array of symptoms, among which fever, shortness of breath, and cough are the most commonly reported. Lymphadenopathy and tonsillar enlargement is a less common finding reported with this infection. This case describes a patient with tonsillar inflammation which was complicated by peritonsillar phlegmon, with negative throat culture and positive COVID-19 test, suggesting a COVID-19-related etiology of the disease. After the literature search, to the best of our knowledge, this is the first reported case of COVID-related peritonsillar inflammation and phlegmon formation. 

COVID-19 or non-COVID viral pneumonia: How to differentiate based on the radiologic findings?

Influenza viruses were responsible for most adult viral pneumonia. Presently, coronavirus disease 2019 (COVID-19) has evolved into serious global pandemic. COVID-19 outbreak is expected to persist in months to come that will be synchronous with the influenza season. The management, prognosis, and protection for these two viral pneumonias differ considerably and differentiating between them has a high impact on the patient outcome. Reverse transcriptase polymerase chain reaction is highly specific but has suboptimal sensitivity. Chest computed tomography (CT) has a high sensitivity for detection of pulmonary disease manifestations and can play a key-role in diagnosing COVID-19. We reviewed 47 studies and delineated CT findings of COVID-19 and influenza pneumonia. The differences observed in the chest CT scan can be helpful in differentiation. For instance, ground glass opacities (GGOs), as the most frequent imaging finding in both diseases, can differ in the pattern of distribution. Peripheral and posterior distribution, multilobular distribution, pure or clear margin GGOs were more commonly reported in COVID-19, whereas central or peri-bronchovascular GGOs and pure consolidations were more seen in influenza A (H1N1). In review of other imaging findings, further differences were noticed. Subpleural curvilinear lines, sugar melted sign, intra-lesional vascular enlargement, reverse halo sign, and fibrotic bands were more reported in COVID-19 than H1N1, while air space nodule, tree-in-bud, bronchiectasia, pleural effusion, and cavitation were more seen in H1N1. This delineation, when combined with clinical manifestations and laboratory results may help to differentiate these two viral infections.

CT chest findings in patients infected with COVID-19: review of literature

Background

Coronavirus disease 2019 (COVID-19) is a highly infectious disease causing severe respiratory distress syndrome that was first discovered by the end of 2019 in Wuhan, China.

Main text

A wide variety of CT findings in COVID-19 have been reported in different studies, and the CT findings differ according to the stage of the disease and disease severity and associated co-morbidities. We will discuss each sign separately and its importance in diagnosis and prognosis.

Conclusion

CT plays a pivotal role in the diagnosis and management of COVID-19 pneumonia. The typical appearance of COVID-19 pneumonia is bilateral patchy areas of ground glass infiltration, more in the lower lobes. The appearance of other signs like consolidation, air bronchogram, crazy pavement appearance, and air bubble signs appear during the course of the disease. In the context of pandemic, the CT chest can be used as a screening tool in symptomatic patients as it is cheaper, available, and time saving.

Transient 18FDG-avid hilar lymph node on PET/CT imaging in asymptomatic COVID-19

The most common features of coronavirus disease-2019 (COVID-19) pneumonia on chest computed tomography imaging are ground glass opacity and consolidation. Mediastinal and hilar lymph node enlargement are less frequently observed. Herein, we present an unexpected finding of fluorodeoxyglucose (FDG)-avid hilar lymph node in an asymptomatic patient with COVID-19, and show that this is a transient phenomenon, subsiding on a follow-up FDG-PET/CT within 10 days.

Clinical Characteristics and Multisystem Imaging Findings of COVID-19: An Overview for Orthopedic Surgeons

The COVID-19 pandemic holds widespread implications for global public health, economies, societies, and the practice of orthopedic surgery. As our knowledge of the transmissibility of SARS-CoV-2 and the symptomatology and management of COVID-19 expands, orthopedic surgeons must remain up to date on the latest medical evidence and surgical perspectives. While COVID-19 primarily manifests with pulmonary symptoms, cardiovascular, neurologic, and other major organ systems may also be affected and present with hallmark imaging findings. This article reviews initial and emerging literature on clinical characteristics and imaging findings of COVID-19.

Extrapulmonary manifestations of COVID-19: Radiologic and clinical overview

COVID-19 is principally a respiratory illness and pulmonary manifestations constitute main presentations of the disease. According to the reported studies, SARS-CoV-2 infection is not limited to the respiratory system and other organs can be also affected. Renal dysfunction, gastrointestinal complications, liver dysfunction, cardiac manifestations, mediastinal findings, neurological abnormalities, and hematological manifestations are among the reported extrapulmonary features. Considering the broad spectrum of clinical manifestations and the increasing worldwide burden of the disease, there is an urgent need to rapidly scale up the diagnostic capacity to detect COVID-19 and its complications. This paper focuses on the most common extrapulmonary manifestations in patients with COVID-19 pneumonia. Further studies are needed to elaborate and confirm the causative relationship between SARS-CoV-2 and the reported extrapulmonary manifestations of COVID-19.

Extent of pulmonary thromboembolic disease in patients with COVID-19 on CT: relationship with pulmonary parenchymal disease

AIM

To report the severity and extent of pulmonary thromboembolic disease (PTD) in COVID-19 patients undergoing computed tomography pulmonary angiography (CTPA) in a tertiary centre.

MATERIALS AND METHODS

This is a retrospective analysis of COVID-19 patients undergoing CTPA over a period of 27 days. The presence, extent, and severity of PTD were documented. Two observers scored the pattern and extent of lung parenchymal disease including potential fibrotic features, as well as lymph node enlargement and pleural effusions. Consensus was achieved via a third observer. Interobserver agreement was assessed using kappa statistics. Student's t-test, chi-squared, and Mann-Whitney U-tests were used to compare imaging features between PTD and non-PTD sub-groups.

RESULTS

During the study period, 100 patients with confirmed COVID-19 underwent CTPA imaging. Ninety-three studies were analysed, excluding indeterminate CTPA examinations. Overall incidence of PTD was 41/93 (44%) with 28/93 patients showing small vessel PTD (30%). D-dimer was elevated in 90/93 (96.8%) cases. A high Wells' score did not differentiate between PTD and non-PTD groups (p=0.801). The interobserver agreement was fair (kappa=0.659) for parenchymal patterns and excellent (kappa=0.816) for severity. Thirty-four of the 93 cases (36.6%) had lymph node enlargement; 29/34 (85.3%) showed no additional source of infection. Sixteen of the 93 (17.2%) cases had potential fibrotic features.

CONCLUSION

There is a high incidence of PTD in COVID-19 patients undergoing CTPA and lack of a risk stratification tool. The present data indicates a higher suspicion of PTD is needed in severe COVID-19 patients. The concomitant presence of possible fibrotic features on CT indicates the need for follow-up.

Positive Chest CT Features in Patients With COVID-19 Pneumonia and Negative Real-Time Polymerase Chain Reaction Test

Objectives Clinically suspicious novel coronavirus (COVID-19) lung pneumonia can be observed typically on computed tomography (CT) chest scans even in patients with a negative real-time polymerase chain reaction (RT-PCR) test. The purpose of the study was to describe the CT imaging findings of five patients with negative RT-PCR results on initial and repeated testing but a high radiological suspicion of COVID-19 pneumonia. Methods Out of 19 clinically and/or radiologically diagnosed COVID-19 patients from our institution, five patients were selected for our study who had typical findings of COVID-19 on CT scan despite two negative RT-PCR results. Two district general hospital radiologists reviewed the chest CT images without prior knowledge of the RT-PCR test results. Scans were analyzed for the density of opacification and the distribution of disease. Results Out of 19 patients, five (26%) had initial negative RT-PCR test findings but positive CT chest features consistent with COVID-19. All patients had typical CT imaging findings of COVID-19. These included one patient with purely ground-glass opacities (GGO) and four patients with mixed GGO and consolidation. The typical distribution of parenchymal involvement was bilateral, posterior, and peripheral. Of the five patients with negative RT-PCR and positive CT findings, the range of CT severity score was 5 to 14. The median score, seen in three patients, was a score of 5, which corresponded to mild disease. One patient had a score of 8, corresponding to moderate disease, and one patient had severe disease with a score of 14. Conclusion Lung parenchymal changes related to COVID-19 can be seen on chest CT clearly despite repeated RT-PCR negative results.

A twisted tale-radiological imaging features of COVID-19 on 18F-FDG PET/CT

The COVID-19 pandemic has had a major impact on health care systems across the globe in a short period of time. There is a growing body of evidence surrounding the findings on hybrid imaging with FDG-PET/CT, and this case highlights the importance of molecular imaging in better understanding of the biomarkers of the disease which ultimately determine the success in building a model to predict the disease severity and monitoring the response to treatment.

Computed tomography findings in a Brazilian cohort of 48 patients with pneumonia due to coronavirus disease

INTRODUCTION

This study was conducted to retrospectively review chest computed tomography (CT) findings in a Brazilian cohort of patients with pneumonia caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

METHODS

Chest CT scans of 78 patients with confirmed coronavirus disease (COVID-19), obtained in March and April 2020, were reviewed. Of 78 cases, the CT scans of 48 (61.5%) showed lung opacities. CT opacity features, their distribution, and the extent of infiltration were evaluated.

RESULTS

The most common CT findings were ground-glass opacities (97.9%), crazy-paving pattern (58.3%), and mixed pattern (18.8%). Rounded lung opacities were observed most frequently (70.8%). Other findings were cystic airspace changes (37.5%), vascular dilatation (35.4%), and the organizing pneumonia pattern (14.6%). The findings were frequently bilateral (87.5%), symmetrical (68.9%), and peripheral (60.2%).

CONCLUSIONS

The most common CT findings were ground-glass opacities and the crazy-paving pattern. Involvement was mostly bilateral, symmetrical, and peripheral. Round opacity morphology was frequently observed and might have some degree of specificity to viral COVID-19 pneumonia.

Current Concepts Imaging in COVID-19 and the Challenges for Low and Middle Income Countries

With nearly 3,800,000 cases and 270,000 deaths reported worldwide, COVID-19 is a global pandemic unlike any we have seen in our lifetimes (1). As early as 1995, the WHO was warning of a global infectious disease crisis, citing 30 new infectious diseases emerging in the past 20 years, loss of antibiotic effectiveness, low rates of immunization, poverty, and inadequate investment in public health contributing to the more than 17 million people dying each year from infectious diseases, principally in Low and Middle Income countries (LMIC) (2). Unlike previous infectious diseases, at the time of this writing over 63% of the total reported cases of COVID-19 are in 6 High Income Countries (HIC): USA, Italy, Spain, France, Germany and the UK. Information concerning the imaging findings in COVID-19 has been rapidly disseminated from the centers first affected by the pandemic. This article attempts to summarize the current state of knowledge regarding the imaging findings in COVID-19, focusing on pulmonary findings, and offer recommendation for the use of imaging for diagnosis and surveillance of COVID-19, particularly in LMIC.