Crazy Paving Research Articles

CT Features of COVID-19 Pneumonia Differ Depending on the Severity and Duration of Disease.

CT is important in the care of patients with COVID-19 pneumonia. However, CT morphology can change significantly over the course of the disease. To evaluate the CT morphology of RT-PCR-proven COVID-19 pneumonia in a German cohort with special emphasis on identification of potential differences of CT features depending on duration and severity of disease. All patients with RT-PCR-proven COVID-19 pneumonia and chest CT performed between March 1 and April 15, 2020 were retrospectively identified. The CT scans were evaluated regarding the presence of different CT features (e. g. ground glass opacity, consolidation, crazy paving, vessel enlargement, shape, and margin of opacifications), distribution of lesions in the lung and extent of parenchymal involvement. For subgroup analyses the patients were divided according to the percentage of parenchymal opacification (0-33 %, 34-66 %, 67-100 %) and according to time interval between symptom onset and CT date (0-5 d, 6-10 d, 11-15 d, > 15 d). Differences in CT features and distribution between subgroups were tested using the Mantel-Haenszel Chi Squared for trend. The frequency of CT features (ground glass opacity, consolidation, crazy paving, bronchial dilatation, vessel enlargement, lymphadenopathy, pleural effusion) as well as pattern of parenchymal involvement differed significantly depending on the duration of disease and extent of parenchymal involvement. The early phase of disease was characterized by GGO and to a lesser extent consolidation. The opacifications tended to be round and to some extent with sharp margins and a geographic configuration. The vessels within/around the opacifications were frequently dilated. Later on, the frequency of consolidation and especially crazy paving increased, and the round/geographic shape faded. After day 15, bronchial dilatation occurred, and lymphadenopathy and pleural effusion were seen more frequently than before. The prevalence of CT features varied considerably during the course of disease and depending on the severity of parenchymal involvement. Radiologists should take into account the time interval between symptom onset and date of CT and the severity of disease when discussing the likelihood of COVID-19 pneumonia based on CT morphology. · The frequency of CT features and pattern of parenchymal involvement vary depending on the duration and extent of COVID-19 pneumonia.. · The early phase is characterized by GGO and consolidation which demonstrate a round shape and at least to some extent have sharp margins and a geographic configuration.. · The frequency of consolidation and especially crazy paving increases during the course of disease.. · Beyond day 15 after symptom onset, bronchial dilatation occurs.. · Radiologists should take into account the duration and severity of disease when considering COVID-19 pneumonia.. · Schaible J, Meiler S, Poschenrieder F et al. CT Features of COVID-19 Pneumonia Differ Depending on the Severity and Duration of Disease. Fortschr Röntgenstr 2021; 193: 672 - 682.

“The Mirror with a Memory”: The Great War through the Lens of Percy Brown, British Correspondent and Photojournalist (1914-1920)

ABSTRACT This article examines the “path of crazy paving” of Percy A. Brown, a British working-class carpenter, figure skater, photo correspondent, and magazine journalist, who covered the twentieth century’s first mass media war. Brown—who is not yet a household name in terms of British war correspondents—would go on to become an international reporter, successful author, and Fleet Street personality. His personal history and biography exemplify at once the demands of war correspondents and photographers, and the professional and personal challenges that mediated these experiences. Brown’s story shows how the First World War (1914–1918) affected people’s lives, not just on the battlefields and trenches, but also those covering the conflict. By backtracking this journalist’s nontraditional career, this article focuses on Brown’s coverage of the Western Front, his time in the Ruhleben prison camp, and his work at the Paris Peace Conference. The historical analysis rests on primary sources and Percy Brown’s collection of pictures, news clippings, correspondence, and notes located at the Hoover Institution and Archives at Stanford University. Brown’s journalism and his personal writings all communicate the immediacy with which he wrote, reported, and lived.

COVID-19 Chest Computed Tomography to Stratify Severity and Disease Extension by Artificial Neural Network Computer-Aided Diagnosis.

Purpose: This work aims to develop a computer-aided diagnosis (CAD) to quantify the extent of pulmonary involvement (PI) in COVID-19 as well as the radiological patterns referred to as lung opacities in chest computer tomography (CT).Methods: One hundred thirty subjects with COVID-19 pneumonia who underwent chest CT at hospital admission were retrospectively studied (141 sets of CT scan images). Eighty-eight healthy individuals without radiological evidence of acute lung disease served as controls. Two radiologists selected up to four regions of interest (ROI) per patient (totaling 1,475 ROIs) visually regarded as well-aerated regions (472), ground-glass opacity (GGO, 413), crazy paving and linear opacities (CP/LO, 340), and consolidation (250). After balancing with 250 ROIs for each class, the density quantiles (2.5, 25, 50, 75, and 97.5%) of 1,000 ROIs were used to train (700), validate (150), and test (150 ROIs) an artificial neural network (ANN) classifier (60 neurons in a single-hidden-layer architecture). Pulmonary involvement was defined as the sum of GGO, CP/LO, and consolidation volumes divided by total lung volume (TLV), and the cutoff of normality between controls and COVID-19 patients was determined with a receiver operator characteristic (ROC) curve. The severity of pulmonary involvement in COVID-19 patients was also assessed by calculating Z scores relative to the average volume of parenchymal opacities in controls. Thus, COVID-19 cases were classified as mild (<cutoff of normality), moderate (cutoff of normality ≤ pulmonary involvement < Z score 3), and severe pulmonary involvement (Z score ≥3).Results: Cohen's kappa agreement between CAD and radiologist classification was 81% (79–84%, 95% CI). The ROC curve of PI by the ANN presented a threshold of 21.5%, sensitivity of 0.80, specificity of 0.86, AUC of 0.90, accuracy of 0.82, F score of 0.85, and 0.65 Matthews' correlation coefficient. Accordingly, 77 patients were classified as having severe pulmonary involvement reaching 55 ± 13% of the TLV (Z score related to controls ≥3) and presented significantly higher lung weight, serum C-reactive protein concentration, proportion of hospitalization in intensive care units, instances of mechanical ventilation, and case fatality.Conclusion: The proposed CAD aided in detecting and quantifying the extent of pulmonary involvement, helping to phenotype patients with COVID-19 pneumonia.

Differential Diagnosis of Lungs Lesions in a New Coronavirus Infection COVID-19 and Diseases of Non-Viral Etiology on the Clinical Cases by Computed Tomography Scans in Outpatient CT Centers

New coronavirus infection (COVID-19) viral pneumonia diagnosed by a complex assessment of the epidemiological history, clinical symptoms, radiological and laboratory tests. Radiologists often play a leading role in diagnosis of viral pneumonia, since they may encounter suspicious changes according to radiological studies before clinicians. However, in a number of diseases, including diseases of non-infectious non-viral etiology with a corresponding similar clinical symptoms, it may be difficult to correctly assess the changes detected by computed tomography. This study uses clinical cases to show the main differential diagnostic criteria for COVID-19 viral pneumonia and non-infectious lesions such as pulmonary edema, pulmonary embolism, acute hypersensitive pneumonitis, drug-induced pneumonitis, non-specific interstitial pneumonia, and adenocarcinoma. All patients were hospitalized based on the results of computed tomography, where a diagnosis of non-infectious non-viral lung injuries was established based on morphological and/or typical clinical symptoms, laboratory or radiological data. We examined clinical cases with radiological signs similar to viral pneumonia, such as areas of ground glass opacities with the presence or absence of areas of consolidation, as well as thickening of the lung interstitium with decreased lung attenuation (crazy paving symptom). In a difficult epidemiological situation, it is important for a radiologist to suspect the above-mentioned pathological conditions in patients who are urgently admitted to outpatient CT centers.

Longitudinal assessment of chest computerized tomography and oxygen saturation for patients with COVID-19

BackgroundCOVID-19 is a pandemic disease and is important to know the nature of the disease during follow-up. We aimed to study different imaging signs and changes that occurred during the initial scan, follow-up, and complications. Moreover, to study the CT severity score and its relation to the patients’ clinical condition using oxygen saturation as a parameter. This was a retrospective study conducted on 125 patients, including 293 CT studies, from March till the end of August 2020. The mean age was 47.4 ± 15.7 years and 64.8% of the patients were males. All patients proved to have COVID-19 by the RT-PCR test. The CT studies of the patients were divided into four stages according to the timing after the onset of symptoms. The incidence of different CT features, patterns, complications, CT severity score, and oxygen saturation were recorded in different stages.ResultsDuring follow-up studies, GGOs were the most constant and common CT features. Consolidation and crazy paving showed gradual progression to reach the peak at the 3rd stage. Mixed attenuation pattern was the commonest pattern at the 3rd stage while a pure GGO pattern was the commonest feature in other stages. The complications occurred mostly in the 3rd stage. Nevertheless, the CT severity score showed an inverse relation with oxygen saturation.ConclusionRadiological evaluation of COVID-19 pneumonia showed gradual progression till the peak critical stage at 8-14 days from the onset of symptoms. Consolidation and mixed attenuation pattern can be considered as CT signs of disease severity.

Chest CT imaging features of COVID-19 and its correlation with the PaO2/FiO2 ratio: a multicenter study in Upper Egypt

BackgroundThe main challenge in managing COVID-19 pandemic is containment of the infection by early detection of the disease and wide dissemination of diagnostic tests with high sensitivity and specificity. Various imaging features were identified by chest CT with different patterns from early disease to diffuse disease with complications. However, CT cannot be performed for all patients. The arterial oxygen partial pressure/fraction of inspired oxygen (PaO2/FiO2) ratio is evaluated as a rapid and widely available test for the preliminary assessment of disease severity. This study aimed to evaluate the clinical and chest CT imaging features of COVID-19 in Egyptian patients as well as assess the correlation between the chest CT total severity score and the PaO2/FiO2 ratio to determine its value for preliminary assessment of disease severity.ResultsThe most common symptoms were fever (83.2%), dry cough (77%), malaise (68.8%), prolonged headaches (48.5%), and dyspnea (37.6%). CT was positive in 79.2% of the patients. The CT features at presentation were ground-glass opacities only (40%), ground-glass opacities with consolidation (34.4%), and consolidation only (25.6%). Associated findings included crazy paving (17.5%), interlobular septal thickening (47.5%), air bronchogram (15%), bronchiectasis (12.8%), fibrous bands (8.1%), vascular enlargement within the lesion (45.6%), nodules (6.8%), pericardial thickening (5%), and pleural thickening (24.7%). The lesions were typically multilobar (50.5%), posterior (58.1%) with peripheral and central distribution (41.9%). Moderate negative correlation was observed between the CT total lung severity score and PaO2/FiO2 ratio with r = − 0.42 and P < 0.001.ConclusionThe most common pattern of COVID-19 pneumonia in multiple quarantine hospitals was peripheral and central ground-glass opacities with bilateral multilobe posterior involvement and fever was the most common symptom. PaO2/FiO2 ratio has a moderate negative correlation with the CT total severity score and thus can be used in the preliminary assessment of disease severity.

Structured reporting of chest CT provides high sensitivity and specificity for early diagnosis of COVID-19 in a clinical routine setting.

Objectives:Although chest CT has been widely used in patients with COVID-19, its role for early diagnosis of COVID-19 is unclear. We report the diagnostic performance of chest CT using structured reporting in a routine clinical setting during the early phase of the epidemic in Germany.Methods:Patients with clinical suspicion of COVID-19 and moderate-to-severe symptoms were included in this retrospective study. CTs were performed and reported before RT-PCR results (reference standard) became available. A structured reporting system was used that concluded in a recently described five-grade score (“CO-RADS”), indicating the level of suspicion for pulmonary involvement of COVID-19 from 1 = very low to 5 = very high. Structured reporting was performed by three Radiologists in consensus.Results:In 96 consecutive patients (50 male, mean age 64), RT-PCR was positive in 20 (21%) cases. CT features significantly more common in RT-PCR-positive patients were ground-glass opacities as dominant feature, crazy paving, hazy margins of opacities, and multifocal bilateral distribution (p < 0.05). Using a cut-off point between CO-RADS 3 and 4, sensitivity was 90%, specificity 91%, positive predictive value 72%, negative predictive value 97%, and accuracy 91%. ROC analysis showed an AUC of 0.938.Conclusions:Structured reporting of chest CT with a five-grade scale provided accurate diagnosis of COVID-19. Its use was feasible and helpful in clinical routine.Advances in knowledge:Chest CT with structured reporting may be a provisional diagnostic alternative to RT-PCR testing for early diagnosis of COVID-19, especially when RT-PCR results are delayed or test capacities are limited.

CT findings of 795 COVID-19 positive cases: a multicenter study in Egypt

BackgroundCorona Virus Disease 2019 (COVID-19) outbreak was officially announced as a global pandemic by the WHO on March 11th 2020. Thorough understanding of CT imaging features of COVID-19 is essential for effective patient management; rationalizing the need for relevant research. The aim of this study was to analyze the chest CT findings of patients with real-time polymerase chain reaction (RT-PCR) proved COVID-19 admitted to four Egyptian hospitals. The recently published RSNA expert consensus statement on reporting COVID-19 chest CT findings was taken into consideration.ResultsNormal CT “negative for COVID-19” was reported in 26.1% of our RT-PCR proved COVID-19 cases. In descending order of prevalence, imaging findings of the positive CT studies (73.9%) included GGO (69%), consolidation (49.7%), crazy paving (15.4%), and peri-lobular fibrosis (40.6%). These showed a dominantly bilateral (68.2%), peripheral (72.4%), and patchy (64.7%) distribution. Remarkably, thymic hyperplasia was identified in 14.3% of studies. According to the RSNA consensus, CT findings were classified as typical in 68.9%, indeterminate in 3.6%, and atypical in 1.4% of the evaluated CT studies.ConclusionAlthough COVID-19 cannot be entirely excluded by chest CT, it can be distinguished in more than two-thirds of cases; making CT a widely available, non-invasive, and rapid diagnostic tool.

Dandelion and focal crazy paving signs: the lung CT based predictors for evaluation of the severity of coronavirus disease

Purpose To describe the radiological features of coronavirus disease 19 (COVID-19) and to explore the significant signs that indicate severity of disease. Materials and methods We collected data retrospectively of 180 cases of COVID-19, from 15 January 2020 to 31 March 2020, from both the Wuhan Zhongnan and Beijing Ditan Hospitals, including 103 cases of mild and 77 cases of severe pneumonia. All patients had their first chest computed tomography scan within five days of symptom onset. The dandelion sign was defined by a focal ground glass opacity (GGO) with a central thickening of the airway wall, and the focal crazy paving sign was defined by a focal GGO with thickening of the interlobular septa. Results Consolidation presented in only 4.9% (5/103) of the mild pneumonia cases, which was significantly lower than that in severe pneumonia cases (70.1% 54/77), p < .001). Multifocal distribution and pure GGOs were observed more frequently in severe cases of pneumonia (p < .05). The dandelion sign was present in 86.4% (89/103) of the mild pneumonia cases, significantly more frequent than those with severe pneumonia (13.0% [10/77], p < .001). The focal crazy paving sign presented in 65.0% (67/103) of the mild pneumonia cases and was significantly more frequent than in severe cases (23.4% [18/77], p < .001). The hospital stay duration of the mild pneumonia group (13.6 ± 7.2 days) was significantly shorter than the severe pneumonia group (26.6 ± 11.7 days, p < .001) Conclusions Consolidation, pure GGO and multifocal distribution on a CT scan were associated with severe COVID-19. The dandelion and focal crazy paving signs indicate mild COVID-19.

Prognostic Factors of Initial Chest CT Findings for ICU Admission and Mortality in Patients with COVID-19 Pneumonia

Background: Studies have shown that computed tomography (CT) could be valuable for prognostic issues in COVID-19. Objectives: To investigate the prognostic factors of early chest CT findings in COVID-19 patients. Patients and Methods: This retrospective study included 91 patients (34 women, and 57 men) of real-time reverse transcription polymerase chain reaction (RT-PCR) positive COVID-19 from three hospitals in Iran between February 25, 2020, to March 15, 2020. Patients were divided into two groups as good prognosis, discharged from the hospital and alive without symptoms (48 patients), and poor prognosis, died or needed ICU care (43 patients). The first CT images of both groups that were obtained during the first 8 days of the disease presentation were evaluated considering the pattern, distribution, and underlying disease. The total CT-score was calculated for each patient. Univariate and multivariate analysis with IBM SPSS Statistics v.26 was used to find the prognostic factors. Results: There was a significant correlation between poor prognosis and older ages, dyspnea, presence of comorbidities, especially cardiovascular and comorbidities. Considering CT features, peripheral and diffuse distribution, anterior and paracardiac involvement, crazy paving pattern, and pleural effusion were correlated with poor prognosis. There was a correlation between total CT-score and prognosis and an 11.5 score was suggested as a cut-off with 67.4% sensitivity and 68.7% specificity in differentiation of poor prognosis patients (patients who needed ICU admission or died). Multivariate analysis revealed that a model consisting of age, male gender, underlying comorbidity, diffused lesions, total CT-score, and dyspnea would predict the prognosis better. Conclusion: Total chest CT-score and chest CT features can be used as prognostic factors in COVID-19 patients. A multidisciplinary approach would be more accurate in predicting the prognosis.

Computed tomography characterization and outcome evaluation of COVID-19 pneumonia complicated by venous thromboembolism.

BackgroundCOVID-19 is frequently complicated by venous thromboembolism (VTE). Computed tomography (CT) of the chest—primarily usually conducted as low-dose, non-contrast enhanced CT—plays an important role in the diagnosis and follow-up of COVID-19 pneumonia. Performed as contrast-enhanced CT pulmonary angiography, it can reliably detect or rule-out pulmonary embolism (PE). Several imaging characteristics of COVID-19 pneumonia have been described for chest CT, but no study evaluated CT findings in the context of VTE/PE.PurposeIn our retrospective study, we analyzed clinical, laboratory and CT imaging characteristics of 50 consecutive patients with RT-PCR proven COVID-19 pneumonia who underwent contrast-enhanced chest CT at two tertiary care medical centers.Material and methodsAll patients with RT-PCR proven COVID-19 pneumonia and contrast-enhanced chest CT performed at two tertiary care hospitals between March 1st and April 20th 2020 were retrospectively identified. Patient characteristics (age, gender, comorbidities), symptoms, date of symptom onset, RT-PCR results, imaging results of CT and leg ultrasound, laboratory findings (C-reactive protein, differential blood count, troponine, N-terminal pro-B-type natriuretic peptide (NT-proBNP), fibrinogen, interleukin-6, D-dimer, lactate dehydrogenase (LDH), creatine kinase (CK), creatine kinase muscle-brain (CKmb) and lactate,) and patient outcome (positive: discharge or treatment on normal ward; negative: treatment on intensive care unit (ICU), need for mechanical ventilation, extracorporeal membrane oxygenation (ECMO), or death) were analyzed. Follow-up was performed until May 10th. Patients were assigned to two groups according to two endpoints: venous thromboembolism (VTE) or no VTE. For statistical analysis, univariate logistic regression models were calculated.ResultsThis study includes 50 patients. In 14 out of 50 patients (28%), pulmonary embolism was detected at contrast-enhanced chest CT. The majority of PE was detected on CTs performed on day 11–20 after symptom onset. Two patients (14%) with PE simultaneously had evidence of deep vein thrombosis. 15 patients (30%) had a negative outcome (need for intensive care, mechanical ventilation, extracorporeal membrane oxygenation, or death), and 35 patients (70%) had a positive outcome (transfer to regular ward, or discharge). Patients suffering VTE had a statistically significant higher risk of an unfavorable outcome (p = 0.028). In univariate analysis, two imaging characteristics on chest CT were associated with VTE: crazy paving pattern (p = 0.024) and air bronchogram (n = 0.021). Also, elevated levels of NT-pro BNP (p = 0.043), CK (p = 0.023) and D-dimers (p = 0.035) were significantly correlated with VTE.ConclusionCOVID-19 pneumonia is frequently complicated by pulmonary embolism (incidence of 28% in our cohort), remarkably with lacking evidence of deep vein thrombosis in nearly all thus affected patients of our cohort. As patients suffering VTE had an adverse outcome, we call for a high level of alertness for PE and advocate a lower threshold for contrast-enhanced CT in COVID-19 pneumonia. According to our observations, this might be particularly justified in the second week of disease and if a crazy paving pattern and / or air bronchogram is present on previous non-enhanced CT.

Postmortem CT lung findings in decedents with Covid-19: A review of 14 decedents and potential triage implications

ObjectiveComputed tomography has significant utility as a diagnostic tool for coronavirus disease 2019 (COVID-19) in the clinical setting. COVID-19 deaths are sometimes examined by forensic pathologists, often in the setting of an unknown diagnosis. We assessed the utility of postmortem computed tomography (PMCT) for use as a triage tool for these autopsy examinations.Materials and methodsWe reviewed PMCT findings in 14 and histopathology in 11 decedents who were positive for COVID-19.ResultsThe predominant imaging findings were bilateral mixed densities, in either a diffuse or peripheral distribution, with traction bronchiectasis, and/or crazy paving. In particular, traction bronchiectasis, ill-defined rounded consolidations, and reverse halo sign are useful when distinguishing from other postmortem changes.ConclusionWe conclude that triage with a PMCT may aid the forensic pathologist in diagnosing possible COVID-19 infection prior to autopsy examination.

Low-dose chest CT for diagnosing and assessing the extent of lung involvement of SARS-CoV-2 pneumonia using a semi quantitative score.

ObjectivesThe purpose is to assess the ability of low-dose CT (LDCT) to determine lung involvement in SARS-CoV-2 pneumonia and to describe a COVID19-LDCT severity score.Materials and methodsPatients with SARS-CoV-2 infection confirmed by RT-PCR were retrospectively analysed. Clinical data, the National Early Warning Score (NEWS) and imaging features were recorded. Lung features included ground-glass opacities (GGO), areas of consolidation and crazy paving patterns. The COVID19-LDCT score was calculated by summing the score of each segment from 0 (no involvement) to 10 (severe impairment). Univariate analysis was performed to explore predictive factor of high COVID19-LDCT score. The nonparametric Mann-Whitney test was used to compare groups and a Spearman correlation used with p<0.05 for significance.ResultsEighty patients with positive RT-PCR were analysed. The mean age was 55 years ± 16, with 42 males (53%). The most frequent symptoms were fever (60/80, 75%) and cough (59/80, 74%), the mean NEWS was 1.7±2.3. All LDCT could be analysed and 23/80 (28%) were normal. The major imaging finding was GGOs in 56 cases (67%). The COVID19-LDCT score (mean value = 19±29) was correlated with NEWS (r = 0.48, p<0.0001). No symptoms were risk factor to have pulmonary involvement. Univariate analysis shown that dyspnea, high respiratory rate, hypertension and diabetes are associated to a COVID19-LDCT score superior to 50.ConclusionsCOVID19-LDCT score did correlate with NEWS. It was significantly different in the clinical low-risk and high-risk groups. Further work is needed to validate the COVID19-LDCT score against patient prognosis.

The Role of Radiologic Technology in Enforcing Diagnosis of Covid-19 Disease: Case Report at RSPAW Salatiga

Coronavirus has become a world pandemic since WHO announced it in March 2020. This study aims to report on the role of radiologic technology in helping to diagnose the Covid-19 disease handled by RSPAW Salatiga. The research method chosen was descriptive-analytic case reports. The results of the study explained that radiologic technology of chest X-Ray was able to provide an image of Covid-19 with 89% sensitivity, namely the discovery of reticulonodular, ground-glass opacity (GGO), crazy paving, consolidation, location in the periphery of the lung, and the inferior lobe of the lung.

Radiological Findings of COVID-19 Patients in Italy

CONTEXTThe emergence of COVID-19/SARS-CoV2 (COVID-19) was an outbreak that began in December 2019 and rose to pandemic levels in 2020. One of the largest problems with COVID-19 is the typical delay in testing and diagnosis that can lead to additional transmission of the disease. Under consultation with a board-certified radiologist, the study team evaluated the common radiological findings of COVID-19 on computed tomography (CT) and compared the efficacy of chest radiographs (i.e., x-rays) to CT in diagnosing COVID-19.METHODSIn 2020, the authors completed a retrospective review of radiologic imaging data (i.e., the original imaging report notes) from Italy performed on 47 patients who had tested positive for COVID-19 in Italy during the national outbreak from February to March 2020. Radiologic images were obtained from Società Italiana di Radiologia Medica e Interventistica radiological database of COVID-19 patients. Each case was analyzed for whether they had positive findings on either chest radiograph or CT or both among patients who had positive COVID-19 test results.RESULTSThe authors found significant radiological finding similarities among the 47 COVID-19 positive case studies from Italy during the February to March 2020 time period. Ground glass opacities and crazy paving were the most significant findings, resembling the findings in China and other Coronavirus strains. The authors’ statistical analyses indicated that CT scans were more reliable by 30.7% than chest radiographs in identifying signs of COVID-19. In cases where either an initial negative swab for COVID-19 or providers lacked patient social histories, chest radiographs were used to show clinical findings consistent with COVID-19.CONCLUSIONSBased on these results, chest radiographs appear to be a consistent method to assist in the diagnosis of most COVID-19 cases. The authors discuss several scenarios in community-based and non-hospital US settings for COVID-19 diagnostic processes.

Imaging of lung pathology in COVID-19 (literature review and own data)

Novel coronavirus infection is predominantly manifests as lung tissue damage. Imaging methods, particularly, chest X-Ray and computed tomography, are of great importance for detecting pulmonary changes and differentiate them with other diseases (mainly other viral pneumonias). In the early disease stages the disease presents on CT with ground glass opacities, consolidations, crazy paving symptom. With time course, they can gradually decrease, evolve into organizing pneumonia or stay stable and even increase in volume with the spread of consolidation and formation of several signs of organizing pneumonia. Although radiological methods show high sensitivity in the detection of pulmonary changes, their specificity and prognostic ability are not so good today. Novel coronavirus infection can be complicated with pulmonary embolism, development thrombosisin situin pulmonary small vessels, acute heart failure and subsequent development of cardiogenic pulmonary edema, bacterial superinfection, exacerbation or worsening of chronic lung disease and several iatrogenic issues (pneumothorax, pneumomediastinum, hematomas).

Comparison of the СT patterns and pulmonary histology in patients with COVID-19

Aim. Compare radiological patterns of COVID-19 pneumonia with pulmonary histology in deceased patients.Materials and methods. The analysis of recent lifetime CT studies of deceased patients was performed with the identification of all existing and leading CT symptoms, including “ground glass”, “crazy paving”, consolidation, as well as the symptom complex (pattern) of organizing pneumonia. Based on the CT symptoms, we selected the target points for taking the specimens by 3-D reconstructions. At the autopsy the lungs were entirely fixed into the front and then marked on CT sections cut from 1 to 3 pieces that were placed in paraffin and processed according to the standard technique, stained with hematoxylin and eosin and fuchsin-facelina. The specimens were analyzed by identifying all available histology changes and selecting the leading one.Results. 45 targeted pieces of lung tissue were obtained from 14 deceased COVID-19 patients (7 men/ 7 women), with an average age of 77.1 ± 12.9 (49–90 years). In deceased patients with the presence of the "ground glass" symptom, in most cases (57.1%) revealed an increase in intra-alveolar cellularity, hyaline membranes, desquamation of the alveolar epithelium and infiltration of the interalveolar septum by lymphocytes, which corresponds to the exudative phase of diffuse alveolar damage (DAP). Mosaic histological changes with alternation of filled alveoli (intraalveolar edema, clusters of red blood cells, macrophages, lymphocytes) and air alveoli were detected from the areas of “crazy paving” zones. Several cases demonstrated interstitial edema and lymphoid infiltration of interalveolar partitions of different severity without their thickening. Areas of consolidation were histologically represented by extensive intraalveolar hemorrhages and / or typical zones of hemorrhagic infarcts in 45.5% of cases. Perilobular consolidation, subpleural cords, symptoms of “halo” and “reverse halo”, which we considered as part of the symptom complex of organizing pneumonia in 43% of cases, morphologically corresponded to organizing pneumonia (the proliferative phase of DAP), as well as to distelectases.Conclusion. Comparison of CT patters and post-mortem pulmonary histology in COVID-19 deceased patients demonstrated that CT symptoms and patterns correspond to certain morphological changes of different phases of DAP.

Differential diagnosis between the coronavirus disease 2019 and Streptococcus pneumoniae pneumonia by thin-slice CT features

ObjectiveThe chest computed tomography (CT) features of coronavirus disease 2019 (COVID-19) and Streptococcus pneumoniae pneumonia (S. pneumoniae pneumonia) were compared to provide further evidence for the differential imaging diagnosis of patients with these two types of pneumonia. MethodsClinical information and chest CT data of 149 COVID-19 patients between January 9, 2020 and March 15, 2020 and 97 patients with S. pneumoniae pneumonia between January 23, 2011 and March 18, 2020 in Zhongnan Hospital of Wuhan University were retrospectively analyzed. In addition, CT features were comparatively analyzed. ResultsAccording to the chest CT images, the probability of lung segmental and lobar pneumonia in S. pneumoniae pneumonia was higher than that in COVID-19(P<0.001); the probabilities of ground-glass opacity (GGO), the “crazy paving” sign, and abnormally thickened interlobular septa in COVID-19 were higher than those in S. pneumoniae pneumonia(P = 0.005, P<0.001, P<0.001, respectively); and the probabilities of consolidation lesions, bronchial wall thickening, centrilobular nodules, and pleural effusion in S. pneumoniae pneumonia were higher than those in COVID-19 (P<0.001, P = 0.001, P = 0.003, P = 0.001, respectively). ConclusionThe findings of GGO, the crazy paving sign, and abnormally thickened interlobular septa on chest CT were significantly higher in COVID-19 than S. pneumoniae pneumonia. The most important differential points on chest CT signs between COVID-19 and S. pneumoniae pneumonia were whether disease lesions were distributed in entire lung lobes and segments and whether the crazy paving sign, interlobular septal thickening, and consolidation lesions were found.

ACUTE DYSPNEA ASSOCIATED WITH CRAZY PAVING APPEARANCE

SESSION TITLE: Global Case Report Posters SESSION TYPE: Global Case Reports PRESENTED ON: October 18-21, 2020 INTRODUCTION: A ‘crazy-paving’ appearance of the lungs on computed tomography scanning of the chest was first described nearly 20 years ago in patients with pulmonary alveolar proteinosis, and was thought to be characteristic of this condition. However, this pattern has subsequently been reported in a variety of pulmonary diseases and is now considered to be nonspecific. We report a case 43 yrs old middle aged lady admitted with Acute onset of breathlessness with crazy paving appearance on chest Computed tomography of chest, secondary to heart failure. CASE PRESENTATION: Middle age lady with no other comorbidities admitted with complaints of sudden onset of breathlessness since today evening. At the time of presentation to emergency room she was dyspneic, Tachypneic, Tachycardia. Her vitals were HR 102/mt, RR 36/mt,spo2 86% on Room air, Bp 180/100mmhg. She was started on high flow oxygen and nebulized medications.Cardiac examination revealed a normal S1 and diminished S2, with no murmurs or extra sounds. Auscultation of the chest revealed inspiratory crackles bilaterally. His abdominal examination was unremarkable without organomegaly. Laboratory findings revealed a normal complete blood count and differential blood count. Serum electrolytes, liver and renal function tests were all normal.A chest radiograph (figure1) demonstrated diffuse airspace opacities on both sides of lung. A CT scan of the chest (figure2) was obtained showed diffuse, multifocal, patchy, ground-glass opacities with superimposed reticulations resulting in a crazy-paving appearance.Routine 2 D echo was done, revealed Rheumatic Heart disease with Severe mitral stenosis, Tricuspid stenosis and Moderate Tricuspid regurgitation,and diagnosed as acute decompensated heart failure. NT-pro BNP was 3450pg/ml. She was started on diuretics along with other medications. Repeated x ray (figure 3)showed complete clearance of airspace opacities. DISCUSSION: A ‘crazy-paving’ appearance of the lungs on a high-resolution computed tomography (CT) scan of the chest, defined as scattered or diffuse ground-glass attenuation superimposed on a network of interlobular septal thickening and intralobular lines. Initially, this radiographic pattern was thought to be specific for alveolar proteinosis, (1) but has subsequently been reported in a variety of interstitial and airspace pulmonary disorders (2,3) Although common, congestive heart failure and cardiogenic pulmonary edema have been reported previously as a cause for crazy-paving appearance in only in few cases. (3) CONCLUSIONS: Crazy-paving pattern on CT scan, once considered to be specific for pulmonary alveolar proteinosis, is now known to be nonspecific and may be seen in association with a wide spectrum of pulmonary diseases. Reference #1: Godwin JD, Muller NL, Takasugi JE. Pulmonary alveolar proteinosis: CT findings. Radiology. 1988;169:609–13. Reference #2: Johkoh T, Itoh H, Muller NL, et al. Crazy-paving appearance at thin-section CT: Spectrum of disease and pathologic findings. Radiology. 1999;211:155–60. Reference #3: Murayama S, Murakami J, Yabuuchi H, Soeda H, Masuda K. “Crazy paving appearance” on high resolution CT in various diseases. J Comput Assist Tomogr. 1999;23:749–52. DISCLOSURES: No relevant relationships by Nagarajan Appusamy, source=Web Response

152 Correlation of Point of Care Lung Ultrasound and CT Scan Findings in Patients with COVID-19

Chest CT scan (CT) is often considered the gold-standard imaging modality to evaluate pulmonary pathology, and thus is used to assess patients with COVID-19. While CT offers higher resolution images, Point-of-care ultrasound (POCUS) has the advantages of being rapid, low cost, low radiation exposure, and offers the ability for monitoring real-time disease progression. As such, POCUS has also been used to assess patients with COVID-19, and characteristic POCUS findings of COVID-19 are described. In the present study, we compare chest CT to lung ultrasound findings in patients with COVID-19 and examine consistency in pathological findings between the two imaging modalities. 125 patients presenting to an urban emergency department in Tehran, Iran with symptoms concerning for COVID-19 were prospectively enrolled. Participants underwent lung POCUS following a 12-zone protocol assessing each zone for pleural line irregularities, alveolar interstitial syndrome (eg, B-lines), and presence of consolidations including subpleural consolidations (SCs). Patients also received chest CT read by a radiologist evaluating for ground glass opacity, crazy paving patterns, or consolidations. For POCUS and CT, each zone was scored using a 4-point measure, then aggregated total lung involvement scores were calculated for each patient and imaging modality. Descriptive statistics were performed to asses consistently between POCUS and CT findings. POCUS findings overall corresponded well with abnormalities seen on CT, without a significant difference in lung involvement scores between the modalities. On CT, COVID-19 patients showed greater incidence of crazy paving in the AI, PS, PI, AX, PLAPS, CS, and CI distributions (p adj= .00293, 0, .000600, .000533, .00272, .0004) and effusion in CI (p adj= .0216), and on POCUS patients had increased B-lines in the AS, AX, and PLAPS distributions (p adj= .0086, .0012, .0024 respectively), increased pleural thickening in all lung regions (AS, AI, PS, PI, AX, PLAPS; p adj= .0182, .0014, .0375, .0328, .0003, 0), and SCs in AS, AX, and PLAPS (p adj= .0312, .0398, .0324). Both CT and POCUS demonstrated more right-sided findings as a whole, though sidedness of findings was not statistically significant. Both CT and POCUS demonstrated differences in finding densities between lung regions (for CT- ARDS: p adj= 1.00e+ 0; consolidation: p adj= 1.04e- 1; Crazy Paving: p adj= 1.92e-16; effusion: p adj= 8 4.94e- 8; GGO: p adj= 8.73e- 2; interstitial: p ajd= 68e- 6; POCUS- atelectasis: p adj= 1.92e- 7; B-lines: p adj= 6.77e -7; consolidation: p adj= 0.00119; effusion: p adj= 7.20e- 9; pleural thickening: p adj= 7.20e -9; SCs: p adj= 4.39e -5) with the highest concentration of positive findings in the PLAPS region on both modalities. Given comparable findings in the presence and distribution of abnormalities between POCUS and chest CT, POCUS may be a viable alternative to chest CT for diagnosis and risk stratification in patients with suspected COVID-19.