Serial Chest X-rays Research Articles

Evaluation of the Progress of Coronavirus Disease-19 Pneumonia using the British Society of Thoracic Imaging Reporting Model: A Validation Study

Abstract: Background: SARS-COV-2 (also known as severe acute respiratory syndrome corona virus-2), emerged as a pandemic and became an overwhelming global concern, causing substantial morbidity and mortality worldwide. Reverse transcription polymerase chain reaction (RT-PCR) is considered a gold standard in detecting clinically symptomatic patients but can have false negative and false positive results. As chest X-Ray (CXR) is considered as a baseline investigation in many hospitals, BSTI reporting model during COVID-19 pandemic has been a useful tool in diagnosis of COVID-19 pneumonia. Objective: To validate the British Society Thoracic Imaging (BSTI) coding system in the evaluation of the progress of the disease severity in patients with coronavirus disease-2019 (COVID-19) pneumonia. Materials and Methods: This is a cross sectional observational study. Total 450 CXRs (which included both the baseline and serial CXRs) of 225 COVID positive patients (RT-PCR positive for COVID-19 on nasal swabs) were included. These were retrospectively reviewed and reported by two Radiologists (having experience of at least 5 years in Radiology Reporting) in Corona Ward in Dr. Ruth K M Pfau Civil Hospital Karachi, Pakistan, for the duration of 10 months from 1st March 2020 till 31st December 2020. BSTI coding system was used to classify and interpret the CXR imaging findings as normal, definitive, indeterminate and non-COVID for baseline (CXR on 1st day of admission) and follow up CXRs (done in between 3rd and 7th day of admission). Data was analyzed using SPSS version 25. Numeric data was assessed for distribution using Shapiro-Wilks test. Median and interquartile range (IQR) were reported for numeric variables. Frequencies and percentages were reported for categorical data. Kappa statistics was applied to assess the agreement between BSTI scoring at baseline and follow-up CXRs. A p-value ≤0.05 was considered as statistically significant. Result: CXRs (including 225 baseline and 225 follow up CXRs) of 225 RT-PCR COVID-19 positive patients were analyzed. Interval change in BSTI coding system was noted, increase in frequency of probable/definitive COVID-19 findings were diagnosed on serial CXRs. The BSTI scoring at baseline and follow-up showed moderate agreement with kappa statistics as 60.3% (p=0.001). Conclusion: BSTI coding system can be helpful to classify the COVID-19 disease on CXR and filter for the prognosis of disease severity in the serial radiographs. Utilization of BSTI reporting model for reporting CXRs, even before RT-PCR, in future COVID pandemic can be considered as a useful tool.

Description of Thorax X-ray and Brixia Score in Pregnancy with COVID-19 Infection

BACKGROUND: Based on data until December 31, 2020, confirmed cases of coronavirus disease 2019 (COVID-19) have been reached nearly 750,000 cases, COVID-19 can infect pregnant women because a reduction in the immune receptor and increase in another pro-inflammatory factor. Complications include fetal distress, premature rupture of membranes, fetal death, chorioamnionitis, preeclampsia, sepsis, renal failure, and disseminated intravascular coagulation. A serial chest X-ray is used as a basis for assessing COVID-19 progression. An experimental study in Italy proposed a scoring system known as the Brixia score divides the chest X-ray image posteroanterior or anteroposterior into 3 zones, namely, the upper, middle, and lower zones labeled as A to F, then assess the abnormalities that exist in each area with a score of 0–3, a score of ranges from 0 to 18. This score can be used to assess the severity of symptoms suffered by confirmed patients and determine the patient’s prognosis. AIM: This study aims to determine the characteristics of the chest X-ray and Brixia score in pregnancy with COVID-19 infection. METHODS: This descriptive research aims to describe the characteristics of the chest X-ray and the Brixia score in pregnancy with COVID-19 infection in pregnancy at the Department/KSM Obstetrics and Gynecology FK Udayana/Sanglah Hospital, Denpasar. This research carried out from April 2020 to March 2021. The sample of this study was all pregnant women with confirmed COVID-19 at Sanglah Hospital Denpasar during the period April 2020–March 2021. Data collected are all pregnant women who are confirmed to have COVID-19 and met the inclusion and exclusion criteria of the study. Data recorded and data tabulation is carried out according to characteristics that have been determined, then data processing is carried out descriptive. RESULTS: In pregnant patients with confirmed COVID-19 in the period from April 2020 to March 2021, there were 95 people. The highest proportion of mothers pregnant with COVID-19 infection performs antenatal care checks at midwives and Obstetric Gynecologist (47.4%) with age 20–35 years (86.3%), primipara (41.1%), age term pregnancy (74.7%), and using the abdominal method for delivery (87.4%). X-ray results that it was found that from 95 pregnant women, there were 56 pregnant women with thorax abnormal and 39 with normal conditions. The highest proportion of the X-ray results was obtained pregnant with COVID-19 infection with abnormal thorax consolidation lesions found (94.6%) and the distribution of the lesions on the right lung side (39.3%). Based on the cross-tabulated analysis, it can be seen that the consolidation lesion is found in all Brixia scores with the highest proportion in the 0–5 category, which is 80.3%. Results chest X-ray of pregnant women with COVID-19 infection with Brixia score 0–5 had the same values including pleural effusion lesions 1.8%, pulmonary edema 1.8%, and fibrotic by 1.8%. CONCLUSION: Following conclusions can be drawn: Overview of the characteristics of pregnant women with the most COVID-19 infections is at the age of 20–35 years with a primiparous pregnancy. Gestational age term gave birth by the abdominal method; abnormal chest X-ray images are more often found in patients with COVID-19 in pregnancy with consolidated lesions as well as diffuse distribution mostly on the right side of the lung; Brixia score in pregnancy with COVID-19 infection with proportion the highest is in parameter 0–5 as much as 85.7%.

Spontaneous Tension Pneumothorax is a Rare and Life-Threatening Complication of COVID-19 Infection: A Case Report and Literature Review

The coronavirus disease is a recent pandemic infection, with the first case being discovered in Wuhan, China, in December 2019. Iran is one of the countries that has been afflicted by this pandemic. A 34-year-old man with no history of pre-existing disease and smoking has been hospitalized in another hospital for the past two weeks due to COVID-19 infection and symptoms of fever, cough, and dyspnea. He received standard medical treatments in that hospital. After two weeks, he was discharged from the hospital with his consent. In the afternoon of the same day, he came to the emergency department of our hospital with severe dyspnea. Tension pneumothorax in the left hemithorax, pulmonary collapse, and shifting mediastinal elements to the contralateral side were observed in his chest x-ray. Tension pneumothorax is an unusual symptom in patients with SARS-CoV-2. Pneumothorax has been reported in 1% of COVID-19 patients who need hospitalization, 2% of those who need intensive care unit admission, and 1% of those who die from the infection. Spontaneous pneumothorax must be ruled out in COVID-19 patients with dyspnea and chest pain, tachycardia, tachypnea, or hypoxemia. It is critical to be familiar with these symptoms to make an accurate diagnosis and treatment plan. A thorough physical examination and serial chest X-rays can be helpful tools in the diagnosis and management of the disease.

Estimating the Volume of Nodules and Masses on Serial Chest Radiography Using a Deep-Learning-Based Automatic Detection Algorithm: A Preliminary Study.

The purpose of this study was to assess the volume of the pulmonary nodules and masses on serial chest X-rays (CXRs) from deep-learning-based automatic detection algorithm (DLAD)-based parameters. In a retrospective single-institutional study, 72 patients, who obtained serial CXRs (n = 147) for pulmonary nodules or masses with corresponding chest CT images as the reference standards, were included. A pre-trained DLAD based on a convolutional neural network was developed to detect and localize nodules using 13,710 radiographs and to calculate a localization map and the derived parameters (e.g., the area and mean probability value of pulmonary nodules) for each CXR, including serial follow-ups. For validation, reference 3D CT volumes were measured semi-automatically. Volume prediction models for pulmonary nodules were established through univariable or multivariable, and linear or non-linear regression analyses with the parameters. A polynomial regression analysis was performed as a method of a non-linear regression model. Of the 147 CXRs and 208 nodules of 72 patients, the mean volume of nodules or masses was measured as 9.37 ± 11.69 cm3 (mean ± standard deviation). The area and CT volume demonstrated a linear correlation of moderate strength (i.e., R = 0.58, RMSE: 9449.9 mm3 m3 in a linear regression analysis). The area and mean probability values exhibited a strong linear correlation (R = 0.73). The volume prediction performance based on a multivariable regression model was best with a mean probability and unit-adjusted area (i.e. 7975.6 mm3, the smallest among the other variable parameters). The prediction model with the area and the mean probability based on the DLAD showed a rather accurate quantitative estimation of pulmonary nodule or mass volume and the change in serial CXRs.

Massive pleural effusion, what should we do in emergency department? a case report

Indonesia has been known as an endemic country of tuberculosis (TB). Most of the cases are pulmonary TB, and pleural effusion is one of the common cases. Untreated pleural effusion can become massive pleural effusion, a true emergency case in the emergency room. In this report we present a 21-years-old female patient with new onset massive pleural effusion due to TB infection. A 21-year-old female patient with no previous medical illness came to ER with shortness of breaths since a week ago. Cough and unmeasured fever have been reported since a month ago. Tachypnea, extreme tachycardia, asymmetric chest movement, decreased vocal fremitus, dullness of percussion, and decreased left pulmonary sound were found. Chest x-ray showed a massive left pleural effusion with tracheal deviation. High flow nasal cannula was given due to blood gas analysis interpreting moderate respiratory distress. Thoracentesis was immediately performed with estimated 1200 CC yellow coloured fluid production. Other laboratory findings include hyponatremia and hypoalbuminemia. This patient was diagnosed with pleural effusion type pulmonary TB, treated with anti-TB drugs, mucolytic, corticosteroid, and analgesics. Serial chest x-rays showed improvement of pleural effusion. In developing countries like Indonesia, the most common causes of pleural effusion was TB infection besides malignancy. A massive pleural effusion diagnosis can be established with history taking, physical examination, chest sonography, chest x-ray, and/or CT-scan. Thoracentesis must be performed within minutes after massive pleural effusion was established.

A case study of polymicrobial pneumonia

A 34-year old woman, presented with high grade fever and productive cough for 10 days. She had history of recurrent lower respiratory tract infections for past four years. Her serial chest X-ray showed evidence of fleeting pneumonitis. She was tachypnoeic at rest but general examination was otherwise normal. Chest X-ray showed homogenous opacity in right lower zone. She was treated with piperacillin-tazobactam, clindamycin, azithromycin, bronchodilators and other supportive measures. Computerised tomography scan of the thorax showed multifocal areas of ground glass attenuation with inter lobular septal thickening in both lungs. Bronchial wash specimen for PCR analysis was positive for Staphylococcus aureus, Enterococcus species, Herpes simplex nuis, Cardida species, E coli and Pseudomonas arrogia. She was then started on acyclovir and voriconazole for one week. Repeat chest X-ray after one week showed radiological clearance. Patient became afebrile and improved symptomatically.

Utility of the serial portable chest x-ray for the diagnosis and quantification of COVID-19 patients

ObjectiveTo determine the role of the serial portable chest X-ray in the diagnosis and quantification of patients with confirmed COVID-19 admitted to a tertiary care hospital. MethodsA retrospective study was conducted at Dow Institute of Radiology, Dow University of Health Sciences. Confirmed positive cases of COVID-19 from November 2020 to January 2021 were retrospectively studied. Patients' demographics and clinical characteristics, chest X-ray findings, and outcomes were retrieved through electronic medical records. Baseline and final follow-up chest X-rays findings were compared by using chest X-ray severity score. Multivariable logistic regression was used to evaluate the relationship between patients’ characteristics and patient outcomes. ResultsThe study included 329 patients with a mean age of 56.43 ± 13.10 years (range 16–85 years). Peripheral consolidation and ground glass opacities (89.4%) were the most common X-ray findings followed by bilateral lung involvement (79.0%) and perihilar consolidation/ground glass opacities (69.9%). Among the patients who were admitted, 61.4% were discharged, 49.5% had prolonged length of stay ≥10 days, and 37.7% died. After adjustment of all patients' characteristics, the multivariate model showed no significant difference in chest X-ray severity score in relation to the patient's outcome. Patients who were admitted to the intensive care unit, and received oxygen support, bilevel positive airway pressure, and a ventilator were significantly associated with the outcome of being discharged, prolonged hospital stay, and death. ConclusionPeripheral consolidation and ground glass opacities were the most common chest X-ray findings in admitted COVID-19 patients. No significant difference in chest X-ray severity score was noted in the primary outcome of being discharged, prolonged hospital stay, and death. There is no requirement for daily chest X-rays in hospitalized patients until required in the condition of worsening symptoms or significant intervention such as endotracheal intubation.

Pneumonia-related infiltration of the pericardium mimics pericardial effusion, with an echocardiographic finding, surgical result, and outcome

The pericardial sac in a healthy person holds 15–50 mL (mL) of serous fluid. Pericardial effusion (PE) is caused by an abnormal buildup of pericardial fluid in the space around the heart. We present here a 2-year-old healthy child who presented with shortness of breath, fever, and poor feeding for 2 days. Based on echocardiography and following the patient's condition detoriation, the patient was taken to the operation theater. Massive infiltration like substances were seen in the pericardial space instead of suspected pericardial effusion and the sample was sent to the pathology center. The child was extubated on day three postoperatively while serial lab tests, echocardiography, and chest x-ray follow-up demonstrated significant improvement. Follow up 1 week and 3 months later, the child's chest x-ray, inflammatory markers lab test, and echocardiography were normal.

Deep learning of longitudinal chest X-ray and clinical variables predicts duration on ventilator and mortality in COVID-19 patients

ObjectivesTo use deep learning of serial portable chest X-ray (pCXR) and clinical variables to predict mortality and duration on invasive mechanical ventilation (IMV) for Coronavirus disease 2019 (COVID-19) patients.MethodsThis is a retrospective study. Serial pCXR and serial clinical variables were analyzed for data from day 1, day 5, day 1–3, day 3–5, or day 1–5 on IMV (110 IMV survivors and 76 IMV non-survivors). The outcome variables were duration on IMV and mortality. With fivefold cross-validation, the performance of the proposed deep learning system was evaluated by receiver operating characteristic (ROC) analysis and correlation analysis.ResultsPredictive models using 5-consecutive-day data outperformed those using 3-consecutive-day and 1-day data. Prediction using data closer to the outcome was generally better (i.e., day 5 data performed better than day 1 data, and day 3–5 data performed better than day 1–3 data). Prediction performance was generally better for the combined pCXR and non-imaging clinical data than either alone. The combined pCXR and non-imaging data of 5 consecutive days predicted mortality with an accuracy of 85 ± 3.5% (95% confidence interval (CI)) and an area under the curve (AUC) of 0.87 ± 0.05 (95% CI) and predicted the duration needed to be on IMV to within 2.56 ± 0.21 (95% CI) days on the validation dataset.ConclusionsDeep learning of longitudinal pCXR and clinical data have the potential to accurately predict mortality and duration on IMV in COVID-19 patients. Longitudinal pCXR could have prognostic value if these findings can be validated in a large, multi-institutional cohort.

S2450 Acute Esophageal Necrosis: Low Flow Leading to Darkness

Introduction: Acute esophageal necrosis (AEN), commonly referred to as black esophagus due to the striking circumferential blackening of the esophageal mucosa, is a rare clinical condition with a prevalence of up to 0.2%. The etiology of this condition is unclear but thought to involve the interplay of ischemia and gastric outlet obstruction with gastroesophageal reflux. As this condition carries with it a mortality rate of nearly 40%, prompt recognition and aggressive management is of the utmost importance to prevent perforation or stricture. Considering this, AEN should be recognized as a possible outcome of an ischemic event and considered a potential cause of spontaneous esophageal perforation. Case Description/Methods: A 43-year-old female with a history of epithelioid hemangioendothelioma status post resection, Crohn’s colitis in remission, and recent hospitalization for a complicated urinary tract infection and abdominopelvic ascites concerning for malignancy with hospitalization complicated by cardiopulmonary arrest presented to the emergency department 8 days after discharge following a near syncopal episode. She was found to be hypotensive with tachycardia concerning for shock. She was started on broad spectrum antibiotics, 3 vasopressors, intubated, and admitted to the ICU. A CT scan of her chest, abdomen, and pelvis showed extensive pneumomediastinum concerning for esophageal perforation and pneumatosis intestinalis. Perforation was confirmed utilizing serial chest x-rays with contrast demonstrating a right-sided esophageal leak at the gastroesophageal junction. Both cardiothoracic surgery and gastroenterology were consulted, she was not deemed a surgical candidate and endoscopy with covered stent placement was planned. Endoscopy revealed a black esophagus consistent with an ischemic process throughout the entire esophagus and pneumatosis intestinalis suggesting small bowel ischemia. Stenting was aborted and the findings were discussed with the patient’s family who decided to pursue comfort measures. The patient died the following day (Figure). Discussion: It has been demonstrated that critically ill patients often experience low flow states, poor nutritional status, and disruption of intrinsic repair mechanisms. Coupled together, these insults increase the risk of developing AEN and must be acknowledged as a possible complication in this patient population. Although this is a rare condition, it should be recognized as a potential outcome of an ischemic event.Figure 1.: Images A-D depicts a diffusely abnormal mucosa throughout the esophagus, characterized by black/brown tissue consistent with ischemia.

Right Phrenic Nerve Injury: A Rare but Possible Complication of Oesophageal Atresia and Tracheoesophageal Fistula Repair

Oesophageal atresia (OA) and Tracheoesophageal fistulas (TOF) are congenital anomalies commonly present in between 1 and 4 per 10 000 births, including stillbirths and termination of pregnancies. Currently, patients with these anomalies are are managed surgically, with common complications including oesophageal formation, anastomotic leakage and recurrence of TOF. This case report highlights the possibility of right phrenic nerve injury as a complication of OA and TOF repair. We report a baby boy born at term with worsening respiratory distress at day 15 of life, two weeks after undergoing an operation to repair OA and TOF. Since the surgery on day 2 of life, he could not be weaned off oxygen support successfully and had two episodes of worsening respiratory distress that was treated as pneumonia. Serial Chest X-Rays (CXR) showed a persistent elevation of the right hemidiaphragm. Ultrasound (USG) thorax supported the findings of right diaphragmatic paralysis by revealing minimal right diaphragm excursion with the paradoxical movement of the right diaphragm. He was initially managed non-operatively with non-invasive ventilation (NIV)/continuous positive airway pressure (CPAP) while monitoring for spontaneous recovery of the right diaphragm, which unfortunately did not occur. He was on NIV/CPAP for a total of 25 days and was tachypnoeic with mild subcostal recessions (SCR) and reduced breath sounds on the right throughout. Six weeks after the initial OA/TOF repair surgery, he was posted for Right Diaphragmatic Plication. Afterwards, he recovered well and was weaned off oxygen support within the next seven days and subsequently discharged.

Giant bronchopleural fistula and empyema in a tuberculosis patient with diabetes mellitus: Vista from a high tuberculosis burden country in Southeast Asia.

Bronchopleural fistula is a pathological tract between the bronchial tree and the pleural space, which can be life-threatening due to tension pneumothorax. It is a rare complication in tuberculosis cases with highly variable in clinical manifestations and persistent air leaks which might lead to complications such as empyema. Herein, we present a tuberculosis and diabetic patient complicated with giant bronchopleural fistula and empyema. A 48-year-old man presented with shortness of breath for two weeks and cough with phlegm for two months. The patient was a smoker with severe Brinkman Index and diabetes. Physical examination revealed hyper resonant percussion and vesicular diminished on the left hemithorax. Laboratory results indicated the patient had anemia, leukocytosis, and hypoalbuminemia. GeneXpert sputum confirmed the presence of Mycobacterium tuberculosis and chest X-ray indicated a collapsed left lung. The patient was diagnosed with left secondary spontaneous pneumothorax, pulmonary tuberculosis, and diabetes. The patient was treated with chest tube drainage and anti- tuberculosis drugs. There was no improvement based on serial chest X-ray, and empyema appeared from the chest tube. CT-scan showed tuberculosis lesion, the collapsed of the left lung and fistula in segments 7-8 inferior lobe. Exploratory thoracostomy was performed, in which a giant bronchopleural fistula was detected and then repaired with BioGlue surgical adhesive. Unfortunately, the thoracostomy led to extensive subcutaneous emphysema and was treated by cervical mediastinotomy. The drainage was unable to be removed, and the patient was discharged with Heimlich-type drainage valves on day 28 of treatment. The empyema fluid was cultured and revealed Staphylococcus haemolyticus. This case highlights that tuberculosis could cause a bronchopleural fistula and empyema may occur secondary to late diagnosis that needs immediate surgery.

Respiratory Bronchiolitis-Interstitial Lung Disease in Chronic Kidney Disease Mimicking Uremic Lung: A Case Report

Introduction: Uremic lung is a frequent complication of chronic kidney disease (CKD), while interstitial lung is an inflammation of the parenchyma which impairs its capacity. These two conditions manifest similar radiological features with bilateral diffuse infiltrates. Therefore, their clinical appearance and radiological lesions are often mistaken. Case: This study reported a case of a 55-year-old male patient with shortness of breath for 1 month and worsening 1 week before hospitalization. The patient had a smoking history for 30 years with severe Brinkman index, hypertension (HT), and diabetes mellitus (DM). Auscultation examination showed crackles in both lungs, while laboratory results showed anemia, leukocytosis, increased urea and creatinine levels, and radiological features of bilateral infiltrate suggesting a uremic lung. Furthermore, the ultrasonography showed bilateral chronic pyelonephritis and was diagnosed with CKD, uremic lung, pneumonia, anemia, hypoalbuminemia, mild hypokalemia, DM, and HT. The patient was treated with regular hemodialysis three times a week, and the serial chest X-ray after hemodialysis showed persistent bilateral infiltrates. An MSCT examination was also performed, and the results showed respiratory bronchiolitis-interstitial lung disease (RB-ILD). The patient was treated with antibiotic therapy, inhaled salbutamol, systemic steroids, and mucolytics. The patient was discharged from the hospital after the respiratory complaint were improved. Conclusion: In uremia patients with bilateral infiltrates resembling uremic lung and unresponsive to hemodialysis or other therapies, interstitial illness should be explored. To improve patient management, risk factors for suspected interstitial lung disease should always be examined.

Outcome After Lung Transplantation From a Donor With Bacterial Pneumonia Under the Japanese Donor Evaluation System

In Japan, a unique medical consultant system for donor evaluation and management has been developed in an effort to maximize the use of extended criteria donor lungs. The aim of this study was to investigate the impact of donor pneumonia (DP) on the outcome after lung transplantation under this system. Clinical data of 85 patients who underwent deceased donor lung transplantation (41 single and 44 bilateral lung transplants) between August 2012 and March 2018 were reviewed. DP was defined as the recognition of pneumonia on imaging with positive bacterial culture in the airway at the time of transplantation. Twenty-three transplanted lung grafts were recognized as having DP (27.1%). Serial chest x-rays at the donor hospital did not show deteriorating infiltration or consolidation. The PaO2/FiO2 ratio at brain death evaluations were similar between the donor pneumonia (DP) negative (-) and donor pneumonia (DP) positive (+) groups. Perioperative antibiotics were effective against 94% of isolated bacteria. The duration of postoperative antibiotics therapy was longer in the DP (+) group (P=.02). The incidence of primary graft dysfunction and acute rejection, intensive care unit stay, chronic lung allograft dysfunction-free survival, and overall survival were similar between the DP (+) and DP (-) groups. Transplantation of donor lung grafts harboring pneumonia but having a similar oxygenation level to those without pneumonia was safely performed and did not affect long-term outcome. Appropriate evaluation of serial imaging at donor hospital and suitable perioperative antibiotic management may be reasons for this outcome.

COVID-2019 Pneumonia: Severity and distribution of lung changes observed on the initial chest X-ray as an indicator of final outcomes.

ObjectivesThis study aimed to assess the correlation between the severity of the initial chest x-ray (CXR) abnormalities in patients with a confirmed diagnosis of COVID-19 and the final outcomes.MethodsThis retrospective study was conducted at the Royal Hospital, Oman between mid-March and May 2020 and included patients who had been admitted with a confirmed diagnosis of COVID-19 and had a final outcome. Serial CXRs were identified and examined for presence, extent, distribution and progression pattern of radiological abnormalities. Each lung field was divided into three zones on each CXR and a score was allocated for each zone (0 is normal and 1–4 is mild–severe). The scores for all six zones per CXR examination were summed to provide a cumulative chest radiographic score (range: 0–24).ResultsA total of 64 patients were included; the majority were male (89.1%) and the mean age was 50.22 ± 14.86 years. The initial CXR was abnormal in 60 patients (93.8%). The most common finding was ground glass opacity (n = 58, 96.7%) followed by consolidation (n = 50, 83.3%). Most patients had bilateral (n = 51, 85.0%), multifocal (n = 57, 95.0%) and mixed central and peripheral (n = 36, 60.0%) lung abnormalities. The median score of initial CXR for deceased patients was significantly higher than recovered patients (17 versus 11; P = 0.009). Five CXR evolution patterns were identified: type I (initial radiograph deteriorates then improves), type II (fluctuate), type III (static), type IV (progressive deterioration) and type V (progressive improvement).ConclusionA higher baseline CXR score is associated with higher mortality rate and poor prognosis in those with COVID-19 pneumonia.

Correlation of Brixia Score Changes with Length of Stay in Patient with COVID-19

Background: The increase in Covid-19 cases in Indonesia as well as the hospital length of stay is unpredictable. The degree of lung damage in Covid-19 largely determines the severity of the disease, a serial chest X-ray using Brixia score can be used to assess changes in pulmonary parenchymal damage and could predict the length of hospitalization. This study aims to analyze the correlation of Brixia score with the length of hospitalization in Covid-19 patients. Subjects and Method: This cross-sectional study was conducted at Sumber Waras Hospital from November 2021 until January 2022. The samples are Covid-19 confirmed patients who were treated at Sumber Waras hospital. Independent variable is Brixia score and dependent variable is length of hospitalization. Brixia's score assessment from two serial chest X-rays was divided into 4 categories: low to low, low to high, high to low, and high to high. All the categories were analyzed using Kruskall-Wallis method then continued with Mann-Whitney U test. The multivariate variable was analyzed using linear regression. Results: There are 190 samples, the median score of Brixia at the beginning of treatment is 4 (range 0-18), and the median score of Brixia on serial examination is 6 (range 0-18). Patients in low to low category had median 10 days length of hospitalization, low to high category and high to low category had median 11 days, and high to high category had median 8 days. There was no statistically significant correlation between Brixia score and length of hospitalization (p= 0.377). Conclusion: There is no significant relationship between the median Brixia score changes with the length of hospitalization of covid-19 patients. Keywords: Covid-19, hospitalized, Brixia score changes, length of stay Correspondence: Widiastuti Soewondo. Faculty of Medicine Universitas Sebelas Maret. Jl. Ir. Sutami 36A, Surakarta, Central Java, Indonesia. Mobile: +6282134368592. Email: widiastuti.sprad56@staff.uns.ac.id. Indonesian Journal of Medicine (2022), 07(03): 262-268 https://doi.org/10.26911/theijmed.2022.07.03.02

Radiological Features of COVID-19 Patients in Hodeidah, Yemen

Background: The radiological techniques namely chest radiography (chest X-ray) and computerized tomography (CT) scan play a major role not only in the early detection and diagnosis, especially for false negative Real Time-Polymerase Reaction (RT-PCR) tests and in admission criteria, monitoring the clinical course and the disease severity.
 Objective: The study aimed to describe the radiological features of chest X-ray and CT scan in coronavirus diseases 2019 (COVID-19) patients, Hodeidah, Yemen.
 Methodology: A descriptive study (a case series) included 49 patients with COVID-19 , confirmed by RT-PCR who were admitted in isolation department of COVID-19, Center of Tropical Medicine and Infectious Diseases (CTMID), AL Thawara Public Hospital Authority, Hodeidah, Yemen who underwent serial chest X-ray and CT scan, from 1st June to 31st December 2021. The cases reports of patients from 3 to 80 years old. Image features and their distribution were analyzed and the COVID-19 Reporting and Data System (CO-RADS) for level of suspicion of COVID-19 infection was applied.
 Results: The results showed that 21 /49 patients (42.86 %) of CO-RAD 4 and 28 /49 patients (57.14 %) of CO-RAD 5. The most patterns were 42/49 patients (85.71 %) of ground glass opacification (GGO), 40/49 patients (81.63%) of bilateral involvement , 41/49 patients (83.67 %) of multi-lobar involvement, 37/49 patients (75,51 %) of peripheral distribution , 15/49 patients (30.61 %) of consolidation pattern and 3/49 patients (6.12%) of crazy paving pattern. On the other hand , in the youngest patients less than 50 year,79 % had GGO, and 21 % had lung consolidations ,while in the patients over 50 year ,GGO were presented in 56 % and consolidations in 44 %. In addition, the lung involvement range of patients was from 40 to 95 % and the median was 60 %. The lung involvement was represented in the patients more than 50 year as 60 – 95 % while in the patients less than 50 years was represented as 40 – 55 %. The lung involvement of death patients was 85 to 95 % of non-chronic diseases and 60 to 70 % of comorbidity and coinfection.
 Conclusion: The study concluded that different radiological patterns and features were reported in elderly patients with COVID-19 infection associated with risk factors (comorbidity and coinfection). The radiological techniques have good predictive values on severity and mortality. Also can support the clinicians staff in early detection, early triage, criteria admission, and effective management of COVID-19 infection.

The Diagnosis of Unilateral Diaphragmatic Paralysis Using M-mode: A Case Report from Palestine

Background: Diaphragmatic paralysis is one the causes of dyspnoea and difficulty in breathing. There are many causes of diaphragmatic paralysis, especially trauma and iatrogenic injury of phrenic nerve. Usually, diaphragmatic paralysis diagnosis depends on fluoroscopic examination of diaphragmatic displacement during sharp sniffs. However, due to disadvantages of fluoroscopic examination, the trend for less radiation examination by using ultrasound is increasing especially using M-mode for detection of diaphragmatic motion during respiration. Case: A new-born baby boy with uneventful pregnancy and normal delivery with good general condition, developed severe respiratory distress at 3rd day of life and was diagnosed to have bilateral pneumothorax. Bilateral chest tubes were inserted with improvement of his condition. The baby then started to develop desaturation with serial chest x-rays done and showed elevated left hemi-diaphragm. Suspicion toward left hemi-diaphragm paralysis increased and due to his general condition, fluoroscopic examination was difficult. So that, Ultrasound with M-mode was used with diagnosis of the patient with left hemi-diaphragmatic paralysis. Conclusion: Ultrasound and the using of M-mode in detection of diaphragmatic motion is one of the most important and applicable diagnostic procedure for diagnosis of diaphragmatic weakness and paralysis.

Role of Chest X-Ray in Coronavirus Disease and Correlation of Radiological Features with Clinical Outcomes in Indian Patients.

Recent literature has reported that radiological features of coronavirus disease (COVID-19) patients are influenced by computed tomography. This study aimed to assess the characteristic chest X-ray features of COVID-19 and correlate them with clinical outcomes of patients. This retrospective study included 120 COVID-19 patients. Baseline chest X-rays and serial chest X-rays were reviewed. A severity index in the form of maximum radiological assessment of lung edema (RALE) score was calculated for each lung, and scores of both the lungs were summed to obtain a final score. The mean ± standard deviation (SD) and frequency (%) were determined, and an unpaired t test, Spearman's rank correlation coefficient, and logistic regression analyses were performed for statistical analyses. Among 120 COVID-19 patients, 74 (61.67%) and 46 (38.33%) were males and females, respectively; 64 patients (53.33%) had ground-glass opacities (GGO), 55 (45.83%) had consolidation, and 38 (31.67%) had reticular-nodular opacities, with lower zone distribution (50%) and peripheral distribution (41.67%). Baseline chest X-ray showed a sensitivity of 63.3% in diagnosing typical findings of SARS-CoV-2 pneumonia. The maximum RALE score was 2.13 ± 1.9 in hospitalized patients and 0.57 ± 0.77 in discharged patients (p value <0.0001). Spearman's rank correlation coefficient between maximum RALE score and clinical outcome parameters was as follows: age, 0.721 (p value <0.00001); >10 days of hospital stay, 0.5478 (p value <0.05); ≤10 days of hospital stay, 0.5384 (p value <0.0001); discharged patients, 0.5433 (p value <0.0001); and death, 0.6182 (p value = 0.0568). The logistic regression analysis revealed that maximum RALE scores (0.0932 [0.024–0.367]), (10.730 [2.727–42.206]), (1.258 [0.990–1.598]), and (0.794 [0.625–1.009]) predicted discharge, death, >10 days of hospital stay, and ≤10 days of hospital stay, respectively. The study findings suggested that the RALE score can quantify the extent of COVID-19 and can predict the prognosis of patients.

A Novel Homozygous Mutation ABCA3gene: Presented as Sever Respiratory Distress Syndrome in a Term Neonate

Congenital surfactant deficiency is a rare condition diagnosed in newborns who present with respiratory distress at birth. We report a case of a term Omani neonate with fatal surfactant protein deficiency who was admitted to the Neonatal Intensive Care Unit (NICU)of the Royal Hospital with respiratory distress syndrome with persistent interstitial infiltrates on serial chest x-ray responsive to intermittent surfactant administration. He underwent a lung biopsy, and immunohistochemistry confirmed the diagnosis of congenital surfactant protein deficiency. However, despite aggressive treatment and supportive measures, his condition rapidly deteriorated, and he succumbed after two months of admission. This case report will highlight and review surfactant deficiency differential diagnoses, management, and complications.