Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Reviews
Year : 2022 | Month : March | Volume : 16 | Issue : 3 | Page : TE01 - TE06 Full Version

Computed Tomography of Chest in COVID-19 Infection: A Narrative Review


Published: March 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/52321.16175
Jitender Singh, Tara Prasad Tripathy, Karamvir Chandel, Ranjan Patel

1. Consultant, Department of Radiology, Shanti Mukund Hospital, New Delhi, India. 2. Assistant Professor, Department of Radiology, AIIMS, Bhubaneswar, Odisha, India. 3. Fellow, Department of Radiology, Institute of Liver and Biliary Sciences, New Delhi, India. 4. Assistant Professor, Department of Radiology, AIIMS, Bhubaneswar, Odisha, India.

Correspondence Address :
Dr. Tara Prasad Tripathy,
Assistant Professor, Department of Radiology, AIIMS, Bhubaneswar, Odisha, India.
E-mail: taraprasad.mkcg@gmail.com

Abstract

Coronavirus Disease 2019 (COVID-19) is caused by a novel coronavirus that is very contagious. Asymptomatic infection to severe and deadly sickness is all possibilities. The gold standard investigation for diagnosing coronavirus infection is Reverse Transcription-Polymerase Chain Reaction (RT-PCR). Computed Tomography (CT) is an important imaging modality for the management of COVID-19 patients. A CT scan of the chest can also be used to check for disease sequelae. During the pandemic, several classifications and CT Scoring Systems (CT-SS) were devised to aid in triage and diagnosis. Literature search was performed in Google Scholar and PubMed databases, using these keywords and their combinations: COVID-19, CT, Ground-Glass Opacity (GGO), RT-PCR. The present review paper aims to summarise, discuss and illustrate the radiological findings of the COVID-19 as well as the current status of the CT chest in the management of the disease. CT is the best imaging method for detecting the involvement of the lungs, as well as the quickest way for determining the nature of abnormalities. CT has a vital role in the diagnosis, management, and prognostication of COVID-19 in the fight against the pandemic, as evidenced by extensive research. Understanding of the imaging characteristics of COVID-19 pneumonia, can help with early control of the disease spread, and CT severity score could be useful for clinical triage, prognosis evaluation, and follow-up.

Keywords

Coronavirus disease 2019, Computed tomography scoring systems, Ground-glass opacity, Reverse transcription-polymerase chain reaction

Coronavirus Disease 2019 (COVID-19), which is caused by a highly contagious new coronavirus that has spread to practically every country in the world. COVID-19 was first detected in Wuhan in December 2019, and the World Health Organisation (WHO) declared it a pandemic on March 11, 2020. Fever, cough, dyspnoea, and chest tightness are the main clinical symptoms of COVID-19, but a large percentage of patients may be asymptomatic. Infection can spread through respiratory air droplets or through direct contact with contaminated surfaces (1),(2),(3),(4). Because asymptomatic patients must be isolated, tests must be highly accurate and quick (5).

Despite the fact that pharyngeal swabs for Reverse Transcription-Polymerase Chain Reaction (RT-PCR) assay is the gold standard for diagnosis, the test can nevertheless result in false negative results for a variety of reasons. This could explain why some RT-PCR assays are negative even when clinical illness is present. Because RT-PCR has limited sensitivity, time commitment, high cost, and limited availability in some countries, Chest CT has been used to diagnose COVID-19 in highly suspected symptomatic RT-PCR negative individuals who had direct contact with confirmed COVID-19 patients and ended up in the hospital for treatment. The utility of a chest CT scan in COVID-19 patients with false negative RT-PCR findings has been proven in a number of studies, with estimated sensitivity of around 98% (6),(7),(8).

With a comprehensive review of published studies, authors intend to present a pictorial overview of the typical and atypical CT manifestations of COVID-19, as well as discuss the current status of the CT chest in the management of the disease.

INDICATIONS FOR CT IMAGING IN COVID-19

The American College of Radiology (ACR), the Society of Thoracic Radiology (STR), and the American Society of Emergency Radiology have all warned against using routine imaging, especially CT chest, as a primary diagnostic test (9),(10).

In mid year of 2020, the Fleischner Society released an international consensus statement to provide doctors with recommendations on the use of thoracic imaging in a variety of healthcare settings and circumstances. Mild disease was defined when there was no evidence of respiratory damage or dysfunction. Moderate to severe respiratory illness was defined when there was significant pulmonary dysfunction or damage (11). The society made the following recommendations:

• There is no rationale to use regular imaging as a screening test in those who are asymptomatic COVID-19 positive.
• Imaging is not indicated for patients with mild illnesses unless they are at danger of worsening their condition.
• Indicated in patients with moderate to severe COVID-19 symptoms, regardless of COVID-19 RT-PCR results.
• All patients with deteriorating respiratory illness should undergo imaging.
• An x-ray can be performed initially, but a CT scan is required if symptoms worsen.

They also suggested CT after infection recovery in patients with functional impairment or hypoxaemia. Daily Imaging is not recommended in intubated patients. In addition, on incidental COVID-19 findings on CT, COVID-19 testing of the subject is recommended.

In the initial phase of the disease, the role of CT chest is limited. The diagnosis is primarily based on RT-PCR. However, due to a lack of RT-PCR testing kits for COVID-19, studies have recommended that thoracic CT scans could be used as a primary screening or diagnostic test in areas with a high prevalence of COVID-19 cases (3). Despite this clinical setting, CT chest indications have increasingly evolved. While some countries, particularly developing countries, have used routine imaging to identify probable COVID-19, others, primarily in the western countries, have argued for a more circumspect approach.

CT CHEST IMAGING FINDINGS

The angiotensin converting enzyme-2 receptors are targeted by the Corona virus in humans, causing damage to the lung interstitium and parenchyma (12). The CT findings of COVID-19 pneumonia are consistent with typical viral pneumonia lung damage. CT imaging is preferred over radiography because it is more sensitive to detecting early disease, determining the nature and extent of lesions, and detecting subtle changes that aren’t always obvious on chest radiography. Depending on the time course and severity of the disease, COVID-19 patient’s chest CT pictures may show various imaging characteristics or patterns.

As in other Institutes, the usual protocol for COVID-19 lung infection assessment in the institute was a supine non contrast CT chest with breath-hold (13). All images were reconstructed using a sharp reconstruction kernel and a 1.0 mm slice thickness with a 1 mm increment. In patients with suspected Pulmonary Embolism (PE) with very high D-dimer values or lower limb deep vein thrombosis, intravenous iodinated contrast is recommended. In COVID-19, Minimum Intensity Projection (MinIP) CT chest reconstructions (Table/Fig 1) can improve diagnostic accuracy for pulmonary Ground-Glass Opacity (GGO). Additionally, it improves diagnostic confidence and subjective time efficiency (14).

According to “Expert Recommendations from the Chinese Medical Association Radiology Branch” clinical guidelines, COVID-19 was divided into three stages based on the period of commencement and the body’s response to the virus, with an additional dissipation stage (15). Based on extent of lung involvement, COVID-19 CT findings can be categorised into early, advanced, severe, and dissipative stages:

Early Stage (0-4 Days)

Single or multifocal scattered patchy or conglomerate ground glass opacities can be seen on chest CT, primarily in the middle and lower lobes, along the bronchovascular bundles. Ground glass lesions are most commonly found in the lung’s peripheral and sub-pleural sections (15). The findings of intra and interlobular septal thickening in areas of ground glass opacity can lead to a crazy paving pattern (15),(16),(17),(18). Lung opacification that does not obscure the bronchovascular markings is known as GGO (Table/Fig 1), (Table/Fig 2), (Table/Fig 3). GGOs are more common in children and young people, while lung involvement, sub-pleural line thickening, fibrosis, and consolidation are more common in older patients (>60 years).

Microvascular thrombosis, which is produced by endothelial injury, dilates the traversing pulmonary vessel within or close to the GGOs, causing vascular expansion (Table/Fig 2), (Table/Fig 3). Pathologically, this stage is characterised by the dilation and congestion of the alveolar septal capillaries, fluid exudation into the alveoli, and interlobular interstitial oedema (19).

Advanced Stage (5-8 Days)

New lesions with increased opacification of prior GGOs merge to produce consolidations with/without air bronchograms in this stage (Table/Fig 4).

Consolidation: Opacification of the parenchyma, which obscures the bronchovascular markings (Table/Fig 1)b. After GGOs, the second most prevalent manifestation is multifocal bilateral patchy consolidations with a peripheral and sub-pleural predominance. On CT, larger and more numerous GGOs, consolidation, and increased fibrous streaks indicate disease progression.

Crazy paving: Thickening of the interlobular septa on the background of GGOs creates a crazy paving pattern (Table/Fig 1)c. The formation of crazy paving, as well as consolidations, indicate that the disease has progressed to a more advanced level (20).

Organising Pneumonia (OP): OP is characterised by halo and reverse halo signs. The halo sign is a GGO-encircled area of consolidation (20),(21). A focal rounded GGO or normal parenchyma is encircled by a rim of consolidation in the reverse halo sign (Table/Fig 2)a.

Pleural involvement: Pleural alterations are more prevalent, with pleural thickening being the most prevalent (Table/Fig 2)d, (Table/Fig 4)c, (Table/Fig 4)d. Pleural effusion, on the other hand, is uncommon, and its occurrence in COVID-19 may indicate a bad prognosis (22).

Airway changes: Bronchiectasis and bronchial wall thickening are the outcome of inflammatory injury to the airways, which can develop to fibrosis (Table/Fig 2)b, (Table/Fig 5)d (18),(23). Central lucencies can be caused by a focal small area of bronchiectasis or partial resorption of consolidation (Table/Fig 2)c (22).

This stage is distinguished by the deposition of exudates in the alveolar cavity, interstitium and vascular enlargement. To form a fusion state, fibrous exudation connects each alveolus through the interalveolar space (19).

Severe Stage (9-13 Days)

This stage is marked by extensive consolidation with different densities (Table/Fig 5)a-c. Air bronchograms and bronchial dilatation are noted due to fibrous exudate into the alveolar cavity. Patchy GGO appears in non consolidated lung regions. When the majority of the lungs are affected, the lungs take on the appearance of a “white out lung”. There is a minor amount of pleural effusion and the pleura are thickened. Advanced or severe stages of fibrosis can move to dissipation stages with residual fibrosis in some cases (24).

Dissipation Stage (≥14 Days)

This stage is distinguished by the gradual resolution of GGOs and consolidations, as well as the emergence of residual fibrosis and curvilinear lines (Table/Fig 5)d.

Fibrosis and sub-pleural curvilinear lines: Fine curvilinear opacities/lines paralleling the pleural surfaces, which are related to fibrosis (Table/Fig 2)d, (Table/Fig 5)d. Extreme lung fibrotic states can move to dissolution stages with remnant fibrosis in some cases (24). It can, however, proceed to interstitial lung disease in some circumstances.

Association with pulmonary thromboembolism: Deep venous thrombosis, PE, acute myocardial infarction, and ischemic stroke related to COVID-19 infection results in significant morbidity and mortality. These symptoms are caused by endothelial injury, inflammation, and microvascular thrombosis. In a study on critically ill patient admitted in ICU, about 31% patients had vascular thrombosis (venous=31%, arterial=3.7%) (25). Also, in a study, it was found that non survivors’ d-dimer levels were consistently higher than survivors’ throughout the clinical course, and that this difference increased as the illness worsened (5).

Atypical imaging features: Atypical COVID-19 presentations include pulmonary nodules, intralobular septal thickening, mediastinal lymphadenopathy, and pleural/pericardial effusions (Table/Fig 5). Pleural effusions and upper-lobe involvement were more common in Middle East Respiratory Syndrome Coronavirus (MERS) pneumonia (26). In contrast to COVID-19, Severe Airway Respiratory Syndrome (SARS) had a higher frequency of focused unilateral lung involvement in the early stages (26).

SEVERITY ASSESSMENT OF COVID-19 BY CT CHEST

In COVID-19, CT chest assessment of disease allows for reliable quantitative severity score, which is useful in diagnosing mild disease, defining temporal change, and aiding clinical decisions. With the aim to improve communication with physicians and multicentre collection of CT diagnostic accuracy data, the use of standardised reporting systems for lung involvement in COVID-19 has been promoted.

Several reporting systems for chest CT scans of patients with COVID-19 have been proposed. These methods use standardised language and diagnostic categories to provide a more comprehensive picture of the COVID-19 infection-related lung parenchymal abnormalities.

The RSNA Expert Consensus Statement, Coronavirus Disease 2019 Reporting and Data System (CO-RADS) by the Dutch Radiologic Society (Table/Fig 6), (Table/Fig 7), British Society of Thoracic Imaging, COVID-RADS are different reporting systems (27),(28),(29),(30),(31). When typical findings are present or absent, each classification system is likely to be helpful in indicating the presence or absence of COVID-19, respectively. The CO-RADS classification was created for a moderate to high prevalence setting and is a standard reporting system for patients with probable COVID-19 infection. With 61% sensitivity and % percent specificity, CO-RADS score >4 were shown to be the best threshold. The CO-RADS 1 and CO-RADS 5 categories had moderate agreement (32).

On a CT chest scan, a variety of approaches can be employed to detect the extent of lung involvement. Parenchymal anomalies are classified as mild, moderate, or severe using qualitative approaches. By using semi-quantitative methods, quartiles can be used to estimate lobar or zonal involvement (33),(34). Quantitative methods based on artificial intelligence that were utilised to determine Total Lung Involvement (TLI), percentage of consolidation, and GGOs showed to be more accurate (35),(36),(37). The degree of lung parenchymal involvement and the disease severity of COVID-19 are specifically related (38).

The CT severity scoring system allows for more accurate identification, allowing for improved control of coronavirus propagation through medical therapy and the reduction of public health surveillance systems. Various CT visual quantitative grading systems exist (Table/Fig 8) (18),(33),(43). The CT severity assessment system has the potential to improve clinical triage and predict clinical outcomes (35),(39).

The CT severity score for severe COVID-19 was 19.5 points, with a sensitivity of 83.3 percent and a specificity of 94% (40). CT severity scores of 18 on a scale of 0 to 25 were linked to a higher probability of death (41). Another score, the Total Severity Score (TSS), revealed a substantial difference between mild and severe-critical patients, with a cut-off value of 7.5 with good sensitivity and specificity (Table/Fig 9) (33). Similar sensitivity and specificity have been found in other CT-SS (18),(42),(43).

The positive predictive value of each of these systems varies according to the prevalence of COVID-19. More study is needed to assess the diagnostic effectiveness of CT chest in persons who have highly suggestive CT readings but aren’t clinically suspected of having COVID-19 (44).

The CT severity ratings along with other several clinical and laboratory variables linked to a patient’s prognosis (45). CT severity scores were found to have significant relationships with serum markers of disease severity (46),(47),(48),(49),(50). The CT severity score and inflammatory marker levels have been found to have a significant positive relationship (38),(39),(41),(46). In a multivariate model that included age and inflammatory serum biomarkers, higher CT severity scores were linked to an increased mortality rates in COVID-19 hospitalised patients. Patients with a CT severity score of 15 or higher were more likely to die, and the CT severity score was the only independent risk factor for mortality (41).

Although preliminary data from clinical research suggests that CT severity rating is effective in the management of COVID-19 patients. Finding a standard scoring methodology requires inter-observer consistency. Furthermore, a significant proportion of asymptomatic patients may have parenchymal involvement on CT that is comparable in severity to that of symptomatic patients, and CT severity scores of clinically severe cases of COVID-19 pneumonia may be comparable to those of moderate clinical severity, highlighting the limitations of relying solely on CT severity to draw clinical conclusions (51).

CT DETECTION VERSUS RT-PCR DETECTION OF COVID-19

The RT-PCR technique is used to identify genetic material in samples in order to diagnose COVID-19 infection (6),(52). However, because RT-PCR was not widely available, particularly in poorer countries, CT chest was employed for early triage and therapy of COVID-19. Multiple factors can influence RT-PCR diagnostic performance, such as incorrect nucleic acid extraction from biological materials, insufficient sampling, variations in the accuracies of different assays, or low viral load in the early or late stages, resulting in false-negative results (53),(54). In 3-56% of RT-PCR positive individuals, false negative CT scans have also been recorded. (17),(55),(56),(57)

COVID-19 lung manifestations on CT chest suggestive with COVID-19 severity usually appear later in the disease course, usually 6-11 days after infection (58). Few studies in symptomatic participants found that CT had a higher sensitivity than RT-PCR. Such findings could be attributed to a number of reasons, including the inclusion of only patients with moderate to severe symptoms (53),(55),(59). The pooled sensitivity for CT chest was 94% in a meta-analysis, and 89% for RT-PCR (3). Lower CT sensitivity was reported as a consequence of symptoms and disease severity in another investigation, but these parameters had no effect on RT-PCR performance (60). CT’s specificity is insufficient to support its use in the diagnosis of COVID-19. The sensitivity of RT-PCR was 65% when chest CT was used as a reference of diagnosis standard for COVID-19, according to a study [61]. In the detection of COVID-19, the RT-PCR assay has a high specificity but a poor sensitivity, whereas the CT assay has a greater sensitivity but a lower specificity. The incidence of COVID-19 and other comparable viral pneumonias, as well as other clinico-radiological mimickers, affects the accuracy of imaging tests in detecting COVID-19 (60). Despite a negative RT-PCR test, patients with clinical symptoms or a history of exposure, CT characteristics of viral pneumonia should be considered highly suspicious for COVID-19 pneumonia in the present pandemic.

COVID-19 AND PAEDIATRIC PATIENTS [62],[63]

The most common symptoms in children with COVID-19, were fever and cough. In certain cases, gastrointestinal problems may be the first symptom to appear. Symptoms of the gastrointestinal tract were more common in younger children. The majority of infected youngsters show just minor clinical symptoms, and their prognosis is good. The majority of paediatric patients recovered within 1-2 weeks after the commencement of the illness. In adults, lymphocytopenia is common after the onset of COVID-19, while in children, it is uncommon. Although abnormal chest CT symptoms in certain children were common, they must be distinguished from other types of viral pneumonitis.

COMPUTED TOMOGRAPHY (CT) AND RADIATION CONCERN

In a retrospective single-center investigation, it was observed that 75.4% of COVID-19 patients were exposed to doses greater than 5 mSv {International Commission on Radiological Protection’s (ICRP) upper limit of permissible, effective dose for community members}. COVID-19 patient treatment should include a more reasonable utilisation of chest CT imaging [64]. Several radiological associations have developed recommendations on the role of chest CT in the diagnosis and follow-up of COVID-19, as discussed, to prevent unrestricted use and associated unnecessary radiation exposure. Several studies have now demonstrated the use of low-dose CT, with image quality comparable to full-dose chest CT. This method was effective in lowering radiation exposure [65],[66].

Conclusion

Due to its high infectivity, COVID-19 cases have been reported in every country around the world. The best imaging method for detecting the involvement of the lungs, as well as the quickest way for determining the nature of abnormalities, is CT. The CT has a vital role in the diagnosis, management, and prognostication of COVID-19 in the fight against the pandemic, as evidenced by extensive research. In the diagnosis of COVID-19 pneumonia, chest CT shows a high sensitivity but a low specificity. Early containment can be aided by understanding the imaging characteristics of COVID-19 pneumonia, and a CT severity score could be beneficial for clinical triage and prognosis evaluation.

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DOI and Others

DOI: 10.7860/JCDR/2022/52321.16175

Date of Submission: Sep 11, 2021
Date of Peer Review: Oct 26, 2021
Date of Acceptance: Jan 05, 2022
Date of Publishing: Mar 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? NA
• Was informed consent obtained from the subjects involved in the study? NA
• For any images presented appropriate consent has been obtained from the subjects. NA

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