COVID-19 pneumonia

Case contributed by Mohammad Al-Tibi
Diagnosis certain


Four-day history of high-grade fever, cough and myalgia. On admission, the patient was tachycardic but maintained oxygen saturation on low flow. On auscultation, he had bilateral crackles and crepitations.

Patient Data

Age: 65 years
Gender: Male

Initial CXR on admission


Coarse patchy opacification of both lower zones which appear inflammatory in nature. No focal collapse or consolidation. The pleural surfaces are clear with normal cardio-mediastinal contour.

Four days following admission, the patient developed increasing hypoxia and sepsis with hypotension, requiring intensive care admission for ventilation and inotropic support.

Day 4


AP supine portable CXR:

The previously seen patchy opacities appear as areas of bilateral peripheral consolidations with air bronchograms. Consolidation above the horizontal fissure suggests right upper lobe pneumonia. Obliteration of the left heart border suggests lower lobe pneumonia.

Support lines (ETT, NG, and left internal jugular CVC) are in situ.

The British Society of Thoracic Imaging implemented standardized CXR imaging criteria which may help guide management in COVID-19 1.

  • classic/probable COVID-19: lower lobe and peripheral predominant multiple opacities that are bilateral (>> unilateral)
  • indeterminate for COVID-19: does not fit classic or non-COVID-19 descriptors
  • non-COVID-19: pneumothorax / lobar pneumonia / pleural effusion(s) / pulmonary edema
  • other

Case Discussion

Throat swab reverse-transcription PCR was negative twice before testing positive for SARS-CoV-2 RNA on day 3 of admission.

The findings on the initial film are subtle and there is a rapid and significant progression on the follow-up radiograph. Radiologists need to look out for these subtle changes when present and hot-report appropriately, particularly given the lag between admission and RT-PCR result availability for SARS-CoV-2 RNA.

Thanks to Dr. Shahid Hussain (consultant cardiothoracic radiologist, University Hospitals Birmingham, United Kingdom) for his critical revision of this case study.

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