32 cases of suspected COVID-19

The CO-RADS classification is a standardized reporting system for patients with suspected COVID-19 infection developed for a moderate to high prevalence setting.

It is a preliminary classification of likelyhood of COVID-19 infection as proposed by the COVID working group of the Dutch Radiological Society.

The interpretation of the CT findings has to be combined with the clinical symptoms and the duration of the symptoms as a CT can be negative in the first few days of a mild infection.
However most patients that we see have complaints for a week or more.

At the moment most patients that are admitted to the hospital either have a CORADS 5, which means that they have a COVID-19 infection or they have a CORADS 1 or 2, which means no COVID-19 infection. 

_1 Crazy paving - ventilation

History
64 year old male with fever and coughing for 2 weeks after a skiing holiday with his family.

CT findings
Widespread GGO in all lobes
Crazy paving (blue arrows)
Vascular enlargement (black arrow)
Subpleural bands with retraction (yellow arrows)
Consolidation and bronchiectasis posteriorly in the lower lobes

CORADS 5 - very high suspicion of COVID-19

PCR positive  

Continue with Chest X-ray...

Within a few hours after presentation on the ER the patient became hypoxic and was treated with mechanical ventilation.

Later that day the patient was transferred to another hospital. 

_2 CORADS 5 - extubation

History
55 year old and previously healthy man presented with a history of 2 weeks of fever and coughing. Although he was in a reasonable condition at arrival, he had to be intubated later that evening.

CT findings at arrival
Consolidations mainly posteriorly in lower and upper lobes
Small areas of GGO

CORADS 5

PCR
The first PCR was negative, but later a sputum test was positive for COVID-19.

Follow up
After three days of mechanical ventilation he could be extubated and was doing well with only oxygen therapy. Nine days after admission to the hospital he was discharged and is doing well.

_3 CORADS 2 - Mycoplasma

History
49 year old male suspected of having COVID-19.
13 days of fever and coughing. Treated with antibiotics for 7 days.

CT findings
Consolidation in right lower lobe
surrounding area with tree-in-bud in lower lobe
also tree-in-bud in other lobes

CORADS 2 - some other infection most likely bacterial

PCR
First test negative. Test nine days later also negative.

Follow up
Tested positive for Mycoplasma pneumoniae. Left the hospital two days after admission.

_4 GGO - bronchiectasis- wide vessels

History
75 year old male with fever for 4 weeks and no coughing. History of lungcancer resection by video-assisted thoracoscopic surgery (VATS) one years ago.

CT findings
Bilateral GGO
Bronchiectasis (green arrow)
Widened vessels (yellow arrow)

CORADS 5

PCR
2x positive

Follow up
Two days after admission to the hospital, there was a rapid decrease in condition of the patient and he had to be transferred to the ICU for mechanical ventilation.

_5 CORADS 2 - Asthma

64 year old female known with asthma suspected of having COVID-19.

CT findings: 

• Mucus plugging in right lower lobe bronchus
• Consolidation and atelectasis of right lower lobe
• Consolidation in middle lobe

CORADS 2 - infection not related to COVID-19

PCR: negative for COVID-19 (twice) and negative for RSV, Inflluenza A and B.

_6 CORADS 5 - bilateral peripheral GGO

COVID-19 infection. 

CT-findings:

• Predominantly bilateral subpleural GGO with some areas of crazy paving. 
  
• In the lower lobes some areas of consolidation. 
  
• Percentage of lung involvement is approximately 25% by visual assessment.
  
• CORADS 5

_7 Fatal COVID-19

83 year old male with mitral insufficiency and pulmonary hypertension was diagnosed with COVID-19 infection.

The chest film shows consolidation in the right upper lobe (green arrow) and probably some consolidation in the left lower lobe.

The patient decided not to be treat with mechanical ventilation and died four days later.

_8 CORADS 5 - Crazy paving

57 year old male without any prior diseases was admitted to the hospital with 14 days of fever and cough.
He was treated with an oxygen mask.
2 days later his condition suddenly worsened and the patient was tranferred to the ICU for mechanical ventilation.

CT findings at the moment of admission to the hospital: 

• Bilateral GGO
• Crazy paving with thickened intra- and interlobular septa
• CORADS 5 - typical COVID-19

PCR: positive for COVID-19.

Crazy paving, consolidation, linear opacities,  bronchial wall thickening and high CT scores are features of severe and critical COVID-19 pneumonia (1).

_9 Suspicion pulmonary emboli

57 year old male with Diabetes type 1 with chronic obstructive lung disease was admitted with shorteness of breath.
Initially there was no suspicion of COVID-19.
A CT was performed to look for pulmonary emboli.

CT findings: 

• No emboli
• Bilateral GGO with a centrilobular pattern imposed
• CORADS 3 - unsure COVID-19

PCR was two times negative for COVID-19 and all other test for RSV, influenza, legionella and pneumococcus were also negative. 

The patient was treated with an oxygen mask for 7 days and then recovered.

10 CORADS 5 - Subpleural bands

69 year old female with mild dyspnoe for one week with cough and fever.
She was treated with 2L O2/min.

CT findings: 

• Subpleural bands and some GGO
• CORADS 5

11 CORADS 1 - Colitis

History
89 year old female, who had fever for seven days with diarrhoea. 

CT findings 
Normal lungs
Thickened wall of the descending colon probably colitis

CORADS 1  no COVID-19

PCR ...

12 CORADS 5 - Peripheral consolidation

49 year old male complained of being extremely tired for 12 days with headache and a dry cough and weight loss of 8 kilos.

CT findings: 

• Bilateral consolidation more pronounced in the lower lobes and peripheral.
• The consolidations are more pronounced then the GGO
• CORADS 5

He was treated with an oxygen mask for 3 days and then recovered.

13 CORADS 5 - 75% involvement

History

40 year old male, who had fever for ten days with progressive coughing and shortness of breath. Saturation at admission was 66%.

CT findings 
Widespread bilateral ground-glass opacities with a posterior predominance.
75% of the lungs are involved.

CORADS 5 very likely COVID-19

PCR positive

14 Subpleural bands

History
75 year old male with fever for 6 days

CT findings
Bilateral subpleural bands

CORADS 5

Comment
Subpleural bands are probably fibrous bands but this is still not certain.
Pan reported 17% COVID-19 patients with fibrous stripes in their study (2).
Fibrous lesions may form during the healing of pulmonary chronic inflammation or proliferative diseases, with gradual replacement of cellular components by scar tissue.
The relation between fibrosis and patients’ prognosis is debatable. 

15 CORADS 3 - focal consolidation with halo

History
34 year old female
High fever for 1 day with coughing

CT findings
Focal consolidation with surrounding GGO
Only in right lower lobe.

CORADS 3 equivocal

PCR 2 x negative
Influenza negative, RSV negative

Clinical course
Continuous fever for two more days. No oxygen. Discharged from hospital on third day.

16 Mild infection

History
61 year old male
10 days fever, dyspnoe and diarrhoea after a holiday in Egypt.

CT findings 
Bilateral faint areas of GGO
Severity index: 5
10% involvement

CORADS 5 very likely COVID-19

PCR positive

Clinical course
After 2 days of oxygen therapy the patient could be discharged from the hospital

17 GGO only in right lung

History
46 year old male
8 days fever, dry cough, dyspnoe and diarrhoea.

CT findings 
GGO in the right lung
Severity index: 5
10% involvement

CORADS 5 very likely COVID-19

PCR not known

Clinical course
not known

18 Mild lymphadenopathy

History
61 year old male had high fever for 10 days.

CT findings 
Bilateral patchy areas of GGO

CORADS 5 very likely COVID-19

PCR positive

Clinical course
4 days of Oxygen therapy

19 Lobar consolidation and GGO

History
67 year old male, who had fever for fourteen days with coughing and lately hemoptoe.

CT findings 
Dense consolidation in left lower lobe
Ground glass in right lower lobe (yellow arrows)
Maybe some tree-in-bud in right upper lobe (red arrow)

CORADS 2  low suspicion COVID-19, probably bacterial pneumoniae

PCR 2 x negative
Influenza negative, RSV negative, no pneumococcus, no legionella.

Treated with antibiotics and was feeling better 2 days later with no fever.

20 Extubation

History
73 year old male with aorta insufficiency and pacemaker was admitted to the hospital with fever and coughing after being in an area with Corona.

X findings
day 1. normal findings
day 4. bilateral consolidations intubated.
day 8. bilateral consolidation
day 13. extubation

PCR
positive

Follow up
Extubated after 9 days of mechanical ventilation

21 Bilateral patchy GGO - no oxygen

History
71 year old male coughing for 10 days, no fever

CT findings 
Bilateral patchy areas of GGO

CORADS 5 very likely COVID-19

PCR positive

Clinical course
Did not need oxygen therapy. Discharge 4 days later.

22 Bilateral GGO 3 days oxygen

History
61 year old male with fever, coughing for 1 week.

CT findings
Bilateral patchy GGO

CORADS 5

PCR
positive

Follow up
Discharge after 3 days of oxygen therapy

23 Vacuolar sign

History
67 year old woman was admitted to the hospital after spending one week in quarantaine with fever, coughing and headache.

CT findings 
Patchy areas of GGO bilateral
Bronchiectasis
Wide vessels
Vacuolar sign (1)
Subpleural bands in lower lobes

CORADS 5 very likely COVID-19

PCR positive

Clinical course
One day after admission she was intubated and transported to another hospital.

24 Fever and hemoptoe

History
58 year old male with mild mitral and aortic insufficiency presented with high fever and coughing for 10 days with exhaustion. 

CT findings
Extensive bilateral GGO
Extensive widenend vessels
Bronchiectasis
> 75% lung involvement

CORADS 5

PCR
positive

Follow up
Immediately after admission the patient was transferred to the ICU and intubated. Patient died eight days later.

25 CORADS 1 Coughing and chest pain

History
61 year old male with a history of bypass surgery and endocarditis complicated by a total AV block for which he had a pacemaker, presented with coughing for 1 week and chest pain.

CT findings
Normal

CORADS 1

PCR
negative - results after discharge

Follow up
There was no cardiac problem involved. Because of the normal CT the patient was reassured and returned to his home and he received a later call that the PCR was negative.

26 Immunodeficiency

History
50 year old female with a common variable immunodeficiency (CVID) had complaints of a cold with a non productive cough was admitted to the hospital because she had fever for one day and headache.

CT findings 
Subtle findings only in left lower lobe
Septal thickening
Subtle areas of GGO 
Bronchial wall thickening

CORADS 3  indeterminate

PCR negative

27 CORADS 5

History
47 year old male with flew-like symptoms for 10 days was admitted to the hospital with progressive dyspnoe and an oxygen saturation of 82%.

CT findings
Bilateral peripheral GGO
Bronchiectasis

CORADS 5

28 CORADS 4

History
40 year old female presented with acute dyspnoe and hemoptoe

CT findings 
Areas of GGO and basal consolidation in lower lobes.

CORADS 4  
probable COVID-19

PCR 
Positive

29 RSV infection

History
67 year old male with Non Hodgkin Lymphoma who had a allogeneic stem cell transplantation half a year ago, was admitted to the hospital with high fever and cold shivers since one day. No coughing.

CT findings 
Multifocal consilidations with halo sign

CORADS 3  
equivocal COVID-19

PCR 
Negative. RSV positive

30 CORADS 5 subpleural bands

History
79 year old male presented with one week dyspnoe and non productive coughing. Received antibiotics since two days. Since one day high fever. R

CT findings 
Bilateral GGO
subpleural bands

CORADS 5  
very likely COVID-19

PCR 
positive

31 Chest pain and low body temperature

History
63 year old female presented with dyspnoe and chest pain since one day. She had a low body temperature and low oxygen saturation. ECG and troponines were normal.

CT findings
No pulmonary emboli or dissection
Some GGO and consolidation not the bilateral patchy pattern that we normally see in COVID-19.
Thickened interlobular septa
Pleural fluid

CORADS 2  
low suspicion of COVID-19
Maybe some other infection in combination with heart failure.

PCR
negative

32 probably heart failure

History
56 year old male with a history of  two times renal tranplant with rejection and hypertension and vomiting and diarrhoea since three days. At admission the oxygen saturation was 74%.

CT findings 
high position tube
diffuse GGO and thickened interlobular septa
bilateral pleural fluid

CORADS 2  
Low suspicion of COVID-19. Most likely heart failure with pulmonar edema.

PCR 
Negative. Influenza and RSV negative

33 CORADS 5

History
73 year old female known with LBTB had progressive dyspnoe for 3 weeks.

CT findings 
Bilateral widespread areas of GGO

CORADS 5  
typical COVID-19

PCR 
positive

34 CORADS 3 PCR+

History
70 year old male with dementia was admitted to the hospital with chest pain and dyspnoe. No cardiac cause.

CT findings 
breathing artifacts.
maybe some areas with GGO

CORADS 3  
Indeterminate

PCR  positive

35 25 year old male

History
25 year old male with fever and dyspnoe for 5 days. Treated with oxygen for one day. Went home but was readmitted the next day with progressive dyspnoe.

CT findings 
Bilateral GGO

CORADS 5  

PCR  positive