Review of Chest Radiograph Findings of COVID-19 Pneumonia and Suggested Reporting Language

Abstract

The diagnosis of coronavirus disease 2019 (COVID-19) is confirmed by reverse transcription polymerase chain reaction. The utility of chest radiography (CXR) remains an evolving topic of discussion. Current reports of CXR findings related to COVID-19 contain varied terminology as well as various assessments of its sensitivity and specificity. This can lead to a misunderstanding of CXR reports and makes comparison between examinations and research studies challenging. With this need for consistency, we propose language for standardized CXR reporting and severity assessment of persons under investigation for having COVID-19, patients with a confirmed diagnosis of COVID-19, and patients who may have radiographic findings typical or suggestive of COVID-19 when the diagnosis is not suspected clinically. We recommend contacting the referring providers to discuss the likelihood of viral infection when typical or indeterminate features of COVID-19 pneumonia on CXR are present as an incidental finding. In addition, we summarize the currently available literature related to the use of CXR for COVID-19 and discuss the evolving techniques of obtaining CXR in COVID-19-positive patients. The recently published expert consensus statement on reporting chest computed tomography findings related to COVID-19, endorsed by the Radiological Society of North American (RSNA), the Society of Thoracic Radiology (STR), and American College of Radiology (ACR), serves as the framework for our proposal.

Performance of a Severity Score on Admission Chest Radiograph in Predicting Clinical Outcomes in Hospitalized Patients with Coronavirus Disease (COVID-19)

“…presentation (3,(8)(9)(10)(11)(12)(13). The challenges in using imaging to diagnose COVID-19 are reflected in recommendations from professional imaging societies to report CT findings in patients under investigation for possible COVID-19 using four categories (typical, indeterminate, atypical, or negative for COVID-19 pneumonia) and to give the disclaimer that the findings may overlap with other infections, drug reactions, and other causes of acute lung injury (14,15).…”

When pneumonia is not COVID-19

“…Signs on chest X-ray in COVID-19 faithfully follow the patterns seen on CT, 1 , 12 , 13 with a bilateral and peripheral distribution as well as a tendency towards a basal predominance (the most characteristic), in the form of frank consolidation, fainter opacities (which can be labelled “ground-glass” opacities, as in CT semiology) or more linear or reticular lesions. 1 , 12 , 14 , 15 , 16 However, it must always be borne in mind that, in the epidemic phase, almost any pulmonary opacity could correspond to SARS-CoV-2 pneumonia.…”

“…It is more common on CT, 12 , 13 , 18 though it is seen in less than 20% of cases in some series. 17 , 18 Regarding the presentation of COVID-19 in the form of interstitial involvement or as a reticular pattern, there must be a differential diagnosis with atypical forms of pneumonia 6 , 15 and non-infectious causes (interstitial oedema, fibrosis, etc.).

Figure 5 Radiological findings in cases of pneumonia with an aetiology other than COVID-19.

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Post-acute COVID-19 syndrome. Incidence and risk factors: A Mediterranean cohort study

“…Chest radiographs at the time of diagnosis and in the follow-up visit were evaluated by a 25year experienced thoracic radiologist, without knowledge of the clinical status. Lung involvement was classified as reticular, ground-glass or consolidation predominance, or as a combination of them, and extension of abnormalities was graded according to an adaptation of a previously described scoring system[8] ranging from 0 to 10. * The referral criteria for pneumology were the presence of cough, dyspnea, radiographic or spirometry abnormalities; for neurology were a referred memory impairment, new-onset selfperceived cognitive impairment or previous exacerbation or new neurological deficit in the anamnesis / exploration.…”