The Valuable Role of Imaging Modalities in the Diagnosis of the Uncommon Presentations of COVID-19: An Educative Case Series

Abstract

The outbreak of coronavirus disease 2019 (COVID-19) in late 2019 rapidly turned into a global pandemic. Although the symptoms of COVID-19 are mainly respiratory ones, the infection is associated with a wide range of clinical signs and symptoms. The main imaging modality in COVID-19 is lung computed tomography (CT) scanning, but the diagnosis of the vast spectrum of complications needs the application of various imaging modalities. Owing to the novelty of the disease and its presentations, its complications—particularly uncommon ones—can be easily missed. In this study, we describe some uncommon presentations of COVID-19 diagnosed by various imaging modalities. The first case presented herein was a man with respiratory distress, who transpired to suffer from pneumothorax and pneumomediastinum in addition to the usual pneumonia of COVID-19. The second patient was a hospitalized COVID-19 case, whose clinical condition suddenly deteriorated with the development of abdominal symptoms diagnosed as mesenteric ischemia by abdominal CT angiography. The third patient was a case of cardiac involvement in the COVID-19 course, detected as myocarditis by cardiac magnetic resonance imaging (MRI). The fourth and fifth cases were COVID-19-associated encephalitis whose diagnoses were established by brain MRI. COVID-19 is a multisystem disorder with a wide range of complications such as pneumothorax, pneumomediastinum, mesenteric ischemia, myocarditis, and encephalitis. Prompt diagnosis with appropriate imaging modalities can lead to adequate treatment and better survival.

Scoping Review of Clinical Presentations and Outcomes in Patients with Concomitant COVID-19 Infection and Acute Mesenteric Ischaemia

“…These studies underwent full-text evaluation, and a further three studies were retrieved upon screening these studies’ references. Forty-one studies reporting on 44 patients were included in the final selection [ 14 , 16 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 ]. Of these, 32 were case reports, and the remaining 9 were case series.…”

“…Five patients presented with solely respiratory symptoms, and all developed abdominal pain later during their admission [ 43 , 53 , 54 , 65 , 66 ]. Thirteen patients who tested positive for COVID-19 made contact with healthcare services before presenting to the emergency department with gastrointestinal symptoms [ 16 , 30 , 31 , 32 , 35 , 37 , 38 , 40 , 41 , 45 , 48 , 54 , 63 ]. All patients had cross-sectional imaging to confirm the diagnosis of acute mesenteric ischaemia.…”

“…Multiple studies have shown that the most common manifestations of thromboembolism in hospitalised COVID-19 patients are deep vein thrombosis and pulmonary embolism, and the risk increases further if the patient is admitted to an intensive care unit [ 3 , 4 , 13 ]. Although thromboembolism in mesenteric vessels is rare, it has been reported in COVID-19 patients in several case series [ 14 , 15 , 16 ]. Acute mesenteric ischaemia (AMI) is defined as a sudden disruption in circulation to the intestines necessitating urgent intervention in most cases to preserve the viability of the bowel [ 17 ].…”

“…The current literature on COVID-19-induced AMI has looked into patient presentations and established a high mortality rate in these patients [ 20 , 21 , 22 ]. A further subset of studies investigated the radiological signs of AMI during COVID-19 and highlighted the importance of cross-sectional imaging to diagnose AMI promptly [ 16 , 23 , 24 , 25 ]. However, there is limited research on the effect different types of AMI have on patient outcomes during COVID.…”

Acute mesenteric ischemia and COVID-19: an integrative review of the literature

“…He continued with oral anticoagulation for 6 months. Discharge Cheung et al 45 USA 1 55 Abdominal pain and tenderness, nausea and vomiting, diarrhea, decreased BS SMA Thrombosis Therapeutic anticoagulation, SMA thrombectomy, and laparotomy with resection of necrotic bowel NR Nada et al 46 USA 1 49 Abdominal pain, signs of peritonitis SMA thrombosis, signs of intestinal ischemia and pneumatosis, pneumoperitoneum, renal infarction Conservative treatment with LMWH due to advanced intestinal necrosis Death Alali et al 47 Saudi Arabia 1 35 Abdominal pain and tenderness, vomiting SMA Thrombosis Therapeutic anticoagulation, later laparotomy Discharge Khaleghi et al 48 Iran 1 54 Abdominal pain, tenderness and distention, nausea and vomiting SMA thrombosis, bowel loop dilation Laparotomy with resection of necrotic bowel, relaparotomy to assess abnormalities NR Posada-Arango et al 49 Peru 3 62 Abdominal pain, vomiting …”