Abdominal pain with incidental lung abnormality on CT • Xray of the Week
No SOB, cough or fever.
Figure 1. CT abdomen and pelvis showing peripherally distributed bibasilar ground-glass opacities (red and blue arrows)
On January 7, 2020, a novel coronavirus was isolated and named as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by the International Committee on Taxonomy of Viruses (ICTV) in the wake of an outbreak of pneumonia of unknown cause in Wuhan city, China[1, 2]. This pneumonia was called Coronavirus Disease 2019 (COVID-19) by the World Health Organization on February 11, 2020. Globally, more than 20 million confirmed cases of COVID-19 have been reported. An outbreak at Wuhan, identified an initial association of human with a seafood market that sold live animals. However, as the outbreak progressed, person-to-person spread through the airborne route became the main mode of transmission. SARS-CoV-2 has been detected in non-respiratory specimens, including stool, blood, ocular secretions, and semen, but the role of these sites in transmission is uncertain [3-6]. Most commonly seen in adults than in children. The incubation period for COVID-19 is up to 14 days, with most cases occurring four to five days after exposure. [7, 8]. Infectivity is high during earlier stages of illness, when viral RNA levels from upper respiratory specimens are the highest [9-12]. The duration of viral RNA shedding is variable and may increase with the severity of illness and does not indicate prolonged infectiousness [11, 13-15].Transmission of SARS-CoV-2 from individuals with infection but no symptoms (including those who later developed symptoms and thus were considered presymptomatic) has been documented [16-18]. As per CDC in United States, pneumonia is the most frequent serious manifestation of infection, characterized primarily by fever ( in 43%), cough (in 50%), dyspnea (in 29%), and bilateral infiltrates on chest imaging. Other features includes sore throat (in 20%), myalgias (in 36%), diarrhea (in 19%), headache (in 34%), nausea/vomiting (in 12 %) and smell or taste disorders, abdominal pain, and rhinorrhea (in <10 % each) [8, 19, 20].
SARS-Cov-2 has high affinity to angiotensin converting enzyme 2 (ACE2) receptors, leading to cytokine-mediated immune response and inflammation, thereby affecting organs posing ACE2 receptors i.e. brain, heart, arterial and venous endothelial cells, kidneys, liver (hepatocytes and cholangiocytes), gastrointestinal tract, and gallbladder giving atypical symptoms of COVID-19 pneumonia [3-5]. The optimal time to test for COVID-19 following exposure is uncertain as the time to detectable RNA following exposure is unknown, hence five to seven days post exposure is recommended and a negative viral test following exposure, still necessitates quarantine. Nucleic acid amplification testing (NAAT), most commonly with a reverse-transcription polymerase chain reaction (RT-PCR) assay, to detect SARS-CoV-2 RNA from the upper respiratory tract is the preferred initial diagnostic test for COVID-19 .
Table 1: Diagnostic tests for COVID-19 . COVID-19: coronavirus disease 2019; RT-PCR: real-time polymerase chain reaction; IgG: immunoglobulin G; CDC: United States Centers for Disease Control and Prevention.* single positive test generally confirms the diagnosis. If initial testing is negative and clinical suspicion remains, performing a second test can enhance diagnostic yield.
In the United States, the CDC recommends collection of one of the upper respiratory specimens: nasopharyngeal/ nasal swab specimen from both anterior nares, nasal or nasopharyngeal wash/aspirate, oropharyngeal swab (has lower sensitivity) (Table 1) Multisystem involvement leads to the following laboratory findings; lymphopenia, elevated aminotransaminase levels, elevated lactate dehydrogenase levels, elevated inflammatory markers (eg, ferritin, C-reactive protein, and erythrocyte sedimentation rate), and abnormalities in coagulation tests [8, 20, 22].
Table 2: Proposed reporting language for CT findings related to COVID-19 . COVID-19: coronavirus disease 2019; CT: computed tomography; GGO: ground-glass opacity; PUI: person under investigation; RT-PCR: reverse transcription polymerase chain reaction.
CXR findings in COVID-19 pneumonia include consolidation and ground glass opacities, with bilateral, peripheral, and lower lung zone distributions. According to the American College of Radiology (ACR), Chest CT is more sensitive than CXR and is reserved for hospitalized patients under treatment. We present a case of 47-year-old female with atypical presentation with abdominal pain and fever but no respiratory symptoms. CT abdomen/pelvis demonstrated bibasilar, peripherally distributed crazy paving pattern (ground-glass opacifications with superimposed septal thickening), which was later diagnosed as COVID-19 pneumonia on further laboratory evaluation (Fig. 1). The Radiological Society of North America has categorized chest CT features as typical, indeterminate, or atypical for COVID-19 (Table 2) . Other chest CT findings includes bronchiectasis, pleural effusion, pericardial effusion, and lymphadenopathy.
Acute respiratory distress syndrome (ARDS) is a serious complication that can manifest shortly after the onset of dyspnea. [20, 24]. Other complications include thromboembolic events [25-27], acute cardiac injury [20, 28], kidney injury, and inflammatory complications [19, 29] The risk of transmission after contact with an individual with COVID-19 increases with the closeness and duration of contact and appears highest with prolonged contact in indoor settings i.e. household contacts, cruise ships , homeless shelters [31, 32], and detention facilities , in health care settings like hospitals  when personal protective equipment are not used, and after social or work gatherings. Hence transmission can be reduced by wearing masks (with NO exhalation valves) in public, washing hands, social or physical distancing.
For patients with non-severe disease, primarily supportive care, with close monitoring for disease progression is recommended. For patients with severe disease requiring supplemental oxygen, mechanical ventilation/ECMO, low dose Dexamethasone and/or Remdesivir has had some success in early clinical trials. [34, 35]
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5. Cheung, K.S., et al., Gastrointestinal Manifestations of SARS-CoV-2 Infection and Virus Load in Fecal Samples From a Hong Kong Cohort: Systematic Review and Meta-analysis. Gastroenterology, 2020. 159(1): p. 81-95 DOI: 10.1053/j.gastro.2020.03.065. Retrieved from http://www.sciencedirect.com/science/article/pii/S0016508520304480
6. Li, D., et al., Clinical Characteristics and Results of Semen Tests Among Men With Coronavirus Disease 2019. JAMA Netw Open, 2020. 3(5): p. e208292 DOI: 10.1001/jamanetworkopen.2020.8292
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10. To, K.K., et al., Temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by SARS-CoV-2: an observational cohort study. Lancet Infect Dis, 2020. 20(5): p. 565-574 DOI: 10.1016/s1473-3099(20)30196-1
11. Wölfel, R., et al., Virological assessment of hospitalized patients with COVID-2019. Nature, 2020. 581(7809): p. 465-469 DOI: 10.1038/s41586-020-2196-x
12. Kujawski, S.A., et al., Clinical and virologic characteristics of the first 12 patients with coronavirus disease 2019 (COVID-19) in the United States. Nature Medicine, 2020. 26(6): p. 861-868 DOI: 10.1038/s41591-020-0877-5
13. Zheng, S., et al., Viral load dynamics and disease severity in patients infected with SARS-CoV-2 in Zhejiang province, China, January-March 2020: retrospective cohort study. BMJ, 2020. 369: p. m1443 DOI: 10.1136/bmj.m1443. Retrieved from http://www.bmj.com/content/369/bmj.m1443.abstract
14. Liu, Y., et al., Viral dynamics in mild and severe cases of COVID-19. Lancet Infect Dis, 2020. 20(6): p. 656-657 DOI: 10.1016/s1473-3099(20)30232-2
15. Xu, K., et al., Factors Associated With Prolonged Viral RNA Shedding in Patients with Coronavirus Disease 2019 (COVID-19). Clin Infect Dis, 2020. 71(15): p. 799-806 DOI: 10.1093/cid/ciaa351
16. Rothe, C., et al., Transmission of 2019-nCoV Infection from an Asymptomatic Contact in Germany. N Engl J Med, 2020. 382(10): p. 970-971 DOI: 10.1056/NEJMc2001468
17. Bai, Y., et al., Presumed Asymptomatic Carrier Transmission of COVID-19. Jama, 2020. 323(14): p. 1406-7 DOI: 10.1001/jama.2020.2565
18. Wang, Y., et al., Characterization of an asymptomatic cohort of SARS-COV-2 infected individuals outside of Wuhan, China. Clin Infect Dis, 2020 DOI: 10.1093/cid/ciaa629
19. Huang, C., et al., Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet, 2020. 395(10223): p. 497-506 DOI: 10.1016/s0140-6736(20)30183-5
20. Wang, D., et al., Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. Jama, 2020. 323(11): p. 1061-9 DOI: 10.1001/jama.2020.1585
21. Patel, A. and D.B. Jernigan, Initial Public Health Response and Interim Clinical Guidance for the 2019 Novel Coronavirus Outbreak - United States, December 31, 2019-February 4, 2020. MMWR Morb Mortal Wkly Rep, 2020. 69(5): p. 140-146 DOI: 10.15585/mmwr.mm6905e1
22. Goyal, P., et al., Clinical Characteristics of Covid-19 in New York City. N Engl J Med, 2020. 382(24): p. 2372-2374 DOI: 10.1056/NEJMc2010419
23. Simpson, S., et al., Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA - Secondary Publication. Journal of Thoracic Imaging, 2020. 35(4): p. 219-227 DOI: 10.1097/rti.0000000000000524.https://journals.lww.com/thoracicimaging/Fulltext/2020/07000/Radiological_Society_of_North_America_Expert.2.aspx
24. Richardson, S., et al., Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. Jama, 2020. 323(20): p. 2052-9 DOI: 10.1001/jama.2020.6775
25. Mao, L., et al., Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China. JAMA Neurol, 2020. 77(6): p. 1-9 DOI: 10.1001/jamaneurol.2020.1127
26. Klok, F.A., et al., Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res, 2020. 191: p. 145-147 DOI: 10.1016/j.thromres.2020.04.013
27. Merkler, A.E., et al., Risk of Ischemic Stroke in Patients With Coronavirus Disease 2019 (COVID-19) vs Patients With Influenza. JAMA Neurology, 2020 DOI: 10.1001/jamaneurol.2020.2730
28. Arentz, M., et al., Characteristics and Outcomes of 21 Critically Ill Patients With COVID-19 in Washington State. JAMA, 2020. 323(16): p. 1612-1614 DOI: 10.1001/jama.2020.4326
29. Mehta, P., et al., COVID-19: consider cytokine storm syndromes and immunosuppression. Lancet, 2020. 395(10229): p. 1033-1034 DOI: 10.1016/s0140-6736(20)30628-0
30. Kakimoto, K., et al., Initial Investigation of Transmission of COVID-19 Among Crew Members During Quarantine of a Cruise Ship - Yokohama, Japan, February 2020. MMWR Morb Mortal Wkly Rep, 2020. 69(11): p. 312-313 DOI: 10.15585/mmwr.mm6911e2
31. Baggett, T.P., et al., Prevalence of SARS-CoV-2 Infection in Residents of a Large Homeless Shelter in Boston. JAMA, 2020. 323(21): p. 2191-2192 DOI: 10.1001/jama.2020.6887
32. Kuehn, B.M., Homeless Shelters Face High COVID-19 Risks. Jama, 2020. 323(22): p. 2240 DOI: 10.1001/jama.2020.8854
33. Saloner, B., et al., COVID-19 Cases and Deaths in Federal and State Prisons. JAMA, 2020. 324(6): p. 602-603 DOI: 10.1001/jama.2020.12528.
34. Horby, P., et al., Dexamethasone in Hospitalized Patients with Covid-19 - Preliminary Report. N Engl J Med, 2020 DOI: 10.1056/NEJMoa2021436
35. Wang, M., et al., Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro. Cell Research, 2020. 30(3): p. 269-271 DOI: 10.1038/s41422-020-0282-0
36. Weissleder, R., et al., COVID-19 diagnostics in context. Science Translational Medicine, 2020. 12(546): p. eabc1931 DOI: 10.1126/scitranslmed.abc1931. Retrieved from https://stm.sciencemag.org/content/scitransmed/12/546/eabc1931.full.pdf
Shama Jaswal is an International Medical Graduate, currently doing research at Mallinckrodt Institute of Radiology (MIR), Saint Louis. She aims at pursuing Diagnostic Radiology residency and poses a keen interest in research alongside academics. At MIR, she has been fortunate to work on various oncology projects including the project in which they studied how the difference in fat metabolism in both sexes can affect the cancer survival and outcome, and how this study can further improve prognosis through treatment modification. Shama is both an accomplished sprinter and singer having won several national competitions in in each discipline in India. She also has a strong passion for cooking and gardening.
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Kevin M. Rice, MD is the president of Global Radiology CME
Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator.
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