Discrepancies in the clinical and radiological profiles of COVID-19: A case-based discussion and review of literature

Abstract

The current gold standard for the diagnosis of coronavirus disease-19 (COVID-19) is a positive reverse transcriptase polymerase chain reaction (RT-PCR) test, on the background of clinical suspicion. However, RT-PCR has its limitations; this includes issues of low sensitivity, sampling errors and appropriate timing of specimen collection. As pulmonary involvement is the most common manifestation of severe COVID-19, early and appropriate lung imaging is important to aid diagnosis. However, gross discrepancies can occur between the clinical and imaging findings in patients with COVID-19, which can mislead clinicians in their decision making. Although chest X-ray (CXR) has a low sensitivity for the diagnosis of COVID-19 associated lung disease, especially in the earlier stages, a positive CXR increases the pre-test probability of COVID-19. CXR scoring systems have shown to be useful, such as the COVID-19 opacification rating score which helps to predict the need of tracheal intubation. Furthermore, artificial intelligence-based algorithms have also shown promise in differentiating COVID-19 pneumonia on CXR from other lung diseases. Although costlier than CXR, unenhanced computed tomographic (CT) chest scans have a higher sensitivity, but lesser specificity compared to RT-PCR for the diagnosis of COVID-19 pneumonia. A semi-quantitative CT scoring system has been shown to predict short-term mortality. The routine use of CT pulmonary angiography as a first-line imaging modality in patients with suspected COVID-19 is not justifiable due to the risk of contrast nephropathy. Scoring systems similar to those pioneered in CXR and CT can be used to effectively plan and manage hospital resources such as ventilators. Lung ultrasound is useful in the assessment of critically ill COVID-19 patients in the hands of an experienced operator. Moreover, it is a convenient tool to monitor disease progression, as it is cheap, non-invasive, easily accessible and easy to sterilise. Newer lung imaging modalities such as magnetic resonance imaging (MRI) for safe imaging among children, adolescents and pregnant women are rapidly evolving. Imaging modalities are also essential for evaluating the extra-pulmonary manifestations of COVID-19: these include cranial imaging with CT or MRI; cardiac imaging with ultrasonography (US), CT and MRI; and abdominal imaging with US or CT. This review critically analyses the utility of each imaging modality to empower clinicians to use them appropriately in the management of patients with COVID-19 infection.

Keywords: COVID-19; Pneumonia; Lung imaging; Chest X-ray; Computed tomography; Lung ultrasound

Core Tip: The coronavirus disease-19 (COVID-19) pandemic has had a devastating impact on the human race, with the current death toll exceeding 2.8 million. Although a positive reverse transcriptase polymerase chain reaction test is the gold standard for diagnosing a COVID-19 infection, the reported sensitivity of the test is < 90%, and clinicians often need to rely upon various imaging studies for definitive diagnoses and prognostication. However, discrepancies between the clinical and imaging profiles of patients with the disease can often pose challenges in therapeutic decision making. Therefore, it is imperative to understand the diagnostic sensitivity, specificity, and positive and negative predictive values of each imaging modality for the rational management of patients with this enigmatic disease. This evidence-based review is a clinical update to empower clinicians across the world who is involved in combatting COVID-19.