Aim The purpose of this study is to describe the main chest radiological features (CXR) of COVID-19 and correlate them with clinical outcome. Materials and methods This is a retrospective study involving patients with clinical-epidemiological suspect of COVID-19 infection, who performed CXRs at the emergency department (ED) of our University Hospital from March 1 to March 31, 2020. All patients performed RT-PCR nasopharyngeal and throat swab, CXR at the ED and clinical-epidemiological data. RT-PCR results were considered the reference standard. The final outcome was expressed as discharged or hospitalized patients into a medicine department or intensive care unit (ICU). Results Patients that had a RT-PCR positive for COVID-19 infection were 234 in total: 153 males (65.4%) and 81 females (34.6%), with a mean age of 66.04 years (range 18-97 years). Thirteen CXRs were negative for radiological thoracic involvement (5.6%). The following alterations were more commonly observed: 135 patients with lung consolidations (57.7%), 147 (62.8%) with GGO, 55 (23.5%) with nodules and 156 (66.6%) with reticular-nodular opacities. Patients with consolidations and GGO coexistent in the same radiography were 35.5% of total. Peripheral (57.7%) and lower zone distribution (58.5%) were the most common predominance. Moreover, bilateral involvement (69.2%) was most frequent than unilateral one. Baseline CXR sensitivity in our experience is about 67.1%. The most affected patients were especially males in the age group 60-79 years old (45.95%, of which 71.57% males). RALE score was slightly higher in male than in female patients. ANOVA with Games-Howell post hoc showed significant differences of RALE scores for group 1 vs 3 (p < 0.001) and 2 vs 3 (p = 0.001). Inter-reader agreement in assigning RALE score was very good (ICC: 0.92-with 95% confidence interval 0.88-0.95). Conclusion In COVID-19, CXR shows patchy or diffuse reticular-nodular opacities and consolidation, with basal, peripheral and bilateral predominance. In our experience, baseline CXR had a sensitivity of 68.1%. The RALE score can be used in the emergency setting as a quantitative method of the extent of SARS-CoV-2 pneumonia, correlating with an increased risk of ICU admission.

Objective To identify the main computed tomography (CT) features that may help distinguishing a progression of interstitial lung disease (ILD) secondary to Systemic sclerosis (SSc) from COVID-19 pneumonia. Methods This multicentric study included 22 international readers divided in the radiologist group (RAD) and non-radiologist group (nRAD). A total of 99 patients, 52 with COVID-19 and 47 with SSc-ILD, were included in the study. Results Fibrosis inside focal ground glass opacities (GGO) in the upper lobes; fibrosis in the lower lobe GGO; reticulations in lower lobes (especially if bilateral and symmetrical or associated with signs of fibrosis) were the CT features most frequently associated with SSc-ILD. The CT features most frequently associated with COVID- 19 pneumonia were: consolidation (CONS) in the lower lobes, CONS with peripheral (both central/peripheral or patchy distributions), anterior and posterior CONS and rounded-shaped GGOs in the lower lobes. After multivariate analysis, the presence of CONS in the lower lobes (p &lt; 0.0001) and signs of fibrosis in GGO in the lower lobes (p &lt; 0.0001) remained independently associated with COVID-19 pneumonia or SSc-ILD, respectively. A predictive score was created which resulted positively associated with the COVID-19 diagnosis (96.1% sensitivity and 83.3% specificity). Conclusion The CT differential diagnosis between COVID-19 pneumonia and SSc-ILD is possible through the combination the proposed score and the radiologic expertise. The presence of consolidation in the lower lobes may suggest a COVID-19 pneumonia while the presence of fibrosis inside GGO may indicate a SSc-ILD.

Purpose Cerebrovascular disease (CVD) is considered a major risk factor for fatal outcome in COVID-19. We aimed to evaluate the possible association between computed tomography (CT) signs of chronic CVD and mortality in infected patients. Materials and methods We performed a double-blind retrospective evaluation of the cerebral CT scans of 83 COVID-19 patients looking for CT signs of chronic CVD. We developed a rapid visual score, named CVD-CT, which summarized the possible presence of parietal calcifications and dolichosis, with or without ectasia, of intracranial arteries, areas of chronic infarction and leukoaraiosis. Statistical analysis was carried out with weighted Cohen’s K test for inter-reader agreement and logistic regression to evaluate the association of in-hospital mortality with CVD-CT, chest X-ray (CXR) severity score (Radiographic Assessment of Lung Edema-RALE) for radiological assessment of pulmonary disease, sex and age. Results CVD-CT (odds ratio 1.6, 95% C.I. 1.2-2.1, p = 0.001) was associated with increased risk of mortality. RALE showed an almost significant association (odds ratio 1.05, 95% C.I. 1-1.1, p 0.06), whereas age and sex did not. Conclusion CVD-CT is associated with risk of mortality in COVID-19 patients. The presence of CT signs of chronic CVD may be correlated to a condition of fragility of the circulatory system, which constitutes a key risk factor for death in infected patients.

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Objectives Physicians’ gestalt is central in the diagnostic pipeline of suspected COVID‐19, due to the absence of a single tool allowing conclusive rule in or rule out. The aim of this study was to estimate the diagnostic test characteristics of physician's gestalt for COVID‐19 in the emergency department (ED), based on clinical findings or on a combination of clinical findings and bedside imaging results. Methods From April 1 to April 30, 2020, patients with suspected COVID‐19 were prospectively enrolled in two EDs. Physicians prospectively dichotomized patients in COVID‐19 likely or unlikely twice: after medical evaluation of clinical features (clinical gestalt [CG]) and after evaluation of clinical features and results of lung ultrasound or chest x‐ray (clinical and bedside imaging–integrated gestalt [CBIIG]). The final diagnosis was adjudicated after independent review of 30‐day follow‐up data. Results Among 838 ED enrolled patients, 193 (23%) were finally diagnosed with COVID‐19. The area under the curve (AUC), sensitivity, and specificity of CG and CBIIG for COVID‐19 were 80.8% and 91.6% (p < 0.01), 82.9% and 91.4% (p = 0.01), and 78.6% and 91.8% (p < 0.01), respectively. CBIIG had similar AUC and sensitivity to reverse transcription–polymerase chain reaction (RT‐PCR) for SARS‐CoV‐2 on the first nasopharyngeal swab per se (93.5%, p = 0.24; and 87%, p = 0.17, respectively). CBIIG plus RT‐PCR had a sensitivity of 98.4% for COVID‐19 (p < 0.01 vs. RT‐PCR alone) compared to 95.9% for CG plus RT‐PCR (p = 0.05). Conclusions In suspected COVID‐19, CG and CBIIG have fair diagnostic accuracy, in line with physicians’ gestalt for other acute conditions. Negative RT‐PCR plus low probability based on CBIIG can rule out COVID‐19 with a relatively low number of false‐negative cases.

Since the first report of the outbreak in Wuhan, China in December 2019, as of 1 September 2021, the World Health Organization has confirmed more than 239 million cases of the novel coronavirus (SARS-CoV-2) infectious disease named coronavirus disease 2019 (COVID-19), with more than 4.5 million deaths. Although SARS-CoV-2 mainly involves the respiratory tract, it is considered to be a systemic disease. Imaging plays a pivotal role in the diagnosis of all manifestations of COVID-19 disease, as well as its related complications. The figure of the radiologist is fundamental in the management and treatment of the patient. The authors try to provide a systematic approach based on an imaging review of major multi-organ manifestations of this infection.

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