JOURNAL READING

Clinical and Imaging Features of COVID-19

Disusun oleh:
Rafidah Hanina Ashil 1102016176
Ramdesima Kasmir 1102016177
Rami Pratama Putra 1102016178
Rania Ghozi 1102016179
Rasyiqah Saratiana 1102016180

Pembimbing:
Dr. Ryan Indra, Sp.Rad

KEPANITERAAN KLINIK RADIOLOGI

RSUD CIBITUNG BEKASI
FAKULTAS KEDOKTERAN UNIVERSITAS YARSI
 ABSTRAK

Sejak Desember 2019, beberapa kasus penyakit coronavirus (COVID-19) dilaporkan

terjadi di Wuhan, Provinsi Hubei, China. Penyakit yang sangat menular ini menyebar dengan
sangat cepat ke beberapa negara karena manusia sangat rentan terhadap infeksi. Gejala klinis
utama COVID-19 adalah demam, kelelahan, dan batuk kering. Pemeriksaan laboratorium pada
stadium awal menunjukkan jumlah sel darah putih normal atau menurun, dan penurunan jumlah
limfosit. Sementara pemeriksaan CT berfungsi sebagai dasar skrining dan diagnostik untuk
COVID-19 karena akurasinya terbatas. Pemeriksaan asam nukleat merupakan baku emas untuk
diagnosis COVID-19, namun memiliki sensitivitas yang rendah. Jurnal ini meninjau literatur,
pedoman, dan konsensus yang telah diterbitkan serta merangkum manifestasi klinis dan hasil
pencitraan COVID-19 untuk memberikan dasar dalam menegakkan diagnosis dan tata laksana
awal.
1. PENDAHULUAN
Sejak Desember 2019, beberapa kasus pneumonia yang tidak dapat dijelaskan dilaporkan
terjadi di Wuhan, Provinsi Hubei, Cina. Seiring dengan menyebarnya penyakit, kasus-kasus
COVID-19 juga telah ditemukan di seluruh Cina dan juga negara lainnya. Deteksi asam nukleat
dari sekresi pernapasan pasien mengidentifikasi sumber infeksi adalah spesies virus corona baru,
yang dinamakan 2019 novel coronavirus (2019-nCoV). Pada 11 Februari 2020, WHO secara
resmi menyebut penyakit yang disebabkan oleh novel coronavirus (2019-nCoV) sebagai
Coronavirus Disease 2019 (COVID-19). Pada 22 Februari 2020, Komisi Kesehatan Nasional
Cina mengumumkan penemuan pneumonia coronavirus baru sebagai penyakit Coronavirus.
Penyakit ini termasuk penyakit tipe B baru yang menular (sesuai dengan manajemen kelas A,
Infeksi Pencegahan Penyakit dan Pengendalian Penyakit). Meskipun ada banyak tumpang tindih
antara manifestasi pencitraan pneumonia virus yang berbeda, analisis komprehensif dari
gambaran klinis, epidemiologi, dan hasil pemeriksaan laboratorium sangat penting dalam
meningkatkan diagnosis COVID-19.

2. ETIOLOGI DAN EPIDEMIOLOGI

Coronavirus merupakan salah satu virus RNA. Permukaan partikel virus dikelilingi oleh duri,
dan secara keseluruhan partikelnya menyerupai mahkota, yang merupakan asal-usul nama dari
coronavirus itu sendiri. Terdapat enam subtipe yang telah ditemukan. Namun, empat subtipe
diantaranya kurang pathogen dan umumnya menyebabkan gejala yang ringan. Dua diantaranya
dapat menyebabkan gejala klinis yang parah. Novel coronavirus merupakan coronavirus tipe
baru yang belum pernah ditemukan di manusia sebelumnya dan sekarang dianggap sebagai
subtipe ketujuh. Gen virus ini memiliki lebih dari 85% kesamaan dengan virus mirip SARS pada
kelelawar. Hal tersebut dispekulasikan bahwa mekanisme patogen virus mungkin karena reseptor
2019-nCov dan SARS-Cov dengan domain struktur receptor binding region (RBD) antara urutan
asam amino dan prediksi struktur protein sangat mirip, 2019-nCov secara efektif dapat
menggunakan angiotensin converting enzyme 2 (ACE2) pada sel epitel alveolar tipe II sebagai
reseptor untuk menyerang sel, sehingga masuk ke sel epitel bronkial untuk bereplikasi dan
menyebabkan penyakit.
Investigasi epidemiologi saat ini menunjukkan masa periode inkubasi dari COVID-19 yaitu
berkisar dari hari pertama hingga hari ke 14, dengan kebanyakan kasus pada hari ketiga hingga
hari ketujuh. Sumber utama infeksi yaitu dari pasien yang terinfeksi oleh novel coronavirus serta
pasien yang terinfeksi namun tanpa gejala (dalam masa inkubasi). Infeksi umumnya dapat
menyebar melalui droplet pernafasan maupun kontak langsung. Terpaparnya membran mukosa
serta mata yang tidak terlindungi dapat meningkatkan resiko untuk terinfeksi. Deteksi virus pada
sampel feses dan urin pasien dapat beresiko untuk terjadi transmisi fekal-oral. Terdapat
kemungkinan penularan aerosol ketika kontak yang terlalu lama dengan konsentrasi aerosol yang
tinggi di lingkungan yang relatif tertutup. Saat ini, belum ada laporan transmisi vertikal yang
terjadi dari ibu kepada anak.

3. MANIFESTASI KLINIS DAN PENCITRAAN

Manifestasi klinis dan tes laboratorium tidak spesifik pada COVID-19. Manifestasi klinis
utama yang biasa muncul adalah demam, kelelahan, batuk kering, dan dalam beberapa kasus
yang parah mengakibatkan kegagalan organ multipel. Gejala lain yang mungkin muncul berupa
mialgia dan diare. Tes laboratorium menunjukkan bahwa jumlah total sel darah putih di perifer
yang awalnya normal mengalami penurunan, dan jumlah limfosit juga mengalami penurunan;
CRP dan sedimentasi serum meningkat pada kebanyakan pasien. COVID-19 dapat dikonfirmasi
dengan mendeteksi asam nukleat virus dengan spesifisitas yang kuat namun sensitivitas yang
buruk. Untuk meningkatkan tingkat deteksi asam nukleat positif, dianjurkan untuk melakukan
pemeriksaan dahak dan sekresi saluran pernafasan bawah yang dikirimkan secepatnya untuk
diperiksa. CT-scan berfungsi sebagai skrining dan dasar diagnostik untuk COVID-19: pencitraan
dada pada tahap awal menunjukkan bayangan plak multipel dan perubahan interstitial, sebagian
besar terlihat pada paru bagian perifer dan sub-pleura, dan kemudian berkembang menjadi
bayangan ground glass multiple dan bayangan infiltrasi di kedua paru-paru. Pada kasus yang
parah, konsolidasi paru dapat terjadi, muncul sebagai "white lung", efusi pleura jarang dijumpai
dan pembesaran kelenjar getah bening mediastinum juga jarang dijumpai.

4. IMAGE FEATURES AND STAGING

Pemeriksaan paru dilakukan dengan CT_scan dada yang dilengkapi dengan rontgen dada.
CT-scan dada merupakan skrining dan dasar diagnosis untuk COVID-19. Gambaran yang
ditemukan merupakan cerminan dari proses inflamasi yang terjadi seperti eksudasi jaringan paru,
proliferasi, dan metamorfisme. Berikut beberapa temuan pada hasil pencitraan yang mungkin
ditemukan pada pasien COVID-19:
 Ground-glass opacity (GGO)
Merupakan gambaran densitas yang cukup tinggi pada paru, terjadi oleh karena invasi virus
ke epitel bronkiolus dan alveous lalu bereplikasi di dalam sel epitel tersebut sehingga rongga
alveolus bocor. Kebocoran tersebut menimbulkan inflamasi dan menipiskan dinding atau
rongga alveolus. Biasanya terdapat pada seluruh lapang paru dan dibawah pleura.

 Konsolidasi dan air brochi sign

Proses peradangan akan menyebabkan ulcer yang luas di alveolus dan mukosa yang diikuti
konsolidasi. Ketika tubuh bereaksi kuat terhadap inflamasi, terdapat eksudat yang luas di
alveoli kedua paru-paru, memberikan gambaran “white lung”. Air bronchi sign merupakan
suatu gambaran bayangan udara pada daerah konsolidasi. Patogenesisnya karena invasi virus
ke sel epitel alveolus sehingga menyebabkan inflamasi, penebalan, dan edema pada dinding
bronkus, tanpa diikuti obstruksi bronkiolus.

 Paving Stone sign

Terlihat pada CT beresolusi tinggi, penebalan interval lobular dan bayangan garis interval
interlobular dibarengi GGO. Disebut paving stone karena kemiripan bentuk dengan batu
paving yang tidak teratur. Terjadi akibat dari penebalan interval lobular dan interstisial
interlobular yang menunjukkan perubahan interstisial.

 Lesi Fibrosa
Terjadi karena proses penyembuhan pada inflamasi kronik atau hyperplasia paru, komponen
fibrosa menggantikan sel-sel normal untuk membentuk bekas luka. Lesi fibrosa dapat
menyebabkan distraksi bronkus atau bronkiektasis.

 Penebalan pembuluh darah

Dapat dilihat di seluruh stadium penyakit ini, terdapat dari pinggir dan tengah lesi .
 Tanda Halo
Merupakan suatu lesi dengan densitas yang lebih tinggi di tengahnya daripada di pinggir lesi,
hal ini dapat terjadi karena replikasi virus di sel epitel. Lingkaran tipis cloud-like ground
glass shadow, yang ketebalannya bervariasi dan berubah seperti lingkaran cahaya
mengelilingi lesi.

Image staging and clinical typing

COVID-19 ini dikelompokkan berdasarkan gejala klinis dan temuan pada pencitraan.
Pertama, stadium awal dan tipe ringan yaitu gejala ringan tanpa ada gambaran pencitraan yang
signifikan. Kedua, stadium progresif dan tipe umum (pasien dengan demam, gejala saluran napas,
dan pencitraan menunjukkan pneumonia). Ketiga, tipe stadium berat dan tipe berat (pasien
dengan napas pendek dan hipoksemia). Umumnya ditemukan gambaran lesi difus pada paru
yang disebut “white lung”. Lesi ini bersifat progresif > 50% pada 24-48 jam.
Namun ada beberapa kasus yang berbeda dengan kategori diatas. Pertama, terdapat
kelainan pada pencitraan, namun tidak memiliki gejala. Kedua, tidak terdapat kelainan pada
pencitraan namun memiliki gejala, hal ini mungkin karena virus masih berada di saluran napas
atas sehingga tidak menghasilkan lesi eksudat di paru. Ketiga, gejala klinis sudah berkurang dan
terdapat progresivitas pada pencitraan. Ketidaksamaan antara gejala klinis dan manifestasi
pencitraan ini yang membuat diagnosis COVID-19 ini menjadi sulit dilakukan. Namun data
epidemiologi dan kualitas dari pencitraan akan membantu penegakan diagnosis COVID-19.
Image expression is differentiated from nucleic acid detection
Baku emas untuk diagnosis COVID-19 adalah hasil tes asam nukleat positif, pemeriksaan
yang memiliki spesifisitas tinggi, dan sensitivitas rendah (30-50%). Data dari rumah sakit Wuhan
menunjukkan angka CT yang positif sebesar > 90%, dan yang positif tes asam nukleat sekitar
40%. Terdapat beberapa faktor yang memengaruhi seperti sumber infeksi, viral load, metode
sampling, reagen, dan standar interpretasi. Oleh karena itu pemeriksaan asam nukleat memiliki
keterbatasan utnuk akurasi diagnosis dan pengobatan COVID-19. Departemen radiologi di
Wuhan merekomendasikan CT scan sebagai alat diagnosis utama dan skrining dasar COVID-19.
Diagnostic value of imaging in COVID-19
CT-scan menjadi hal yang penting untuk deteksi tanda-tanda penting untuk pasien
dengan deteksi asam nukleat negatif untuk memantau tatalaksana COVID-19, dan untuk deteksi
dini komplikasi lain. Dalam jurnal ini merekomendasikan waktu yang tepat untuk melakukan CT
scan: 1) Pasien baru dengan manifestasi klinis dan tes genom positif, 2) Kasus diagnosis dengan
gejala tidak khas dan karakteristik pneumonia ditambah dengan pengulangan tes genom dan CT
scan dada 5-7 hari hari kemudian, 3) Kasus terkonfirmasi namun tidak gawat, direkomendasikan
CT scan dada 5-7 hari.

5. DIAGNOSIS BANDING COVID-19

Diagnosis banding COVID-19 dalam “Diagnosis and Treatment Scheme for Coronavirus
Disease (Trial Version 6)” terutama termasuk kebutuhan untuk membedakan gejala ringan dari
infeksi pernafasan lainnya yang disebabkan oleh virus lain seperti virus influenza, adenovirus,
respiratory syncytial virus, dan virus penyebab pneumonia yang lain serta infeksi pneumonia
akibat mycoplasma. Penyakit ini juga harus dibedakan dari penyakit tidak menular seperti
vaskulitis, dermatomyositis, dan organizing pneumonia.

5.1 Pneumonia virus lainnya

Manifestasi pencitraan dari pneumonia virus utamanya adalah perubahan interstitial
paru disertai dengan edema dinding alveolus, sedangkan manifestasi CT adalah GGO,
dengan konsolidasi, penebalan septa interlobular, bayangan mesenchymal, nodul lobular
sentral, tree buds, retensi udara dan fiber cable shadow. Ada tumpang tindih signifikan
antara manifestasi pencitraan pada pneumonia virus yang berbeda, sehingga diagnosis akhir
 harus dikombinasikan dengan data klinis, epidemiologi dan hasil laboratorium. Diagnosis
tergantung pada deteksi dari etiologi.
5.1.1 Virus Influenza A (H1N1)
GGO multipel unilateral atau bilateral, dengan atau tanpa konsolidasi, letaknya di
bronchovascular bundle atau sub-pleura. Sulit untuk membedakan gambarnya dari
pneumonia coronavirus tipe baru. Namun, tahap awal dari pneumonia coronavirus baru
dapat bermanifestasi sebagai small ground glass density shadow atau small flake of
ground glass density shadow yang dapat dilihat dalam bayangan pembuluh darah yang
menebal. Ini mungkin bermanfaat untuk identifikasi awal pada lesi H1N1.

5.1.2 Pneumonia adenovirus

Umumnya terjadi pada anak-anak. GGO multifokal di kedua paru dengan patchy
consolidation, terdapat tren distribusi paru multisegmental. Atelektasis dapat terjadi pada
anak-anak. Terkadang sulit untuk membedakan penyakit ini dari pneumonia bakterial.
5.1.3 Pneumonia human parainfluenza virus
Penyebab umum infeksi pernapasan musiman. Temuan pencitraan bervariasi, dan
termasuk nodul peribronkial multipel, konsolidasi GGO dan aerated bronchi. Distribusi
pusat lesi berbeda dari karakteristik distribusi sub-pleura pneumonia coronavirus baru.

5.1.4 Pneumonia respiratory syncytial virus

Umum terjadi pada bayi, pasien dengan cacat kongenital, imunosupresi dan penyakit
paru-paru kronis. Nodul lobular sentral adalah gambaran yang paling khas, dan tingkat
kejadiannya hingga 50%, yang dapat membedakannya dari pneumonia coronavirus baru.
Selain itu dapat terlihat konsolidasi udara (35%), GGO (30%), dan penebalan dinding
bronkus (30%). Ini terdistribusi di tengah atau area sekitar paru-paru dan distribusinya
asimetris bilateral.
5.2 Pneumonia menular selain virus
5.2.1 Pneumonia mycoplasma
Umum pada anak-anak dan remaja, terdapat gambaran nodul lobular sentral, GGO,
konsolidasi, dengan penebalan dinding bronkus, bronchiole tree buds, pembesaran KGB
hilus dan mediastinum. Tes laboratorium positif untuk antibodi mycoplasma.
5.2.2 Pneumonia bacterial
Tidak ada gejala prodormal dari infeksi saluran pernapasan atas, batuk berdahak
purulen, dahak berdarah atau dahak berwarna karat, pemeriksaan laboratorium terdapat
peningkatan jumlah sel darah putih, pada pencitraan terdapat bayangan konsolidasi single
leaf segment atau sub segment. Pemberian antibiotik memberikan respon yang baik.

5.3 Penyakit tidak menular

5.3.1 Pneumonia mekanik
Manifestasi yang khas adalah bilateral sub-pleural patchy ground-glass opacity atau
konsolidasi, air bronchi sign, GGO sentral, konsolidasi berbentuk cincin marginal atau
bulan sabit menggambarkan tanda "anti-halo", pembesaran hilus dan KGB mediastinum,
serta efusi pleura pada sejumlah kecil kasus.
5.3.2 Pneumonitis hipersensitif
GGO difus pada kedua paru. Nodul lobus sentral dengan tepi kabur, perfusi
mozaik dan retensi udara pada fase ekspirasi, lapang paru pada tahap kronis menunjukkan
bayangan berbentuk jaring halus dan ekstensi peregangan. Pasien biasanya memiliki
riwayat mengembangbiakan burung atau paparan pekerjaan.
5.3.3 Vaskulitis
Manifestasinya adalah nodul multipel dengan kavitasi, nodul yang terhubung dengan
pembuluh darah pulmonalis (tanda-tanda pembuluh darah baik), tanda halo atau anti-
halo, konsolidasi multipel, fiber cord shadow, dan ground-glass density shadow yang
terdistribusi difus, area sub-pleura jarang terjadi. Sering terjadi di tengah band dengan
perdarahan alveolar difus. Manifestasi klinis dapat berupa hemoptysis, dan efusi pleura
sering terjadi. Tes laboratorium antibodi cANCA positif sangat membantu dalam
menegakkan diagnosis.
 KESIMPULAN

COVID-19 sangat menular dan manusia umumnya rentan terhadap infeksi. Sementara
gejala klinis dan pemeriksaan CT scan menunjukkan karakteristik tertentu, ada beberapa
perbedaan antara CT scan dan deteksi asam nukleat dalam beberapa kasus. Namun, analisis
komprehensif tentang riwayat epidemiologi pasien, hasil pemeriksaan laboratorium, gejala klinis
dan pencitraan dibutuhkan untuk pencegahan awal, deteksi awal, diagnosis awal, isolasi awal,
dan pengobatan awal.
Since January 2020 Elsevier has created a COVID-19 resource centre with
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company's public news and information website.

Elsevier hereby grants permission to make all its COVID-19-related

research that is available on the COVID-19 resource centre - including this
research content - immediately available in PubMed Central and other
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for unrestricted research re-use and analyses in any form or by any means
with acknowledgement of the original source. These permissions are
granted for free by Elsevier for as long as the COVID-19 resource centre
remains active.
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H O S T E D BY Available online at www.sciencedirect.com

ScienceDirect 64
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2 Radiology of Infectious Diseases xxx (xxxx) xxx 67
3 www.elsevier.com/locate/jrid 68
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5 Review 70
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Clinical and imaging features of COVID-19 72
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10 Q3 Haixia Chen a, Li Ai a, Hong Lu a,*, Hongjun Li b,** 75
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12 a
Department of Medical Imaging, Seventh People's Hospital of Chongqing, Chongqing 400054, China 77
13 b
Department of Radiology, Beijing YouAn Hospital, Capital Medical University, Beijing 100069, China 78
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Received 5 March 2020; revised 24 March 2020; accepted 16 April 2020
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Available online ▪ ▪ ▪
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Abstract
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Since December 2019, multiple cases of 2019 coronavirus disease (COVID-19) have been reported in Wuhan in China's Hubei Province, a
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disease which has subsequently spread rapidly across the entire country. Highly infectious, COVID-19 has numerous transmission channels and
humans are highly susceptible to infection. The main clinical symptoms of COVID-19 are fever, fatigue, and a dry cough. Laboratory exam- 88
24 89
25 ination in the early stage of the disease shows a normal or decreased white blood cell count, and a decreased lymphocyte count. While CT
examination serves as the screening and diagnostic basis for COVID-19, its accuracy is limited. The nucleic acid testing is the gold standard for 90
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27 the diagnosis of COVID-19, but has a low sensitivity is low. There is clearly a divide between the two means of examination. This paper reviews
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28 the published literature, guidelines and consensus, and summarizes the clinical and imaging characteristics of COVID-19, in order to provide a
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29 reliable basis for early diagnosis and treatment.
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30 © 2020 Beijing You’an Hospital affiliated to Capital Medical University. Production and hosting by Elsevier B.V. This is an open access article
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31 under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 96
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33 Keywords: Novel coronavirus; Coronavirus disease 2019; Clinical features; Image features
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38 1. Introduction as Coronavirus disease. The disease is a new type B infectious
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39 disease (in accordance with the class A management, Infec- 104
40 Since December 2019, multiple cases of unexplained tious Disease Prevention and Control Law). Although there is 105
41 pneumonia have been reported in Wuhan, in China's Hubei considerable overlap between imaging manifestations of 106
42 107
Province. As the disease has spread, cases of COVID-19 have different viral pneumonia, comprehensive analysis of clinical
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also been found across the whole of China and overseas. features, epidemiology and laboratory examination results are
Nucleic acid detection of a patient's respiratory secretions of significance in improving the diagnosis of COVID-19. 109
45 110
46 identified the source of infection to be a new type of corona-
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47 virus, which was been defined as 2019 novel coronavirus 112
48 (2019-nCoV) [1]. On 11 February 2020, the WHO officially 2. Etiology and epidemiology
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49 named the disease caused by the novel coronavirus (2019- 114
50 Coronaviruses form a large RNA virus family. The surface 115
nCoV) as Coronavirus Disease 2019 (COVID-19) [2]. On
51 of virus particles is covered in many spines, and the virus 116
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February 22, 2020, China's National Health Commission
announced the designation of the new coronavirus pneumonia particles as a whole resemble a crown, which is the origin of 117
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the name “coronavirus”. Six subtypes have been found; of
these, four are less pathogenic and generally lead to mild 119
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56 * Corresponding author. symptoms after infection; two subtypes can cause severe in-
** Corresponding author. 121
57 fections. The novel coronavirus is a new-type coronavirus that 122
E-mail addresses: 471739847@qq.com (H. Lu), lihongjun00113@126.
58 has not been previously been found in humans being. It is now 123
com (H. Li).
59 considered to be a seventh subtype, but its genes have more 124
Peer review under responsibility of Beijing You'an Hospital affiliated to
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Capital Medical University. than 85% homology with a SARS-like virus in bats. It has
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https://doi.org/10.1016/j.jrid.2020.04.003
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2352-6211/© 2020 Beijing You’an Hospital affiliated to Capital Medical University. Production and hosting by Elsevier B.V. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Please cite this article as: Chen H et al., Clinical and imaging features of COVID-19, Radiology of Infectious Diseases, https://doi.org/10.1016/j.jrid.2020.04.003
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2 H. Chen et al. / Radiology of Infectious Diseases xxx (xxxx) xxx

1 been speculated that the pathogenic mechanism of the virus [10,11]. CT examination is the main screening and diagnosis 66
2 may be that because the 2019-nCoV receptor and SARS-CoV basis for COVID-19. The image changes basically reflect the 67
3 68
receptor binding region (RBD) structure domain between the inflammatory pathological process of lung tissue-exudation,
4 69
5
amino acid sequence and the prediction of protein structure are proliferation, and metamorphism [12]. 70
6 highly similar, 2019-nCoV can effectively use angiotensin- 71
7 converting enzyme 2(ACE2) on alveolar type II epithelial 4.1. Image features 72
8 cells as the receptor to invade cells, thus entering the bronchial 73
9 epithelial cells to replicate and cause disease [3,4]. 4.1.1. Ground-glass opacity (GGO) 74
10 Current epidemiological investigations show the incubation GGO is a slightly higher density blurred image in the lungs, 75
11 76
period of COVID-19 to range from one to fourteen days, and where the pulmonary blood vessels are visible. The patho-
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13
in most cases to be three to seven days. The main source of logical change of GGO is that the virus invades the bronchi- 78
14 infection is patients infected with the novel coronavirus oles and alveolar epithelium, and replicates in the epithelial 79
15 infection. Patients with asymptomatic infection (incubation cells, causing the alveolar cavity to leak, and the alveolar wall 80
16 period) can also be a source of infection. Infection is mainly or the alveolar space to become inflamed or thickened, with a 81
17 spread by respiratory droplets and contact. Exposed mucus distribution mainly around the lung and under the pleura 82
18 membranes and unprotected eyes increase the risk of infection, [13,14]. 83
19 84
and the detection of the virus in stool and urine samples from
20 85
21
patients also suggests the possibility of fecal-oral transmission. 4.1.2. Consolidation and air bronchi sign 86
22 There is a possibility of aerosol transmission under the con- As inflammation progresses, there is extensive involve- 87
23 dition of prolonged exposure to high concentrations of aero- ment of alveoli and mucosal ulcers, followed by consoli- 88
24 sols in a relatively closed environment [5e7]. At present, there dation; when the body reacts strongly as to an inflammatory 89
25 are no reports of vertical transmission from mother to child. storm, large exudation occurs in the alveoli of both lungs, 90
26 showing a “white lung” performance. Air bronchus sign 91
27 92
3. Clinical and imaging refers to the phenomenon of dendritic low-density shad-
28 93
29
owing of air-containing bronchus in the consolidation of 94
30 COVID-19 lacks specificity in both clinical manifestations lung tissue, which is more common in the progress of the 95
31 and laboratory tests. The main clinical manifestations of the disease. The pathological basis is that the pathogen invades 96
32 disease are fever, fatigue, and a dry cough, and in severe cases, epithelial cells, causing inflammatory thickening and 97
33 multiple organ failure [7e9]. Its atypical symptoms may swelling of the bronchial wall, but without obstructing the 98
34 include myalgia and diarrhea. Laboratory tests have shown bronchioles [15]. 99
35 100
that the total number of white blood cells in early peripheral
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37
blood is normal or has decreased, and the lymphocyte count 4.1.3. Paving stone sign 102
38 has progressively decreased; C-reactive protein and serum On high-resolution CT, the lobular interval thickening and 103
39 sedimentation rates were increased in most patients [7e9]. interlobular interval line shadows are superimposed on a 104
40 COVID-19 was confirmed by viral nucleic acid detection with ground glass-like opaque background. They are called paving 105
41 strong specificity and poor sensitivity [10]. In order to improve stones due to the resemblance of the forms to irregularly 106
42 the rate of positive nucleic acid detection, it is recommended shaped paving stones. The pathological changes are lobular 107
43 108
to retain sputum and lower respiratory secretions as far as intervals and interlobular interstitial thickening, suggesting
44 109
45
possible and promptly submit them for examination [7]. CT interstitial changes. 110
46 examination serves as the screening and diagnostic basis for 111
47 COVID-19: chest imaging in the early stage shows multiple 4.1.4. Fibrous lesions 112
48 plaque shadows and interstitial changes, mostly seen in the During repair and healing of chronic inflammation or hy- 113
49 peripheral lung and subpleural, and then developed into mul- perplasia of the lung, fibrous components gradually replace the 114
50 tiple ground glass shadows and infiltration shadows in both normal cellular components to form scars. Fibrous lesions can 115
51 116
lungs. In severe cases, lung consolidation can occur, present- cause distracted bronchi or bronchiectasis and distorted travel.
52 117
53
ing as “white lung”, with rare pleural effusion and mediastinal 118
54 lymph node enlargement [6,7]. 4.1.5. Vascular thickening 119
55 Thickening vessels can be seen at the edge or the center of 120
56 4. Image features and staging the lesion, and are observable at various stages of the disease. 121
57 122
58 Since the outbreak of the COVID-19 epidemic in December 4.1.6. Halo sign 123
59 124
2019, the “Diagnosis and Treatment Scheme for Coronavirus The density of the lesion is slightly higher at the center and
60 125
61
Disease (Trial Version 5)” [6] recommended that suspected slightly lower at the edges. A thin circle of cloud-like ground 126
62 cases with pulmonary imaging characteristics be included for glass shadow, which varies in thickness and changes like a 127
63 the first time in “clinical diagnosis” in Hubei Province. Pul- halo surrounds the lesion. Pathological changes may be virus 128
64 monary imaging is mainly performed by chest CT (particu- replication in epithelial cells [16]. 129
65 larly HRCT), supplemented by X-ray chest radiographs 130

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1 4.2. Image staging and clinical typing and imaging performance is more helpful for the diagnosis of 66
2 COVID-19. 67
3 68
In “Diagnosis and Treatment Scheme for Coronavirus
4 69
5
Disease (Trial Version 6)”, infection is classified according to 4.3. Image expression is differentiated from nucleic acid 70
6 its clinical symptoms and imaging manifestations [7]. There is detection 71
7 a one-to-one correspondence between the imaging stage 72
8 (early, advanced, and severe) and clinical classification (mild, The gold standard for diagnosis of COVID-19 is a positive 73
9 general, and severe) in most patients with COVID-19. ① nucleic acid test with high specificity, and a low sensitivity of 74
10 Early-stage and mild type (mild patients have mild clinical 30e50% [20]. It is common in clinical work to find that 75
11 76
symptoms and no significant imaging findings such as pneu- clinical and imaging findings support the diagnosis of COVID-
12 77
13
monia performance). ② Progressive stage and common type 19 while multiple consecutive nucleic acid tests are negative 78
14 (general type patients have fever, respiratory tract symptoms, (Fig. 4). It has been reported that up to eight nucleic acid tests 79
15 and imaging shows pneumonia). ③ Severe stage and severe have been negative in infected patients before COVID-19 was 80
16 type (Patients with shortness of breath and hypoxemia. The finally diagnosed. Over-reliance on nucleic acid tests may lead 81
17 images mainly show diffuse lung lesions, some of which to the misdiagnosis of patients who do in fact have COVID-19. 82
18 manifest “white lung” changes; the range of lesions within This is not conducive to the control of the epidemic. Pre- 83
19 84
24e48 h significantly progresses >50% [7]). There are, liminary data from a designated virus hospital in Wuhan
20 85
21
however, some cases which do not comply to the above one- showed that the CT positive rate of clinically highly suspected 86
22 to-one correspondence. ① Some cases have obvious imag- cases was 90%, while the positive rate of nucleic acid tests 87
23 ing manifestations, but the clinical symptoms are atypical was about 40%. This is due to the many factors which affect 88
24 (Fig. 1). Among the close-contact cases diagnosed through the nucleic acid test such as the course of infection, viral load, 89
25 screening as having COVID-19, most patients had no obvious sampling method, detection reagents, and interpretation stan- 90
26 clinical symptoms at the initial diagnosis, and the corre- dards. Reagents in particular greatly affect the detection effect 91
27 92
sponding clinical symptoms appeared after a period of time; a [21]. Therefore, nucleic acid test cannot be a factor in
28 93
29
few patients showed no obvious clinical symptoms for a long restricting the accurate diagnosis and treatment of diseases. 94
30 period, with the infection becoming “invisible ”. However, the The director of the radiology department of a hospital in 95
31 images of the above cases did show pneumonia at the time of Wuhan strongly recommends CT scan as the main diagnostic 96
32 screening, the signs of which were mainly ground glass and and screening basis for COVID-19. The “Diagnosis and 97
33 patchy shadows under the pleura or outside the lungs [17,18]. Treatment Scheme for Coronavirus Disease (Trial Version 5)” 98
34 ② The clinical manifestations of some cases are typical, and [6] specifically formulated clinical diagnosis standards for 99
35 100
no obvious manifestations of pneumonia were found on im- patients in Hubei Province, and defined suspected cases with
36 101
37
aging examination (Fig. 2). This may relate to the virus being pneumonia imaging manifestations as “clinical diagnostic 102
38 mainly located in the upper respiratory tract and not causing cases”, which reduced the risk of further spread. 103
39 exudative lesions in the lung. Such patients should be diag- With the exception of the above cases, some mild cases had 104
40 nosed, isolated, and treated early to prevent transmission of the no obvious imaging changes of pneumonia, but the nucleic 105
41 virus. ③ In some cases, the clinical symptoms are relieved, acid test was negative (Fig. 5). The use of imaging pneumonia 106
42 and the imaging manifestations have progressed (Fig. 3) [19]. as a prerequisite for the diagnosis of COVID-19 may lead to 107
43 108
The mismatch between clinical and imaging manifestations clinicians focusing solely on patients with pneumonia and
44 109
45
becomes a difficult problem for COVID-19 diagnosis. There- missing the diagnosis of infected patients who show no 110
46 fore, comprehensive analysis of clinical data, epidemiology changes in pneumonia. The “Diagnosis and Treatment Scheme 111
47 for Coronavirus Disease (Trial Version 4)” stipulates that [22] 112
48 113
49 114
50 115
51 116
52 117
53 118
54 119
55 120
56 121
57 122
58 123
59 124
60 125
61 126
62 127
Fig. 1. Female patient, 30 years old, clinical symptoms are not typical, CT examination (A, B); image shows ground-glass exudation in both lungs (see the red
63 128
frame).
64 129
65 130

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1 66
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12 Fig. 2. Male patient, 23 years old; Clinical manifestations of fever, dry cough for 5 days, and fatigue for 2 days; relevant contact history; CT examination (A, B); no 77
13 obvious signs of pneumonia were seen in either lung (see the red frame). 78
14 79
15 80
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17 82
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19 84
20 85
21 86
22 87
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24 89
25 90
26 91
27 92
28 Fig. 3. Female patient, 38 years old, first examination (A); image shows solitary consolidative peripheral opacities with ground-glass density in right lower lobe; 93
after 2 days (B); image shows progressive consolidative peripheral opacities in right lower lobe (see the red frame).
29 94
30 95
31 96
32 97
33 98
34 99
35 100
36 101
37 102
38 103
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40 105
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51 Fig. 4. Male patient, 60 years old, first examination (AeC); multiple exudative lesions in both lungs; the nucleic acid test was negative. Five days later (DeF); 116
52 exudative lesions of both lungs, with a few lines of shadow; the nucleic acid test was positive. (With thanks to the First Affiliated Hospital of Xi'an Jiaotong 117
53 University for providing this case) (see the red frame). 118
54 119
55 120
56 a patient who meets any one of the epidemiological history 4.4. Diagnostic value of imaging in COVID-19 121
57 criteria and any two of the clinical manifestations can be 122
58 included in suspected cases, and that an etiological test then be Chest radiographs are suitable for primary hospitals which 123
59 124
conducted. Such an approach is conducive to the detection of do not have CT machines, and for the bedside examination of
60 125
61
patients with COVID-19 [6,7]. critically ill patients. CT tomography, especially high- 126
62 127
63 128
64 129
65 130

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1 66
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12 Fig. 5. Male patient, 44 years old, first examination (A); no obvious abnormality was found in both lungs; the nucleic acid test was positive. After 4 days (B); 77
13 ground-glass exudation of left lower lobe. (With thanks to the First Affiliated Hospital of Xi'an Jiaotong University for providing this case) (see the red frame). 78
14 79
15 80
16 resolution CT, has no overlapping structural interference and consolidation, thickening of interlobular septa, mesenchymal 81
17 can detect small lesions early. The value of a CT scan for shadow, central lobular nodules, tree buds, air retention, and 82
18 COVID-19 lies in it being: the key technology for detecting fiber cable shadow. There is significant overlap between the 83
19 84
the presence of lesions in the lungs; the important basis for the imaging manifestations of different viral pneumonia, so the
20 85
21
diagnosis and differential diagnosis of COVID-19; detecting final diagnosis should be combined with clinical data, epide- 86
22 important warning signals for patients with negative virus miology and laboratory results. Diagnosis depends on the 87
23 nucleic acid test; an important means to monitor COVID-19 detection of etiology. 88
24 treatment outcome (progression, stability, absorption); an 89
25 early detection of other complications; the best follow-up 5.1.1. Influenza A virus (HIN1) 90
26 method for patients following discharge [23]. As mentioned Unilateral or bilateral multiple GGO, with or without 91
27 92
above, the CT scan occupies an important position in the consolidation, located in the bronchovascular bundle or sub-
28 93
29
diagnosis of COVID-19; in clinical work, however, we must pleural (Fig. 6) [25,26]. It is difficult to distinguish the image 94
30 perform CT examinations without affecting the premise of from the new type of coronavirus pneumonia. However, the 95
31 diagnosis, and we must not over-examine. Therefore, based on early stage of the new coronavirus pneumonia can be man- 96
32 the observation of existing cases and combined with clinical ifested as a small ground glass density shadow, or a small flake 97
33 experience, we recommend the following CT examination of ground glass density shadow can be seen in the thickened 98
34 time window: ① Newly diagnosed patients with typical clin- blood vessel shadow. This may be helpful for the early iden- 99
35 100
ical manifestations and positive nucleic acid tests, with a tification of H1N1 lesions.
36 101
37
negative chest CT scan at the initial diagnosis, and a review of 102
38 chest CT scan within 3e5 days; ② Clinical diagnosis cases 5.1.2. Adenovirus pneumonia 103
39 with atypical clinical manifestations and viral pneumonia Common in children. Multifocal GGO in both lungs with 104
40 characteristics. In addition to repeated nucleic acid tests, a patchy consolidation, present a multisegmental pulmonary 105
41 chest CT is recommended for 5e7 days; ③ Non-critical distribution trend (Fig. 7). Atelectasis can occur in children. It 106
42 confirmed cases: a chest CT scan is recommended at 5e7 can sometimes be difficult to distinguish it from bacterial 107
43 108
days [24]. pneumonia [25,26].
44 109
45 110
46 5. Differential diagnosis of COVID-19 5.1.3. Human parainfluenza virus pneumonia 111
47 A common cause of seasonal respiratory infections. Im- 112
48 The differential diagnosis of COVID-19 in “Diagnosis and aging findings are varied, and include multiple peribronchial 113
49 Treatment Scheme for Coronavirus Disease (Trial Version 6)” nodules, consolidation of GGO and aerated bronchi (Fig. 8) 114
50 primarily includes [7]: the need to distinguish mild manifes- [25,26]. The central distribution of the lesion is different from 115
51 116
tations from other respiratory infections caused by other vi- the characteristic subpleural distribution of new coronavirus
52 117
53
ruses such as influenza viruses, adenoviruses, respiratory pneumonia. 118
54 syncytial virus and other known viral pneumonia and myco- 119
55 plasma pneumoniae infections. They should also be distin- 5.1.4. Respiratory syncytial virus pneumonia 120
56 guished from non-infectious diseases such as vasculitis, Common in infants, congenital defects, immunosuppres- 121
57 dermatomyositis, and organizing pneumonia. sion and chronic lung disease. The central lobular nodule is the 122
58 most characteristic image, and its occurrence rate is up to 50% 123
59 124
5.1. Other viral pneumonia (Fig. 9), which can be distinguished from the new coronavirus
60 125
61
pneumonia. In addition, air consolidation (35%), GGO (30%), 126
62 The imaging manifestations of viral pneumonia were and bronchial wall thickening (30%) are seen. It is distributed 127
63 mainly pulmonary interstitial changes accompanied by alve- in the central or surrounding area of the lung and presented 128
64 olar wall edema, while the CT manifestations were GGO, with bilateral asymmetric distribution [25,26]. 129
65 130

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1 66
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12 Fig. 6. Male patient, 17 years old, clinical manifestations of fever for 1 day, and dry cough for 3 days; no relevant contact history; CT examination (A, B); multiple 77
13 exudates in both lungs; located in bronchovascular bundle or subpleural (see the red frame). 78
14 79
15 80
16 81
17 82
18 83
19 84
20 85
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22 87
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26 91
27 Fig. 7. Male patient, 23 years old, fever for 4 day, no relevant contact history; CT examination (A, B); multifocal GGO in both lungs with patchy consolidation, 92
present a multisegmental pulmonary distribution trend; pleural effusion (see the red frame).
28 93
29 94
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31 96
32 97
33 98
34 99
35 100
36 101
37 102
38 103
39 104
40 105
Fig. 8. Female patient, 37 years old, no relevant contact history; CT examination (A, B); multiple peribronchial nodules, consolidation of GGO, the distribution of
41 106
lesions is different, mainly for the central nodules (see the red frame).
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47 112
48 113
49 114
50 115
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53 118
54 119
55 Fig. 9. Male patient, 25 years old, fever for 4 days, no relevant contact history; CT examination (A, B); central lobular nodule and GGO in both lungs, the 120
56 distribution of lesions differs from that in COVID-19 (see the red frame). 121
57 122
58 123
59 124
5.2. Infectious pneumonia other than virus and mediastinal lymph node enlargement [27]. Laboratory
60 125
61
tests are positive for the mycoplasma antibody. 126
62 5.2.1. Mycoplasma pneumonia 127
63 Common in children and adolescents, image presenting as 5.2.2. Bacterial pneumonia 128
64 central lobular nodules, ground-glass opacity, consolidation, There are no prodromal symptoms of upper respiratory 129
65 with thickening of bronchial wall, Bronchiole tree buds, hilar tract infection, cough purulent sputum, bloody sputum or rust- 130

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1 colored sputum, laboratory examination of increased white [2] World Health Organization. WHO director-general's remarks at the 66
2 blood cell count, imaging features of single leaf segment or media briefing on 2019-nCoV on 11 February 2020 [EB/OL], vol. 2; 67
3 2020. p. 11. 68
sub segment consolidation shadow. Treatment with antibiotics
4 [3] Wang H, Yang P, Liu KT, Guo F, Zhang Y, Zhang G. SARS coronavirus 69
5
is good. entry into host cells through a novel clathrin and caveolae independent 70
6 endocytic pathway. Cell Res 2008;8:290e301. 71
7 5.3. Non-infectious diseases [4] Kuba K, Imai Y, Rao S, Gao H, Guo F, Guan B. A crucial role of 72
8 angiotensin converting enzyme 2 (ACE2) in SARS coronavirus-induced 73
lung injury. Nat Med 2005;1:875e9.
9 5.3.1. Mechanical pneumonia 74
[5] Wu F, Zhao S, Yu B, Chen YM, Wang W, Song ZG. A new coronavirus
10 Typical manifestations are bilateral subpleural patchy Q2
75
associated with human respiratory disease in China. Nature 2020.
11 76
ground-glass opacity or consolidation, the air bronchi sign. In [6] The national health commission. Diagnosis and treatment scheme for
12 77
13
some lesions, the central ground-glass opacity, marginal ring coronavirus disease 2019 (Trial Version 5), 2.8; 2020.
78
14 or crescent shape consolidation presents an “anti-halo” sign, [7] The national health commission. Diagnosis and treatment scheme for
79
coronavirus disease 2019 (Trial Version 6), 2.18; 2020.
15 hilum and, mediastinal lymph node enlargement, as well as [8] Chang D, Lin M, Wei L, Xie L, Zhu G, Dela Cruz CS. Epidemiologic 80
16 pleural effusion in a small number of cases [28]. and clinical characteristics of novel coronavirus infections involving 13 81
17 patients outside Wuhan, China. JAMA 2020. https://doi.org/10.1001/ 82
18 5.3.2. Hypersensitivity Pneumonitis jama.2020.1623. 83
19 [9] Holshue ML, Debolt C, Lindquist S, Lofy KH, Wiesman J, Bruce H. First 84
Diffuse ground-glass opacities in both lungs. Central lobe
20 case of 2019 novel coronavirus in the United States [J/OL]. N Engl J Med 85
21
nodules with fuzzy edges, mosaics perfusion and air retention 2020;382(10):929e36. 86
22 in expiratory phase, lung field in chronic stage shows fine [10] Huang C, Wang Y, Li X, Lofy KH, Wiesman J, Bruce H. Clinical features 87
23 mesh shape shadow and stretch extension. The patient usually of patients infected with 2019 novel coronavirus in Wuhan, China. 88
24 has a history of bird breeding or of occupational exposure Lancet 2020;S0140e6736(20):30183e5. 89
25 [29]. [11] Lu H, Stratton CW, Tang YW. Outbreak of pneumonia of unknown 90
26 etiology in Wuhan China: the mystery and the miracle. J Med Virol 2020; 91
27 92(4):401e2. 92
5.3.3. Vasculitis [12] Koo HJ, Lim S, Choe J, Choi SH, Sung H, Do KH. Radiographic and CT
28 93
29
The manifestations are multiple nodules with cavitation, features of viral pneumonia. Radiographics 2018;38:719e39. 94
30 nodules connected to pulmonary vessels (nourishing vascular [13] Yang W, Cao Q, Qin L, Wang X, Cheng Z, Pan A, et al. Clinical char-
95
signs), halo or anti-halo signs, multiple consolidation, fiber acteristics and imaging manifestations of the 2019 novel coronavirus
31 96
disease (COVID-19): a multi-center study in Wenzhou city, Zhejiang,
32 cord shadow and ground glass density shadow diffuse distri- 97
China. J Infect 2020;80(4):388e93.
33 bution, the subpleural area is rare. It occurs mostly in the [14] Yoon SH, Lee KH, Kim JY, Lee YK, Ko H, Kim KH, et al. Chest 98
34 middle of the band with diffuse alveolar hemorrhage. Clinical radiographic and CT findings of the 2019 novel coronavirus disease 99
35 100
manifestations can be hemoptysis, and pleural effusion is (COVID-19): analysis of nine patients treated in korea. Korean J Radiol
36 2020;21(4):494e500. 101
37
common [30]. A laboratory test of positive cANCA antibody 102
[15] Li H, Liu S. Guideline for medical imaging in auxiliary diagnosis of
38 is helpful in diagnosis. coronavirus disease 2019. Chin J Med Imaging Technol 2020;36(3): 103
39 321e31. 104
40 6. Conclusion [16] Song F, Shi N, Shan F, Zhang Z, Shen J, Lu H, et al. Emerging 2019 105
41 novel coronavirus (2019-nCoV) pneumonia. Radiology 2020;295(1): 106
42 COVID-19 is highly contagious and humans are generally 210e7. 107
43 [17] Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early transmission 108
susceptible to infection. While clinical and CT scans do share
44 dynamics in Wuhan, Hubei, of novel coronaviruseinfected pneumonia. 109
45
certain characteristics, there is some separation between a CT N Engl J Med 2020;382(13):1199e207. 110
46 scan and a nucleic acid detection in some cases. Therefore, [18] Wang W, Tang J. Updated understanding of the outbreak of 2019 novel 111
47 comprehensive analysis of the patient's epidemiological his- coronavirus (2019-nCoV) in Wuhan, China. J Med Virol 2020;92(4): 112
48 tory, laboratory test results, clinical symptoms and imaging 441e7. 113
49 [19] Hu X, Chen J, Jiang X, Tao S, Zhen Z, Zhou C. CT imaging of two 114
manifestations is necessary in order to effect early prevention, cases of one family cluster 2019 novel coronavirus (2019-nCoV)
50 early detection, early diagnosis, early isolation, and early 115
pneumonia: inconsistency between clinical symptoms amelioration
51 116
treatment. and imaging sign progression. Quant Imag Med Surg 2020;10(2):
52 117
508e10.
53 118
Ethic statement [20] Bai L, Wang M, Tang XQ. Thinking about the hot issues in the diagnosis
54 and treatment of novel coronavirus pneumonia. Hua xi Med 2020;35(2): 119
55 125e31. 120
56 Q1 Written informed consent was obtained from the patients [21] Zhu N, Zhang D, Wang W, Li X, Yang B, Song J. A novel coronavirus 121
57 for the publication of this report and any accompanying from patients with pneumonia in China, 2019. N Engl J Med 2020; 122
58 images. 382(8):727e33. 123
59 [22] The national health commission. Diagnosis and treatment scheme for 124
60 coronavirus disease 2019 (Trial Version 4), 1.27; 2020. 125
61
References [23] Wang YB, He Y. Identification of novel coronavirus pneumonia [J/OL]. 126
62 Chongqing Med 2020:1e4. 127
63 [1] World Health Organization. WHO/Novel coronavirus (China), vol. 1. [24] Li Y. Coronavirus disease 2019 (COVID-19): role of chest CT in diag- 128
64 WHO; 2020. nosis and management. AJR Am J Roentgenol 2020:1e7. 129
65 130

Please cite this article as: Chen H et al., Clinical and imaging features of COVID-19, Radiology of Infectious Diseases, https://doi.org/10.1016/j.jrid.2020.04.003
 JRID198_proof ■ 26 April 2020 ■ 8/8

+ MODEL

8 H. Chen et al. / Radiology of Infectious Diseases xxx (xxxx) xxx

1 [25] Franquet T. Imaging of pulmonary viral pneumonia. Radiology 2011; [29] Silva CI, Churg A, Müller NL, Pneumonitis Hypersensitivity. Spectrum 8
2 260(1):18e39. of high-resolution CT and pathologic findings. AJR Am J Roentgenol 9
3 [26] Koo HJ, Lim S, Choe J, Choi S, Sung H, Do K. Radiographic and CT 2007;188:334e44. 10
4 Features of Viral Pneumonia1. RadioGraphics 2018;38:719e39. [30] Castaner E, Alguersuari A, Gallardo X, Andreu M, Pallardo Y, Mata JM, 11
5 [27] Bajantri B, Venkatram S, Diaz-Fuentes G. Mycoplasma pneumoniae: a et al. When to suspect pulmonary vasculitis: radiologic and clinical clues. 12
6 potentially severe infection. Clin Med Res 2018;10(7):535e44. Radiographics 2010;30(1):33e53. 13
7 [28] Vincent Cottin, Cordier Jean-François. Cryptogenic organizing pneu- 14
monia. Semin Respir Crit Care Med 2012;33:462e75.

Please cite this article as: Chen H et al., Clinical and imaging features of COVID-19, Radiology of Infectious Diseases, https://doi.org/10.1016/j.jrid.2020.04.003