Clinical and Imaging Findings in COVID-19 Patients Complicated by Pulmonary Embolism

  1. Ting Li
  2. Gregory Kicska
  3. Paul E Kinahan
  4. Chengcheng Zhu
  5. Murat Alp Oztek
  6. Wei Wu

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Abstract

Objective

To describe clinical, and imaging findings including the evolution pattern in COVID-19 pneumonia complicated by pulmonary embolism (PE).

Methods

Eleven of 1453 patients with a probable diagnosis of COVID-19 pneumonia were retrospectively selected for the presence of PE. Clinical and laboratory data were recorded. All cross-sectional CT imaging was qualitatively scored for the first 28 days after onset of symptoms.

Results

Of 24 patients underwent CTA-PE, 11 were confirmed with PE. All 11 patients developed acute respiratory distress syndrome (ARDS). The pulmonary emboli were most common in segmental and subsegmental pulmonary arteries. We observed an evolution pattern of predominant findings with ground-glass opacities (GGO) to GGO with crazy paving in 3 patients, then to consolidation with linear densities, or to reticulation in 9 patients. Lung cysts or traction bronchiectasis could be seen from day 5 to 9 after symptoms and reticulation, subpleural curvilinear lines were more common from day 20. The pulmonary opacities were predominantly peripheral in distribution with relative sparing of nondependent lungs. The severity of lung involvement was high with an average score of 9.7 in the first phase, 18 in the second phase plateauing in the next two phases, with a slight decrease to 16.9 in the late phase.

Conclusion

The incidence of PE among suspected patients in COVID-19 was high. The pulmonary emboli were most common in segmental and subsegmental pulmonary arteries. Our study suggests PE may occur with increased frequency in the ARDS subgroup. The evolution of radiographic abnormalities showed a general pattern, but are also unique with more extensive lung injury and specific imaging features, which may due to the exist of ARDS in these patients.

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    SciScore for 10.1101/2020.04.20.20064105: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board StatementIRB: The Ethics Committee of Wuhan Central Hospital, Tongji Medical College, Huazhong University of Science and Technology approved this retrospective study and informed consent was waived.
    Consent: The Ethics Committee of Wuhan Central Hospital, Tongji Medical College, Huazhong University of Science and Technology approved this retrospective study and informed consent was waived.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    Descriptive analysis was performed with MATLAB (R2014b, MathWorks, Natrick, MA)
    MATLAB
    suggested: (MATLAB, RRID:SCR_001622)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Our study has several limitations: First, only 11 patients were used in this analysis. However, the population from which these patients were selected represents approximately 1.5% of all COVID-19 patients reported worldwide. A larger data set could be achieved with a multicenter study or in the future as more patients present. A second limitation is that the CT scans in different time phases were not equally represented. For example, there were fewer CT scans performed in the first 10 days after onset of symptoms compared other time periods. A third limitation is that only 4 out of 11 patients were RT PCR test positive. Although a positive RT-PCR test is not required for diagnosis based on current guidelines in Hubei province, the test is considered highly specific, increasing confidence in the diagnosis. COVID-19 virus load is higher in early days after infection [30], and the limited number of the RT-PCR kits available delayed testing for many the patients, causing the test to be performed when it is less accurate. Patient with negative RT-PCR would be retested in 3 days, but 3 of the patients died before this was possible, also suggesting they presented at a later stage of infection. RT-PCR is not required for diagnosis and this is supported by multiple studies. For example, on study showed that 60% to 93% of patients with an initial positive chest CT consistent with COVID-19 had negative RT-PCR results [31]. In another case series, the sensitivity of CT for COVID-19 diag...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    About SciScore

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  2. Version published to 10.1101/2020.04.20.20064105v1 on medRxiv