ORIGINAL ARTICLE n Special Report

Coronavirus (COVID-19) Outbreak:

What the Department of Radiology
Should Know
Soheil Kooraki, MD a, Melina Hosseiny, MD b, Lee Myers, MD c, Ali Gholamrezanezhad, MD c

Abstract

In December 2019, a novel coronavirus (COVID-19) pneumonia emerged in Wuhan, China. Since then, this highly contagious
COVID-19 has been spreading worldwide, with a rapid rise in the number of deaths. Novel COVID-19–infected pneumonia (NCIP) is
characterized by fever, fatigue, dry cough, and dyspnea. A variety of chest imaging features have been reported, similar to those found in
other types of coronavirus syndromes. The purpose of the present review is to briefly discuss the known epidemiology and the imaging
findings of coronavirus syndromes, with a focus on the reported imaging findings of NCIP. Moreover, the authors review precautions
and safety measures for radiology department personnel to manage patients with known or suspected NCIP. Implementation of a robust
plan in the radiology department is required to prevent further transmission of the virus to patients and department staff members.
Key Words: Coronavirus, CT cut scan, chest, pneumonia, viral, radiography, radiology, outbreak, safety

J Am Coll Radiol 2020;-:---. Copyright ª 2020 American College of Radiology

BACKGROUND been reported in 28 countries as of this writing, has shown

Coronaviruses are nonsegmented, enveloped, positive-sense, human-to-human transmission and is feared to have the po-
single-strand ribonucleic acid viruses, belonging to the tential to cause a pandemic [2,3]. The mean incubation period
Coronaviridae family [1]. Six types of coronavirus have been is estimated to be 5.2 days, which allows air travelers to spread
identified that cause human disease: four cause mild the disease globally [4].
respiratory symptoms, whereas the other two, Middle East Evidence shows that virus transmission can occur during the
respiratory syndrome (MERS) coronavirus and severe acute incubation period in asymptomatic patients. Moreover, high
respiratory syndrome (SARS) coronavirus, have caused sputum viral loads were found in a patient with NCIP
epidemics with high mortality rates. during the recovery phase [5]. As of February 5, 2020, more
In December 2019, a new type of coronavirus called than 25,000 confirmed cases have been reported worldwide,
COVID-19 was extracted from lower respiratory tract samples with a rapid rise in the number of deaths. The World Health
of several patients in Wuhan, China. These patients presented Organization has announced the outbreak a global health
with symptoms of severe pneumonia, including fever, fatigue, emergency.
dry cough, and respiratory distress. Novel COVID-19– Imaging is critical in assessing severity and disease pro-
infected pneumonia (NCIP) is believed to have originated gression in COVID-19 infection. Radiologists should be
in a wet “seafood market” in Wuhan. The virus, which has aware of the imaging manifestations of the novel COVID-
19 infection. A variety of imaging features have been
described in similar coronavirus-associated syndromes. In
a
Keck School of Medicine, University of Southern California, Los Angeles, this brief review, we discuss the epidemiologic and radio-
California. logic features of coronavirus syndromes, with a focus on the
b
Department of Radiological Sciences, David Geffen School of Medicine,
University of California at Los Angeles, Los Angeles, California. known imaging features of NCIP. In addition, precautions
c
Division of Emergency Radiology, Department of Radiology, Keck School and safety measures for radiology department personnel in
of Medicine, University of Sothern California, Los Angeles, California. managing patients with known or suspected NCIP are
Corresponding author and reprints: Ali Gholamrezanezhad, MD, Division
of Emergency Radiology, Department of Radiology, Keck School of
discussed.
Medicine, University of Sothern California, 1500 San Pablo Street, Los
Angeles, CA 90033; e-mail: [email protected].
SARS: EPIDEMIOLOGY AND IMAGING
The authors state that they have no conflict of interest related to the ma- SARS coronavirus was first recognized in 2003 after a
terial discussed in this article. global outbreak originating in southern China. The virus

Copyright ª 2020 American College of Radiology

1546-1440/20/$36.00 n https://doi.org/10.1016/j.jacr.2020.02.008 1
 Graphical abstract

spread to 29 countries globally, affecting 8,422 patients, Chest CT will show areas of ground-glass opacity and
with a mortality rate of 11%. The transmission of this consolidation in involved segments.
coronavirus occurs via large droplets and direct inocula-
tion [6]. The virus may remain viable for up to 24 MERS: EPIDEMIOLOGY AND IMAGING
hours on dry surfaces, but it loses its infectivity with MERS coronavirus infection was first reported in Jeddah,
widely available disinfectants such as Clorox and Saudi Arabia, in 2012 [10]. Since then, approximately 2,500
formaldehyde [7]. laboratory-confirmed human infections have been reported
Initial chest radiography in individuals with SARS will in 27 countries, with a mortality rate reaching more than
frequently show focal or multifocal, unilateral, ill-defined 30% [11]. The risk for transmission to family members and
air-space opacities in the middle and lower peripheral lung health workers seems to be low. Despite the potential for
zones [8], with progressive multifocal consolidation over a epidemics through Hajj pilgrimages in Saudi Arabia,
course of 6 to 12 days involving one or both lungs [9]. there has not been a notable outbreak recently. It seems

Fig 1. Chest CT scan from a 50-year-old male Chinese patient with a confirmed diagnosis of novel COVID-19-infected
pneumonia. The patient presented with low-grade fever, cough, sneezing, fatigue, and lymphopenia. Multiple peripheral
ground-glass opacities are present in both lungs (predominant on the right side), with a subpleural distribution. Imaging
finding are nonspecific and might be seen with other viral pneumonias as well. Images are courtesy of Min Liu, MD,
Department of Radiology, China-Japan Friendship Hospital (Beijing, China).

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Volume - n Number - n Month 2020
Fig 2. Chest CT scan of a 50-year-old Iranian man with confirmed diagnosis of COVID-19 pneumonia. The patient presented
with low-grade fever, cough, respiratory distress and confusion. Extensive subpleural and peripheral multifocal areas of
consolidation (A,B) are seen in both lungs predominantly in lower lobes.

that in contrast to the human-to-human pathway as the subsegmental areas of air-space consolidation, whereas in
main route of virus spread in SARS coronavirus, the trans- non–intensive care unit patients, transient areas of sub-
mission in MERS coronavirus occurs mainly through segmental consolidation are seen early, with bilateral
nonhuman, zoonotic sources (eg, bats, camels) [12,13]. ground-glass opacities being predominant later in the course
In 83% of patients with MERS coronavirus infection, of the disease (Figs. 1-3). Serial chest radiography of a 61-
initial radiography will show some degree of abnormality, with year-old man who died of NCIP showed progressively
ground-glass opacities being the most common finding [14]. worsening bilateral consolidation during a course of 7 days.
Likewise, CT will show bilateral and predominantly ground- Another report on 99 individuals with confirmed NCIP
glass opacities, with a predilection to basilar and peripheral described similar imaging findings, with bilateral lung
lung zones, but observation of isolated consolidation (20%) or involvement in 75% and unilateral involvement in 25%
pleural effusion (33%) is not uncommon in MERS [15]. [17]. Another study of five individuals in a family cluster
with NCIP [18] described bilateral patchy ground-glass
NCIP: WHAT DO WE KNOW? opacities, with more extensive involvement of lungs paren-
Patients with COVID-19 infection present with pneumonia chyma in older family members. The reported imaging
(ie, fever, cough, and dyspnea). Although fatigue is com- features most closely resemble those of MERS and SARS.
mon, rhinorrhea, sore throat, and diarrhea uncommonly No pleural effusion or cavitation has been reported so far in
occur. A recent report in The Lancet described the clinical confirmed cases of NCIP, but pneumothorax was reported
manifestations of NCIP in 41 patients [16]. According to in 1% of patients (1 of 99) in a study by Chen et al [17].
that report, abnormal chest imaging findings were Overall, the imaging findings are highly nonspecific and
observed in all patients, with 40 having bilateral disease at might overlap with the symptoms of H1N1 influenza,
initial imaging. This early report on the presentation of cytomegalovirus pneumonia, or atypical pneumonia. The
the NCIP in intensive care unit patients indicated bilateral acute clinical presentation and history of contact with a

Fig 3. Chest CT scan of a 48-year-old woman with confirmed diagnosis of COVID-19 pneumonia. The patient presented with
fever and cough. Small ill-defined subpleural and peripheral areas of consolidation (A, B) are noted in both lungs which are
non-specific in this patient with COVID-19 pneumonia.

Journal of the American College of Radiology 3

Special Report n Kooraki et al n Coronavirus Outbreak Radiology
COVID-19-infected patient or history of recent travel to an classification of the Centers for Disease Control and
eastern Asian country (eg, China, South Korea, or Japan) Prevention and FDA, these surfaces need to be either
should raise clinical suspicion for the diagnosis of NCIP. washed with soap and water or decontaminated using a low-
Although further investigations on the clinical and radio- level or intermediate-level disinfectant, such as iodophor
logic aspects of the COVID-19 are ongoing, imaging will germicidal detergent solution, ethyl alcohol, or isopropyl
continue to be a crucial component in patient management. alcohol. Environmental services staff members need to be
specifically trained for professional cleaning of potentially
contaminated surfaces after each high-risk patient contact [24].
PRECAUTIONS FOR RADIOLOGY Radiology departments should contact their equipment
DEPARTMENT PERSONNEL vendors to find the safest disinfectant for each piece of
Radiographers are among the first-line health care workers equipment in use.
who might be exposed to 2019 novel COVID-19. Diag- US health care imaging facilities need to be prepared
nostic imaging facilities should have guidelines in place to for the escalating incidence of new cases of COVID-19. If
manage individuals with known or suspected COVID-19 appropriately prepared, radiology department staff members
infection. The novel COVID-19 is highly contagious and is can take greater measures to manage the impact of the
believed to transmit mostly through respiratory droplets, but COVID-19 outbreak on the facility and personnel. A
there is uncertainty as to whether the virus can be trans- multidisciplinary committee should convene to outline
mitted by touching a surface or an item that is contaminated guidelines for imaging facility personnel to prevent virus
(ie, a fomite). A thorough understanding of the routes of spread thorough human-to-human contact and the depart-
virus transmission will be essential for patients’ and health ment equipment. Implementation of a robust plan can
care professionals’ safety. Droplets have the greatest risk of provide protection against further transmission of the virus
transmission within 3 ft (91.44 cm), but they may travel up to patients and staff members.
to 6 ft (183 cm) from their source [19]. For the purpose of
diagnostic imaging in individuals with NCIP, whenever TAKE-HOME POINTS
possible, portable radiographic equipment should be used to
limit transportation of patients. On the basis of experience - The imaging features of COVID-19 pneumonia are
with SARS, the use of a satellite radiography center and highly nonspecific and are more often bilateral with
dedicated radiographic equipment can decrease the risk for subpleural and peripheral distribution and range from
transmission from known infected individuals. If a patient ground-glass opacities in milder forms to consolida-
needs to be transported to the radiology department, he or she tions in more severe forms.
should wear a surgical mask during transport to and from the - If properly prepared, radiology department personnel
department. can take greater measures to manage the impact of
As of March 4, 2020, for providers, the World Health the COVID-19 outbreak on the department and staff.
Organization recommends respiratory protection with use of a - Continued data collection and larger epidemiologic
standard medical mask, unless aerosol-generating procedures studies are needed for both a full range of imaging
are performed. [20,21]. Additional guidelines from The Centers findings and routes of transmission.
for Disease Control and Prevention recommend airborne
precautions and the use of a N95 mask or higher when in
close contact with patients that have confirmed or are under ACKNOWLEDGMENTS
investigation for for COVID-19. In addition, the droplet The authors gratefully thank Dr. Min Liu, MD, Depart-
precaution instruction recommends appropriate personal ment of Radiology; China-Japan Friendship Hospital, Bei-
protective equipment, including a disposable isolation gown jing, China, for his valuable contribution to this article.
with fluid-resistant characteristics, a pair of disposable gloves
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Special Report n Kooraki et al n Coronavirus Outbreak Radiology