68 yo female presents with shortness of breath, dry cough and fevers that has been worsening over the course of 5 days. Past medical/surgical/social history is negative. Patient takes no medications, other than occasional acetaminophen for headache. Pertinent negatives on review of systems include: No unilateral or bilateral leg swelling. Vital signs are as follows: HR: 112, BP: 101/67, RR: 38, Temp: 101.2°. Physical exam demonstrates bilateral scattered crackles with occasional wheezing on auscultation of the chest.
An ultrasound transducer is placed on the anterior, lateral and posterior lung fields and the following ultrasound images are obtained:
Answer and Pearl: COVID-19 Pneumonia
This scan demonstrates an irregular plural line, scattered b-lines and a few 3-5mm subpleural consolidations. These are findings suggestive of viral pneumonia. This patient was subsequently diagnosed with COVID-19 by PCR testing.
Coronavirus disease 2019 (COVID-19) is caused by SARS-CoV-2. The virus was first described in Wuhan, China in late December 2019, and has subsequently spread to many parts of the world.1
The most common symptoms reported are fever, dry cough and shortness of breath.2
There is significant overlap between COVID-19 and other viral respiratory syndromes. A careful travel history can be helpful to increase (or decrease) suspicion of COVID-19.
Diagnosis of COVID‐19 can be obtained via RT-polymerase chain reaction (PCR) detection from respiratory specimens. 3 However, total positive rate of PCR for throat swab samples was reported to be as low as 30% to 60% at initial presentation 4. Additionally, the turn-around time for the test has been reported to be between 1-7 days1
CT scans of the thorax have been suggested as a potential screening tool since the findings on CT may appear before a PCR results and has a faster turn-around time 1 Unfortunately, there is a high economic burden on performing screening CT scans in suspected viral pneumonia.
CT findings associated with COVID-19 include ground-glass opacities, consolidation, reticulation/thickened interlobular septa and nodules.5
Ultrasound has been proposed as an alternative diagnostic tool for COVID-19. While more data is needed, preliminary reports demonstrate the following sonographic characteristic findings of COVID-19: 6,7
Thickening/irregularities of the pleural line
B-lines (focal, multi-focal and/or confluent)
Consolidations of varying patterns
These findings are consistent with previous reports of viral pneumonias.8,9,10
Rezaie, S., 2020. COVID-19: The Novel Coronavirus 2019 – REBEL EM – Emergency Medicine Blog. [online] REBEL EM – Emergency Medicine Blog. Available at: <https://rebelem.com/covid-19-the-novel-coronavirus-2019/> [Accessed 13 March 2020].
Zhu N, Zhang D, Wang W. A Novel Coronavirus from Patients with Pneumonia in China, 2019. The New England journal of medicine. 2020; 382(8):727-733. [PMID: 31978945]
CDC. “FAQs on COVID-19 Testing at Laboratories.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 10 Mar. 2020, www.cdc.gov/coronavirus/2019-ncov/lab/testing-laboratories.html.
Fang Y, Zhang H, Xie J. Sensitivity of Chest CT for COVID-19: Comparison to RT-PCR. Radiology. 2020; [PMID: 32073353]
Ai T, Yang Z, Hou H. Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 Cases. Radiology. 2020; [PMID: 32101510]
Peng, Q., Wang, X. & Zhang, L. Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic.Intensive Care Med (2020). https://doi.org/10.1007/s00134-020-05996-6
Huang, Yi and Wang, Sihan and Liu, Yue and Zhang, Yaohui and Zheng, Chuyun and Zheng, Yu and Zhang, Chaoyang and Min, Weili and Zhou, Huihui and Yu, Ming and Hu, Mingjun, A Preliminary Study on the Ultrasonic Manifestations of Peripulmonary Lesions of Non-Critical Novel Coronavirus Pneumonia (COVID-19) (February 26, 2020). Available at SSRN: https://ssrn.com/abstract=3544750 or http://dx.doi.org/10.2139/ssrn.3544750
Berce V, Tomazin M, Gorenjak M, Berce T, Lovrenčič B. The Usefulness of Lung Ultrasound for the Aetiological Diagnosis of Community-Acquired Pneumonia in Children. Scientific reports. 2019; 9(1):17957. [PMID: 31784642]
Yousef N, De Luca D. The Role of Lung Ultrasound in Viral Lower Respiratory Tract Infections. American journal of perinatology. 2018; 35(6):527-529. [PMID: 29694988]
Rossetti E, Bianchi R, Di Nardo M, Picardo S. Lung ultrasound assessment of influenza A(H1N1)-associated ARDS in a child with acute lymphoblastic leukemia outbreak undergoing extracorporeal membrane oxygenation. Paediatric anaesthesia. 2015; 25(12):1301-2. [PMID: 26507922]