The COVID-19 pandemic of atypical pneumonia leads to health emergency problems all over the world which is more or less similar to SARS in 2003 and MERS in 2012; all these outbreaks occurred due to virus belonging to the family coronaviridae [6].
Fever and cough were the most common symptoms in patients with COVID-19. The incidence of other upper and severe lower respiratory tract symptoms as well as headache was ranging between 10 and 20%. Diarrhea occurred infrequently and was not encountered in our patient collective at first presentation. Malaise approached 30% of our patients. Thirteen out of 120 patients required mechanical ventilation. This may be consistent with several previous studies documenting that the main target cells for the virus are those located in the lower respiratory tract [7].
Early studies showed that the main diagnostic CT imaging features of COVID-19 are bilateral multilobar peripheral GGO [6, 8]. The presence of peripheral and central GGO, as well as single lobe affection, consolidation, pleural effusion, and mediastinal lymphadenopathy, are not matching with COVID-19; however, later on, after an increased number of diseased cases worldwide was reported, these CT imaging features had been found in some COVID-19 positive patients although it is uncommon [2, 9]. In the current study, we also confirmed that peripheral GGO scattered at both lungs is the most common finding as it was found in 83 cases (74.7%) while the other findings were uncommonly found in a much smaller number of cases. This also was in agreement with Adam et al. [3] and Yan et al. [5]
Song et al. [2] reported that GGO mainly of peripheral distribution in multilobes is the most common imaging feature in COVID-19 positive patients and may be associated with interlobar and interlobular thickening, even consolidation may be present in less frequency. The results of our cases were similar to these findings.
In clinically severe cases, we detected the presence of multiple bilateral central and peripheral GGO in 20 cases, white lung in eight cases, and pleural effusion in six cases. Zu et al. [4] also described these findings as imaging features in severely affected patients. Also, we reported a few cases with pleural effusion (six cases) and mediastinal lymphadenopathy (eight cases) which was also confirmed as atypical findings in other studies [5].
From the results of our cases, we noticed the added value of CT chest imaging with clinical data to diagnose COVID-19 patients and this is helpful in situations such as shortage of test kits or false-negative results; this was in agreement with Wenjing et al. [10] who also concluded the importance of imaging in the diagnosis of COVID-19 patients.
After increasing the number of affected patients worldwide and unfortunately the health systems in most countries cannot cope with this pandemic, most of the studies should look for the impact of the disease course on the outcome and how clinical and radiological data can predict this. In our study, we detected a higher death rate among elderly patients with a statistically significant difference and this was a coincidence with Yang et al. [11], Hani et al. [12], Li et al. [13], and Carlos et al. [14]
We detected an association between the presence of multiple multilobar peripheral GGO, white lung, and pleural effusion in CT and the need for mechanical ventilation as the results showed three quarters (75%) of those who showed white lung on the radiological imaging needed ventilation compared with only 6.3% among those without white lung and this association was highly statistically significant, (p = <0.001). Half of the patients with pleural effusion experienced shortness of breath or needed ventilation compared with a small percent among those without pleural effusion (7.0 and 8.8%, respectively) and these associations were statistically significant. Also, a significantly higher percentage of patients with pleural effusion (33.3%) suffered from tachypnea compared with only 4.4% among those without (p = 0.003). This was matching with Hani et al. [12], Li et al. [15], Peijie et al. [16]
Obviously, tachypnea, shortness of breath, and the requirement of mechanical ventilation were specifically associated with the studied patients with the development of pleural effusion. Peijie et al. [16] and Zhao et al. [17] documented that pleural effusion was much more prevalent in cases who were considered medical emergency than those who were not. The clinical prognosis was poor in cases suffering from tachypnea, shortness of breath, and headache and in the higher age group. Death as an outcome was highly associated with such clinical features. However, tachypnea was the only clinical feature that may be considered a predicting factor for death. So, tachypnea may be considered bad prognostic factors in the COVID-19 disease course.
Limitations of the current study included the retrospective nature of the study in addition to the fact that we only included the findings of the CT at first presentation with the possibility that some patients might present themselves at different stages of the disease; however, we consider this to be a simulation of real-life situation based on different cultural and personal differences between the patients.