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Differential radiographic chest findings in COVID-19 positive patients with and without comorbidities
Akul Mohan, Rajul Rastogi, Amit Agarwal, Gaurav Patnayak, Neha, Vijai Pratap, Satish Pathak, Anshul Jain, Kush Dugad
Department of Radiodiagnosis, Teerthanker Mahaveer Medical College and Research Center, Moradabad, Uttar Pradesh, India
| Date of Submission | 14-Apr-2022 |
| Date of Acceptance | 20-Dec-2022 |
| Date of Web Publication | 30-May-2023 |
Correspondence Address:
Prof. Rajul Rastogi
Department of Radiodiagnosis, Teerthanker Mahaveer Medical College and Research Center, Moradabad - 244 001, Uttar Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/abr.abr_116_22
Background: The pandemic of Covid-19 resulted in significant morbidity and mortality, especially in those with pre-existing diseases like diabetes mellitus, cardiovascular diseases, etc., primarily due to extensive pulmonary involvement. The chest radiograph is the first imaging tool used in all Covid-19 patients. Hence, in this study, we attempt to understand and evaluate the role of the chest radiograph in Covid-19 patients with and without coexisting diseases.
Materials and Methods: Our study included RTPCR-positive Covid-19 patients with comorbidities (560 cases) and without comorbidities (145 controls), viz. diabetes mellitus, hypertension, coronary artery disease, or thyroid disease. All controls and cases had chest radiographs with simple fractional zonal scores in a predesigned proforma. Statistical evaluation of chest radiograph scores was compared with and within groups.
Results: Among the controls, approximately 63.5% revealed pulmonary findings on chest radiographs contrary to 77% among cases. No statistical differences were noted among controls and cases based on age and gender. The presence of pleural effusion was noted as a significant factor affecting the score and hence the prognosis in both controls and cases. Statistically significant differences were noted in SFZ scores between controls and various case groups.
Conclusion: Chest radiograph scores in Covid-19 disease are higher in patients with comorbidities at the time of presentation, most marked in those with both hypertension and thyroid disease followed by those with hypertension and coronary artery disease. Lower zone predominance is seen in all patients including those with and without comorbidities. The chest radiograph scores become statistically significant with more than one existing comorbidity.
Keywords: Chest, comorbidities, Covid-19, differential, radiographic
How to cite this article:
Mohan A, Rastogi R, Agarwal A, Patnayak G, Neha, Pratap V, Pathak S, Jain A, Dugad K. Differential radiographic chest findings in COVID-19 positive patients with and without comorbidities. Adv Biomed Res 2023;12:143 |
How to cite this URL:
Mohan A, Rastogi R, Agarwal A, Patnayak G, Neha, Pratap V, Pathak S, Jain A, Dugad K. Differential radiographic chest findings in COVID-19 positive patients with and without comorbidities. Adv Biomed Res [serial online] 2023 [cited 2023 Sep 21];12:143. Available from: https://www.advbiores.net/text.asp?2023/12/1/143/377855 |
| Introduction | |  |
Wuhan, China was the first place where the deadly Covid-19 was reported and subsequently spread to the rest of the world and in January'2020, it was declared a Public Health Emergency of International Concern by the WHO.[1] Though the infection is known to primarily affect the lungs, now it has been found to affect almost all the systems of the body and therefore early intervention is required to decrease the mortality.
The presence of any comorbidity has till now proven to be a deterrent to recovery. More than 80% of fatalities are associated with one or more comorbidities.[2] Hypertension (HTN) is the most commonly associated comorbidity followed by diabetes mellitus (DM) and coronary artery disease (CAD). Chronic obstructive pulmonary disease, cancer, chronic kidney disease, and other comorbidities are also associated with a considerable percentage of patients.[2]
The chest radiograph (CXR) is the first investigation performed in Covid-19 patients primarily due to the high rate of pulmonary affection. Ground-glass opacities with bilateral, peripheral, and predominant lower zone distribution progressing to consolidation with or without pleural effusion have been found to be the most common findings.[3]
Though computed tomography of the chest has been found to be more than 95% sensitive for the diagnosis of Covid-19, but has limited availability as well as higher cost compared to CXR.[4]
BrixIA score was first described to understand the relationship between pulmonary parenchymal involvement based on CXR findings and the degree of mortality in Covid-19 patients.[5],[6] But its major disadvantage was the inability to identify the soft tissue mediastinal landmarks in portable CXR performed in many of these patients during stay in hospital wards and intensive care units. Hence, we tried to devise our simple CXR score based on the degree of involvement of zones in both lungs—Simple Fractional Zonal Score (SFZS).
With this background, we are trying to predict the association of severity of Covid-19 lung disease based on SFZS on CXR with various comorbidities that may predict future clinical outcomes or prognosis helping them to initiate aggressive management not only to reduce mortality but also morbidity relating to Covid-19 pneumonia.
| Materials and Methods | | |
Our study is a retrospective, observational study conducted on patients over a period of six months visiting our institution between July and December 2020 following approval from the Institutional Ethics Committee with the following.
The aim of this study was comparison of CXR findings in Covid-19 positive patients with and without DM, HTN, CAD, and thyroid disease. In addition, we will compare the CXR findings in Covid-19 positive patients with more than one comorbidity and without any other comorbidity.
All patients with CXR of optimal quality (in both control and cases) were included in our study. The presence of ground-glass opacity, consolidation, and pleural effusion was noted on CXR in both cases and controls. Any additional finding was also recorded.
The recorded datasets were statistically evaluated between and within groups using appropriate tools and methods. The P value of <0.05 was considered statistically significant.
Inclusion criteria
- Patients positive for Covid-19 infection by RT-PCR and diagnosed with DM, HTN, coronary artery disease (CAD), and/or thyroid disease (cases)
- Patients positive for Covid-19 infection by RT-PCR without any comorbidity (controls)
- Patients having CXR within 5 days of the positive report of RT-PCR.
Exclusion criteria
- Patients positive with Covid-19 infection by RT-PCR and diagnosed with comorbidity other than DM, HTN, CAD, and/or thyroid disease.
- CXR of suboptimal quality.
During CXR evaluation, each lung was divided into three zones (upper, middle, and lower)[7] and scoring was given from 1–3 depending on the percentage of involvement by ground-glass opacity or consolidation in the respective zone, i.e., score 1 for less than 33% involvement, 2 for 34–66% involvement, and 3 for more than 66% involvement, based on visual estimation. An additional score of 1 was given for the presence of pleural effusion on each side. Hence, a maximum score of 10 could be given to each lung and a score of 20 for both lungs. The score was recorded in the following predesigned below given proforma:
Observations and Analysis [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5] | Figure 2: Portable chest AP radiograph in COVID-19 patient showing ground-glass haziness in bilateral lower zones
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 | Figure 3: Portable chest AP radiograph in COVID-19 patient showing ground-glass haziness with fibrotic lesions in bilateral middle and lower zones
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 | Figure 4: Portable chest AP radiograph in COVID-19 patient showing ground-glass haziness in bilateral upper and middle zones with consolidation in lower zones
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 | Figure 5: Portable chest AP radiograph in COVID-19 patient showing ground-glass haziness in bilateral upper and middle zones with consolidation in lower zones and pleural effusion on left side
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Our study included Covid-19 positive patients with and without comorbidities, viz. DM, HTN, CAD and thyroid disease, patients without comorbidities acting as controls. [Table 1] shows the distribution of cases and controls in our study. It is evident that the largest group in our study among cases was those having both DM and HTN followed by those with only DM and only HTN. A significant number of patients also had DM, HTN, and CAD. Patients with both HTN and CAD were the least followed by those with thyroid disease.
[Table 2] shows the distribution of ground-glass opacity and consolidation in various groups based on the involvement of various zones in both lungs. Among the controls, 92 out of 145 (63.5%) had pulmonary findings on CXR against 431 out of 560 (77%) among cases showing a high prevalence of findings among cases. Among cases, the prevalence of pulmonary findings was noted as 50% in those with only thyroid disease, 68.9% with only HTN, 72% with only DM, 72.7% with both DM and thyroid disease, 80.5% with both DM and HTN, 85.7% with DM, HTN, and CAD; 90% with HTN and CAD, and 100% with HTN and thyroid disease. Though there was not much difference in the involvement of right and left lungs, there was a definite higher prevalence of lower zone involvement in both controls and cases except those with thyroid diseases.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5] show the representation of radiographs in our study with varying degrees of severity from normal [Figure 1] to GGO limited to bilateral lower zones [Figure 2], more extensive GGO with fibrotic changes in bilateral middle and lower zones [Figure 3], extensive GGO in bilateral upper and middle zones with consolidation in bilateral lower zones [Figure 4], and all the features of Image 4 with the presence of pleural effusion [Figure 5].
[Table 3] and [Table 4] show the distribution of SFZS on CXR among various subgroups of cases based on gender and age. No obvious statistical difference within different subgroups was noted except for borderline significance of age in those with both HTN and CAD.
[Table 5] shows the distribution of SFZS on CXR based on pleural effusion among controls and cases. Statistical significance was noted among controls and multiple subgroups among cases, viz. only DM, only HTN, only thyroid disease, DM with HTN, HTN with thyroid disease, DM with thyroid disease, and DM with HTN and CAD. This shows that the presence of pleural effusion is indicative of severe disease in the above-described subgroups among cases. However, no significant difference was noted in those with both HTN and CAD.
[Table 6] and [Table 7] show a lack of statistical significance in SFZS on CXR among cases with only DM and only HTN when compared with controls. The subgroup with only thyroid disease was too small and those with only CAD were not seen in our study group.
[Table 8] shows statistically significant differences in SFZS on CXR between controls and patients with various combinations of comorbidities, viz. DM with HTN and DM with HTN and CAD reflecting the negative effect of multiple comorbidities. | Table 8: Comparison of SFZS on CXR among control vs cases with various comorbidity combinations
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[Table 9] shows statistically significant differences in SFZS on CXR within controls and the different subgroups of cases signifying the increased negative effect of the presence of comorbidities, especially combinations. No significant difference was noted among those with only thyroid disease or its combination with other diseases due to a very small subgroup. | Table 9: Comparison of SFZS on CXR among control vs cases with one or more comorbidities
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| Discussion | | |
Beta and delta variants of SARS-CoV-2 are associated with significant pulmonary parenchymal involvement in the form of ground-glass haziness progressing to alveolar infiltrates and well-established consolidation with or without air-bronchogram or air-bronchiologram and complete loss of pneumatization.[8] Computed tomography of the thorax is a very sensitive imaging tool for detecting the above findings but with the disadvantage of limited availability, higher cost, and limited application to patients in intensive care units on various life-support systems,[8] justifying the use of chest radiographs in such patients, a major rationale to conduct this study.
Borgesi et al. in their study have demonstrated the significance of a high BrixIA score on CXR for predicting the risk of in-hospital death.[9] Giraudo et al. in their study also demonstrated the reliable role of chest radiography score in assessing the severity of pulmonary disease in Covid-19 patients with good prognostic performance.[10] Monaco et al. in their study demonstrated moderate to the high interobserver agreement in chest X-ray scores though with weak correlations with clinical parameters.[11]
The present study aimed to understand the differences in the CXR objectively using SFZS at the time of presentation of symptoms in Covid-19 positive patients without and with comorbidities including DM, HTN, CAD, and thyroid disease as this may help predict prognosis and differentiate patients that may require hospitalization or tertiary care referral.[12]
A simple fractional zone score (SFZS) on CXR used in our study is easy to understand and apply and has been demonstrated to be clinically useful Gaurav et al.[13] We demonstrated higher SFZS on CXR at the time of presentation in Covid-19 patients with one or more comorbidities similar to Singh et al., also predicting the course of the disease and long-term consequences.[12],[13],[14],[15] Like any other study, the involvement of bilateral lower zones was the commonest in our study also.[3],[16]
Limitations of the study
- Only the CXR at presentation was used in the study. Serial CXR that may be performed during the course of the disease was not a part of the study.
- The scoring used on CXR was not based on severity as ground-glass haziness is the initial manifestation that may resolve or progress to consolidation.
- All the subgroups within cases were not equally represented in terms of frequency in our study.
- The final outcome was not a part of the study.
| Conclusions | | |
- Higher prevalence of pulmonary involvement is noted in Covid-19 disease with comorbidity.
- Though all the subgroups among cases except that with only thyroid disease had a higher prevalence of pulmonary findings on CXR than controls at the time of presentation, the highest prevalence was noted among those with HTN and thyroid disease; HTN and CAD; HTN, CAD and DM, and HTN and DM in the decreasing order of frequency.
- Lower zone predominance was noted in Covid-19 patients with and without comorbidities.
- SFZS was not statistically different in patients with Covid-19 without and those with only DM or only HTN.
- SFZS score increases in Covid-19 patients with HTN, DM, DM and HTN, and with DM, HTN, and CAD in the increasing order of frequency and it was statistically significant.
| Conclusion | | |
To summarize, simple fractional zonal score (SFZS) provides a reliable tool for evaluating the chest X-ray for pulmonary disease in Covid-19 patients with comorbidities like diabetes mellitus, hypertension, coronary artery disease, and thyroid diseases. Higher scores are noted in Covid-19 patients with the above comorbidities than those without. This may help not only in management but also in predicting the course of the disease and monitoring long-term consequences.
Ethical approval and consent to participant
The authors confirm that they are accountable for all aspects of the work (including full data access, the integrity of the data, and the accuracy of the data analysis) in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Consent to participate
Since this is a retrospective data analysis, hence it does not require any consent of patient participation.
Financial support and sponsorship
Nil.
Conflict of interest
There are no conflicts of interest.
| References | | |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]
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