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Diagnostic and Prognostic Value of Chest Radiographs for COVID-19 at Presentation.
West J Emerg Med. 2020 Aug 17; 21(5):1067-1075.WJ

Abstract

INTRODUCTION

Pulmonary opacities in COVID-19 increase throughout the illness and peak after ten days. The radiological literature mainly focuses on CT findings. The purpose of this study was to assess the diagnostic and prognostic value of chest radiographs (CXR) for coronavirus disease 2019 (COVID-19) at presentation.

METHODS

We retrospectively identified consecutive reverse transcription polymerase reaction-confirmed COVID-19 patients (n = 104, 75% men) and patients (n = 75, 51% men) with repeated negative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) tests. Two radiologists blindly and independently reviewed the CXRs, documented findings, assigned radiographic assessment of lung edema (RALE) scores, and predicted the patients' COVID-19 status. We calculated interobserver reliability. The score use for diagnosis and prognosis of COVID-19 was evaluated with the area under the receiver operating characteristic curve.

RESULTS

The overall RALE score failed to identify COVID-19 patients at presentation. However, the score was inversely correlated with a COVID-19 diagnosis within ≤2 days, and a positive correlation was found six days after symptom onset.Interobserver agreement with regard to separating normal from abnormal CXRs was moderate (k = 0.408) with low specificity (25% and 27%). Definite pleural effusion had almost perfect agreement (k = 0.833) and substantially reduced the odds of a COVID-19 diagnosis. Disease distribution and experts' opinion on COVID-19 status had only fair interobserver agreement. The RALE score interobserver reliability was moderate to good (intraclass correlation coefficient = 0.745). A high RALE score predicted a poor outcome (intensive care unit hospitalization, intubation, or death) in COVID-19 patients; a score of ≥5 substantially increased the odds of having a poor outcome.

CONCLUSION

Chest radiography was found not to be a valid diagnostic tool for COVID-19, as normal or near-normal CXRs are more likely early in the disease course. Pleural effusions at presentation suggest a diagnosis other than COVID-19. More extensive lung opacities at presentation are associated with poor outcome in COVID-19 patients. Thus, patients with more than minimal opacities should be monitored closely for clinical deterioration. This clinical application of CXR is its greatest strength in COVID-19 as it impacts patient care.

Authors+Show Affiliations

Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Israel.Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Israel.Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Israel.Department of Medicine 'B', Sheba Medical Center, Tel Hashomer, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Israel.Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Israel.Clinical Microbiology, Sheba Medical Center, Tel Hashomer, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Israel.Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Israel.Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Israel.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

32970556

Citation

Kerpel, Ariel, et al. "Diagnostic and Prognostic Value of Chest Radiographs for COVID-19 at Presentation." The Western Journal of Emergency Medicine, vol. 21, no. 5, 2020, pp. 1067-1075.
Kerpel A, Apter S, Nissan N, et al. Diagnostic and Prognostic Value of Chest Radiographs for COVID-19 at Presentation. West J Emerg Med. 2020;21(5):1067-1075.
Kerpel, A., Apter, S., Nissan, N., Houri-Levi, E., Klug, M., Amit, S., Konen, E., & Marom, E. M. (2020). Diagnostic and Prognostic Value of Chest Radiographs for COVID-19 at Presentation. The Western Journal of Emergency Medicine, 21(5), 1067-1075. https://doi.org/10.5811/westjem.2020.7.48842
Kerpel A, et al. Diagnostic and Prognostic Value of Chest Radiographs for COVID-19 at Presentation. West J Emerg Med. 2020 Aug 17;21(5):1067-1075. PubMed PMID: 32970556.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Diagnostic and Prognostic Value of Chest Radiographs for COVID-19 at Presentation. AU - Kerpel,Ariel, AU - Apter,Sara, AU - Nissan,Noam, AU - Houri-Levi,Esther, AU - Klug,Maximiliano, AU - Amit,Sharon, AU - Konen,Eli, AU - Marom,Edith M, Y1 - 2020/08/17/ PY - 2020/06/24/received PY - 2020/07/22/accepted PY - 2020/9/24/entrez PY - 2020/9/25/pubmed PY - 2020/10/2/medline SP - 1067 EP - 1075 JF - The western journal of emergency medicine JO - West J Emerg Med VL - 21 IS - 5 N2 - INTRODUCTION: Pulmonary opacities in COVID-19 increase throughout the illness and peak after ten days. The radiological literature mainly focuses on CT findings. The purpose of this study was to assess the diagnostic and prognostic value of chest radiographs (CXR) for coronavirus disease 2019 (COVID-19) at presentation. METHODS: We retrospectively identified consecutive reverse transcription polymerase reaction-confirmed COVID-19 patients (n = 104, 75% men) and patients (n = 75, 51% men) with repeated negative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) tests. Two radiologists blindly and independently reviewed the CXRs, documented findings, assigned radiographic assessment of lung edema (RALE) scores, and predicted the patients' COVID-19 status. We calculated interobserver reliability. The score use for diagnosis and prognosis of COVID-19 was evaluated with the area under the receiver operating characteristic curve. RESULTS: The overall RALE score failed to identify COVID-19 patients at presentation. However, the score was inversely correlated with a COVID-19 diagnosis within ≤2 days, and a positive correlation was found six days after symptom onset.Interobserver agreement with regard to separating normal from abnormal CXRs was moderate (k = 0.408) with low specificity (25% and 27%). Definite pleural effusion had almost perfect agreement (k = 0.833) and substantially reduced the odds of a COVID-19 diagnosis. Disease distribution and experts' opinion on COVID-19 status had only fair interobserver agreement. The RALE score interobserver reliability was moderate to good (intraclass correlation coefficient = 0.745). A high RALE score predicted a poor outcome (intensive care unit hospitalization, intubation, or death) in COVID-19 patients; a score of ≥5 substantially increased the odds of having a poor outcome. CONCLUSION: Chest radiography was found not to be a valid diagnostic tool for COVID-19, as normal or near-normal CXRs are more likely early in the disease course. Pleural effusions at presentation suggest a diagnosis other than COVID-19. More extensive lung opacities at presentation are associated with poor outcome in COVID-19 patients. Thus, patients with more than minimal opacities should be monitored closely for clinical deterioration. This clinical application of CXR is its greatest strength in COVID-19 as it impacts patient care. SN - 1936-9018 UR - https://www.unboundmedicine.com/medline/citation/32970556/Diagnostic_and_Prognostic_Value_of_Chest_Radiographs_for_COVID_19_at_Presentation_ L2 - https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/32970556/ DB - PRIME DP - Unbound Medicine ER -