This document discusses chest X-ray findings in COVID-19 patients from Carolinas Medical Center. It presents a series of de-identified chest X-rays from COVID-19 patients ranging from initial presentation through hospital course. Key findings discussed include ground glass opacities, local and bilateral patchy shadowing, and interstitial abnormalities. Guidelines for use of chest imaging in evaluating and managing suspected and confirmed COVID-19 patients are also summarized. The goal is to promote understanding and mastery of chest X-ray interpretation for COVID-19.

1. COVID-19 Chest X-Ray Cases
Shelby Hixson, PA; Claire Milam, MD;
Nikki Richardson, MD; Alyssa Thomas, MD
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs, MD: Lead Editor Chest X-Ray Mastery Project™
Johnathan Clemente, MD
Charlotte Radiology
Guest Editor
Catherine Passaretti, MD
CMC Infectious Disease
Guest Editor

2. Disclosures
 This ongoing chest X-ray interpretation series is proudly sponsored by the
Emergency Medicine Residency Program at Carolinas Medical Center.
 The goal is to promote widespread mastery of CXR interpretation.
 There is no personal health information [PHI] within, and all ages have
been changed to protect patient confidentiality.

3. Process
• Many are providing clinical cases and presentations are then shared with
all contributors on our departmental educational website.
• Contributors from many Carolinas Medical Center departments, and now…
Brazil, Chile, and Tanzania.
• We will review a series of CXR case studies and discuss an approach to the
diagnoses at hand: COVID-19 Case Studies.

4. Visit Our Website
www.EMGuidewire.com
For A Complete Archive Of Chest X-Ray Presentations And Much More!

5. Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

6. It’s All About The Anatomy!

7. COVID-19 Case Studies From Carolinas Medical Center &
Levine Children’s Hospital

8. Healthy 35-
Year Old One
Week Of
Dyspnea,
Subjective
Fever And
Loose Stools.
He Is Treated
For
Pneumonia
And Swabbed
For COVID.

9. He Presents
To The ED
Three Days
Later In
Severe
Respiratory
Distress.
COVID [+].

10. Healthy 42-
Year Presents
In Severe
Respiratory
Distress And
Severe
Hypoxemia.
COVID [+]
Two Days
Ago.
Intubated
Upon Arrival
To The ED.

11. Healthy 42-
Year Presents
In Severe
Respiratory
Distress And
Severe
Hypoxemia.
COVID [+] 72
Hours Ago.

12. Healthy 55-
Year-Old Is
Evaluated For
A Cough.
His Chest X-
Ray Is Normal.
COVID Testing
[+].

13. Our Patients
Presents To
The ED Three
Days Later In
Respiratory
Distress.

14. 78-Year-Old With
Cough, Dyspnea,
And Fever.
Day Of Admission.

15. 78-Year-Old With
Cough, Dyspnea,
And Fever.
Hospital Day 3.

16. 78-Year-Old With
Cough, Dyspnea,
And Fever.
Hospital Day 5.

17. 78-Year-Old With
Cough, Dyspnea,
And Fever.
Hospital Day 7.

18. 75-Year-Old With
Cough, Dyspnea,
And Fever
PCP’s Office.
Swabbed For COVID-19

19. 75-Year-Old Now
Presents To The
ED
Two Days Later.
Worsening
Dyspnea And
Hypoxia.

20. 75-Year-Old Now
Presents To The
ED
Two Days Later.
Worsening
Dyspnea And
Hypoxia.

21. 75-Year-Old With
Progressive
Respiratory
Failure.
Hospital Day 3.

22. 75-Year-Old With
Progressive
Respiratory
Failure.
Hospital Day 5.

23. 23-Year-Old With
A History Of Sickle
Cell Disease
Presents With
Cough, Dyspnea
And Fever.
Day Of Admission.

24. 23-Year-Old With
A History Of Sickle
Cell Disease
Presents With
Cough, Dyspnea
And Fever.
Hospital Day 2.

25. 23-Year-Old With
A History Of Sickle
Cell Disease
Presents With
Cough, Dyspnea
And Fever.
Hospital Day 5.

26. 23-Year-Old With
A History Of Sickle
Cell Disease
Presents With
Cough, Dyspnea
And Fever.
Hospital Day 10.

27. 35-Year-Old With
Cough And Fever.
Day Of Admission.

28. 35-Year-Old With
Cough And Fever.
Hospital Day 2.

29. 35-Year-Old With
Cough And Fever.
Hospital Day 3.

30. 35-Year-Old With
Cough And Fever.
Hospital Day 5.

31. 17-Year-Old presented
with fever, chest pain and
body aches.
Dx: COVID with wedge
shaped pneumonia

32. 4-year-old with history of
transposition of the great
arteries presents with
wheezing and respiratory
distress.
Dx: COVID with worsening
heart failure

33. 10-year-old with history of
recent URI illness in the
entire family presents in
acute respiratory failure.
Dx: ARDS secondary to
multisystem inflammatory
syndrome in children
(MIS-C)

34. 14-year-old with no medical
history presents with
shortness of breath and
hypoxia in the setting of
known COVID-19 exposure.
Day of Admission

35. 14-year-old with no medical
history presents with
shortness of breath and
hypoxia in the setting of
known COVID-19 exposure.
Hospital Day 2

36. 14-year-old with no medical
history presents with
shortness of breath and
hypoxia in the setting of
known COVID-19 exposure.
Hospital Day 3

37. 14-year-old with no medical
history presents with
shortness of breath and
hypoxia in the setting of
known COVID-19 exposure.
Hospital Day 4

38. 14-year-old with no medical
history presents with
shortness of breath and
hypoxia in the setting of
known COVID-19 exposure.
Thoracostomy
Pneumothorax
Air Bronchograms
Consolidation
Ground Glass
Hospital Day 7

39. What Are The Key Chest Imaging Findings In Patients
With COVID-19?

41. Chest Imaging Findings In Patients
With COVID-19 [n=1099]
Findings Total Non-Severe (926) Severe (173)
Ground Glass Opacity 56% 56% 60%
Local Patchy Shadowing 42% 39% 55%
Bilateral Patchy Shadowing 52% 45% 82%
Interstitial Abnormality 15% 12% 26%

43. Chest Imaging Findings In 24 ICU
Patients With COVID-19
Plain Film Chest X-Ray
Clear 0/23
Bilateral Infiltrates 23/23
Pleural Effusion 0/23
Computed Tomography
Clear 4/5 [80%]
Bilateral Infiltrates 1/5 [20%]
Pleural Effusion 0/5

44. What Are The Guidelines For Chest Imaging In
Patients With Suspected And Proven COVID-19?

46. R1 For asymptomatic contacts of patients with COVID-19, WHO suggests not using chest imaging for
the diagnosis of COVID-19. [Use RT-PCR to confirm diagnosis].
R2.1 For symptomatic patients with suspected COVID-19, WHO suggests not using chest imaging for
the diagnostic workup of COVID-19 when RT-PCR testing is available with timely results.
R2.2 For symptomatic patients with suspected COVID-19, WHO suggests that using chest imaging for
the diagnostic work-up COVID-19 when:
• RT-PCR testing is not available;
• RT-PCR testing is available, but results will be delayed;
• Initial RT-PCR testing is negative, but there is high clinical suspicion for COVID-19
R3 For patients with suspected or confirmed COVID-19, not currently hospitalized and with mild
symptoms, WHO suggests using chest imaging in addition to clinical and laboratory assessment
to decide on hospital admission versus home discharge.

47. R4 For patients with suspected or confirmed COVID-19, not currently hospitalized and with
moderate to severe symptoms, WHO suggests using chest imaging in addition to clinical and
laboratory assessment to decide on regular ward admission versus intensive care unit admission.
R5 For patients with suspected or confirmed COVID-19, currently hospitalized and with moderate to
severe symptoms, WHO suggests using chest imaging in addition clinical and laboratory
assessment to inform the therapeutic management.
R6 For hospitalized patient with COVID-19 whose symptoms are resolving, WHO suggests not using
chest imaging in additional to clinical and/or laboratory assessment to inform the decision
regarding discharge.

58. If you have interesting cases of COVID-19 pneumonia, we invite you
to send a set of digital PDF images and a brief descriptive clinical history to:
michael.gibbs@atriumhealth.org
Your de-identified case(s) will be posted on our education website and you
and your institution will be recognized!