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Einstein (São Paulo)

versão impressa ISSN 1679-4508versão On-line ISSN 2317-6385

Einstein (São Paulo) vol.18  São Paulo  2020  Epub 09-Abr-2020 


Structured thoracic computed tomography report for COVID-19 pandemic

Hamilton Shoji1

Eduardo Kaiser Ururahy Nunes Fonseca1

Gustavo Borges da Silva Teles1

Rodrigo Bastos Duarte Passos1

Elaine Yanata1

Murilo Marques Almeida Silva1

Marcelo Buarque de Gusmão Funari1

Roberto Sasdelli Neto1

Walther Yoshiharu Ishikawa1

Rodrigo Caruso Chate1

Gilberto Szarf1

1Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.

By the end of 2019, a novel coronavirus (severe acute respiratory syndrome coronavirus 2 or SARS-CoV-2) was identified as the etiologic agent of an outbreak of pneumonia in the city of Wuhan, province of Hubei, in China. The virus had a rapid dissemination, with person-to-person transmission and cases soon identified throughout the world. The disease was called COVID-19 (coronavirus disease 2019), with several new outbreaks related to community transmission. It is now classified as pandemic.1 - 4

We have observed an increase in requests of chest computed tomography (CT) since the first records of cases in Brazil; therefore, in a near future, the current installed capacity of the system to analyze and produce the CT reports may be exceeded. It is crucial to highlight that the definite diagnosis of COVID-19 is made by real-time polymerase chain reaction (RT-PCR), and a normal (negative) chest CT does not rule out diagnosis. However, currently, the RT-PCR result has taken longer than CT reports to be available, so CT has taken an important role in a comprehensive assessment of patients, for demonstrating high sensitivity (although low specificity), to detect the most frequent pulmonary findings of the disease.

In this high demand urgency context to provide results, it is advisable that the content of the radiological report be very objective and as clear as possible for the requesting physicians from the emergency department. The most relevant pieces of information to be conveyed are presence (or not) of pulmonary involvement, if the findings are compatible with infectious process, and, in positive cases, if the changes are suggestive of viral etiology, particularly COVID-19, even if there is overlapping of findings with other infectious diseases (including other viruses). We also included an approximate estimate of extent of pulmonary involvement by the disease (visual analysis), which has been considered useful by them in management of patients, together with other clinical data and physical examination. In our Institution, involvement of >50% of parenchyma5 has been used as an additional criterion to decide for hospitalization.

In a structured report, we initially describe if there are pulmonary changes or not, and if they are suggestive of a pulmonary infectious process. In case of alterations, if the features are in accordance or not with the more typical pattern described in COVID-19: including ground-glass opacities, sometimes with superimposed interlobular septal thickening (crazy paving), consolidations and reversed halo, presenting a bilateral multilobar distribution, predominantly peripheral, with mild predilection for the posterior regions and lower lobes.6 - 10 In these cases, we have highlighted in our reports that “the possibility of COVID-19 should be considered in the differential diagnoses”, and also included the estimated extent of parenchyma involvement (greater or lesser than 50%).5Figure 1 shows a case with typical imaging findings of COVID-19 and the model of provided report.

Figure 1 Computed tomography image of a confirmed case of COVID-19 with typical findings and its respective report 

In patients with tomographic findings more suggestive of other type of infection which obviously must not be neglected amidst the pandemic, we have described the changes and concluded as follows: “Such findings are compatible with pulmonary infectious process, and its characteristics are not typically observed in cases of pulmonary involvement by COVID-19; other etiologic agents should be initially considered in the differential diagnosis.” As examples of changes described in the literature as uncommon in cases of COVID-19, which increase the probability of infection by other agents, we underline numerous centrilobular micronodules with tree-in-bud pattern, relatively well-defined solid nodules, cavities, predominant central parenchyma involvement, mainly affecting the airways.6 - 9Figure 2 displays an example of one of those cases and its respective report, with final diagnosis of tuberculosis after complete investigation.

Figure 2 Computed tomography images of a case with initial clinical suspicion of COVID-19 and its respective report, with tomographic findings suggestive of infectious process, but with characteristics that are not usual in COVID-19. After performing ancillary investigations, the diagnosis was pulmonary tuberculosis 

In the subgroup of patients with no tomographic evidence of pulmonary infectious process, we clearly and explicitly report the following phrase: “Absence of focal pulmonary opacities suggestive of active parenchymal infectious process.”

Next, other additional relevant findings are briefly included, emphasizing the presence or not of lymph node enlargement, pleural effusion, as well as pulmonary nodules, emphysema, chronic interstitial disease, aneurysms and marked atheromatous disease.

Developing structured reports in radiology, primarily those oriented to certain diseases, provides several benefits, including clarity in conveying information to requesting physicians and use of a common terminology, enabling all those involved to be familiar with specific terms used for each disease. Moreover, this later enables collecting data for epidemiological purposes, quality control and research.11 , 12 Other advantages comprise increased radiologist productivy with less burden.12

Implementing a structured report should be beneficial, particularly in the current scenario of COVID-19 pandemic, for increasing productivity of radiologists and enabling better understanding of the requesting physicians, with a potential positive impact in management of patients.13


1. National Health Commission of the People’s Republic of China. New coronavirus cases rise to 571 in Chinese mainland [Internet]. China: 2020 [cited 2020 Mar 16]. Available from: ]

2. World Health Organization (WHO). Novel Coronavirus – Republic of Korea (ex-China) [Internet]. Geneva: WHO; 2020 [cited 2020 Mar 16]. Available from: ]

3. European Centre for Disease Prevention and Control [ECDC]. Geographical distribution of 2019-nCov cases. Situation update worldwide, as of 27 March 2020 [Internet]. ECDC; 2020 [cited 2020 Mar 16]. Available from: ]

4. Centers for Disease Control and Prevention [CDC]. Coronavirus Disease 2019 (COVID-19). Cases in U.S [Internet]. USA: CDC; 2020 [cited 2020 Mar 16]. Available from: ]

5. Zhao W, Zhong Z, Xie X, Yu Q, Liu J. Relation between chest CT findings and clinical conditions of coronavirus disease (COVID-19) pneumonia: a multicenter study. AJR Am J Roentgenol. 2020 Mar 3:1-6. doi: 10.2214/AJR.20.22976. [ Links ]

6. Bai HX, Hsieh B, Xiong Z, Halsey K, Choi WC, Tran TM, et al. Performance of radiologists in differentiating COVID-19 from viral pneumonia on chest CT. Radiology. 2020 Mar 10:200823. [ Links ]

7. Ng MY, Lee EY, Yang J, Yang F, Li X, Wang H, et al. Imaging profile of the covid-19 infection: radiologic findings and literature review. Radiol Cardiothorac Imaging. 2020;2(1):e200034. [ Links ]

8. Chung M, Bernheim A, Mei X, Zhang N, Huang M, Zeng X, et al. CT Imaging Features of 2019 Novel coronavirus (2019-nCoV). Radiology. 2020;295(1):202-7. [ Links ]

9. Kong W, Agarwal PP. Chest Imaging Appearance of COVID-19 Infection. Radiol Cardiothorac Imaging. 2020;2(1):e200028. [ Links ]

10. Rodriguez-Morales AJ, Cardona-Ospina JA, Gutiérrez-Ocampo E, Villamizar-Peña R, Holguin-Rivera Y, Escalera-Antezana JP, Alvarado-Arnez LE, Bonilla-Aldana DK, Franco-Paredes C, Henao-Martinez AF, Paniz-Mondolfi A, Lagos-Grisales GJ, Ramírez-Vallejo E, Suárez JÁ, Zambrano LI, Villamil-Gómez WE, Balbin-Ramon GJ, Rabaan AA, Harapan H, Dhama K, Nishiura H, Kataoka H, Ahmad T, Sah R; Latin American Network of Coronavirus Disease 2019-COVID-19 Research (LANCOVID-19). Electronic address: https: // Clinical, laboratory and imaging features of COVID-19: a systematic review and meta-analysis. Travel Med Infect Dis. 2020 Mar 13:101623. Review. doi: 10.1016/j.tmaid.2020.101623. [ Links ]

11. Noumeir R. Benefits of the DICOM structured report. J Digit Imaging. 2006;19(4):295-306. [ Links ]

12. Ganeshan D, Duong PT, Probyn L, Lenchik L, McArthur TA, Retrouvey M, et al. Structured Reporting in Radiology. Acad Radiol. 2018;25(1):66-73. Review. [ Links ]

13. Simpson S, Kay FU, Abbara S, Bhalla S, Chung JH, Chung M, Henry TS, et al. Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA. Radiology: Cardiothoracic Imaging. 2020;2:2:1-24. ]

Corresponding author: Eduardo Kaiser Ururahy Nunes Fonseca. Avenida Albert Einstein, 627/701 – Morumbi Zip code: 05652-900 – São Paulo, SP, Brazil Phone: (55 11) 2151-1233 E-mail:

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