1 / 27 Radiographic Findings and other Predictors in Adults with Covid-19 Kaiyan Li 1 , Dian Chen 1 , Shenchong Chen 1 , Yuchen Feng 1 , Chenli Chang 1 , Zi Wang 2 , Nan Wang 2 , Guohua Zhen 1, * 1 Division of Respiratory and Critical Care Medicine, Department of Internal Medicine, and 2 Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China *Correspondence to: [email protected]As of March 20, 2020, there were 234,073 confirmed cases of coronavirus disease 2019 (Covid-19) and 9,840 deaths worldwide 1 . Older age and elevated d-dimer are reported risk factors for Covid-19 2,3 . However, whether early radiographic change is a predictor of fatality remains unknown. We retrospectively reviewed records of all laboratory-confirmed patients admitted to a quarantine unit at Tongji Hospital, a large regional hospital in Wuhan, China, between January 31 and March 5, 2020. The Tongji Hospital ethics committee approved this study. A total of 128 patients were admitted. 102 patients were confirmed to have severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection using RNA detection. As of March 20, 82 confirmed patients were discharged, 15 died, and 5 remained hospitalized. The median age was 57 years (range, 27 - 85), 59 (58%) were male, and 44 (43%) patients had a comorbidity. The most common symptoms were fever, cough, and dyspnea (Table S1). When compared with survivors, non-survivors were older and more likely to have lymphopenia, elevated lactate dehydrogenase All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted March 27, 2020. . https://doi.org/10.1101/2020.03.23.20041673 doi: medRxiv preprint NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.
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Radiographic Findings and other Predictors in Adults with Covid-19
As of March 20, 2020, there were 234,073 confirmed cases of coronavirus disease
2019 (Covid-19) and 9,840 deaths worldwide 1. Older age and elevated d-dimer are
reported risk factors for Covid-19 2,3. However, whether early radiographic change is a
predictor of fatality remains unknown. We retrospectively reviewed records of all
laboratory-confirmed patients admitted to a quarantine unit at Tongji Hospital, a large
regional hospital in Wuhan, China, between January 31 and March 5, 2020. The Tongji
Hospital ethics committee approved this study.
A total of 128 patients were admitted. 102 patients were confirmed to have severe
acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection using RNA
detection. As of March 20, 82 confirmed patients were discharged, 15 died, and 5
remained hospitalized. The median age was 57 years (range, 27 - 85), 59 (58%) were
male, and 44 (43%) patients had a comorbidity. The most common symptoms were
fever, cough, and dyspnea (Table S1). When compared with survivors, non-survivors
were older and more likely to have lymphopenia, elevated lactate dehydrogenase
All rights reserved. No reuse allowed without permission. perpetuity.
preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for thisthis version posted March 27, 2020. .https://doi.org/10.1101/2020.03.23.20041673doi: medRxiv preprint
NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.
(LDH), elevated d-dimer, and increased hypersensitive troponin I (Table S1, S2). In a
multivariate regression model that included these predictors, older age and elevated
LDH were independent risk factors for fatality (Table S3).
Figure 1. Total severity score and the number of involved lung lobes in CT images. A-B,
total severity score (A) and the number of involved lung lobes (B) for CT images of survivors
and non-survivors within the first week (≤7d) after symptom onset. C, total severity score for
CT images of survivors over the 4 weeks after symptom onset. Values of survivors and non-
survivors are presented with open and closed circles, respectively. Mann-Whitney U test was
used to compare the values of survivors in Week 1 with those of non-survivors, and with those
of survivors in Week 2, 3, 4, respectively. ****, p < 0.0001; **, p < 0.01; *, p < 0.05.
Twenty-one survivors and 11 non-survivors had CT scans within the first week. We
used severity score to quantify the extent of lung opacification as described in the
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preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for thisthis version posted March 27, 2020. .https://doi.org/10.1101/2020.03.23.20041673doi: medRxiv preprint
2. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult
inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020
Mar 11. pii: S0140-6736(20)30566-3. doi: 10.1016/S0140-6736(20)30566-3. [Epub
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preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for thisthis version posted March 27, 2020. .https://doi.org/10.1101/2020.03.23.20041673doi: medRxiv preprint
3. Wu C, Chen X, Cai Y, et al. Risk Factors associated with acute respiratory distress
syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan,
China. JAMA Internal Medicine. 2020 Mar 13. doi: 10.1001/jamainternmed.2020.0994.
[Epub ahead of print]
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preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for thisthis version posted March 27, 2020. .https://doi.org/10.1101/2020.03.23.20041673doi: medRxiv preprint
Declaration of interests ................................................................................................26
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preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for thisthis version posted March 27, 2020. .https://doi.org/10.1101/2020.03.23.20041673doi: medRxiv preprint
This retrospective study was approved by the institutional ethics board of Tongji
Hospital of Huazhong University of Science and Technology. Written informed consent
was waived. The study included all patients with laboratory-confirmed COVID-19
admitted to a quarantine unit of Tongji Hospital, a large regional hospital in Wuhan,
China, between January 31 and March 5, 2020. COVID-19 patients were diagnosed
according to World Health Organization (WHO) interim guideline 1. Confirmed cases
were defined by the positive findings in reverse-transcriptase–polymerase-chain-
reaction (RT-PCR) assay of throat swab specimens. Clinical characteristics, laboratory
test results, and treatment information were extracted from electronic medical records.
All laboratory testing and radiological examination were performed according to the
clinical care needs of the patient.
RT-PCR for SARS-CoV-2
Throat swab specimens were tested for SARS-CoV-2 using real-time RT-PCR
according to the WHO protocol 3. The following primers and probes were used for real-
time RT-PCR detection of N gene of SARS-CoV-2: N forward primer 5'-
GAGCCTTGAATACACCAAAAG-3', N reverse primer 5'-
GCACGATTGCAGCATTGTTAGCAGGATT-3', N probe 5'-
FAMCACATTGGCACCCGCAATCC-MGB-3'. Positive results were confirmed in
two independent real-time RT-PCR assays.
Chest CT Protocols and Evaluation
High-resolution transverse CT images were obtained using Optima 660 (GE Medical
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involvement; 4, 50% - 75% involvement; 5, > 75% involvement. The total severity
score was the sum of scores of each lobe, ranging from 0 (no involvement) to 25
(maximum involvement).
Statistical Analysis
Statistical analysis was done with SPSS Statistics Software (version 26; IBM, New
York, USA). Continuous variables were presented as median (IQR) and analyzed using
Mann-Whitney U test; categorical variables were presented as number (%) and
analyzed by χ² test or Fisher’s exact test between survivors and non-survivors where
appropriate. Univariable and multivariable logistic regression models were used to
estimate odds ratios and the 95% confidence intervals of the risk factors associated with
fatal outcome. A two-sided α of less than 0.05 was considered statistically significant.
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>20 breaths per min 47 (46%) 12 (80%) 35 (40%) 0.004
Time from symptom onset
to hospital admission, days
11.0(7.0-16.0) 9.0(6.0-14.0) 11.0(8.0-18.0) 0.291
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Data are median (IQR), n (%), or n/N (%), where N is the total number of patients with available
data. p values comparing survivor with non-survivor were calculated by χ² test, Fisher’s exact test,
or Mann-Whitney U test, as appropriate. Covid-19, coronavirus disease 2019.
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preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for thisthis version posted March 27, 2020. .https://doi.org/10.1101/2020.03.23.20041673doi: medRxiv preprint
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preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for thisthis version posted March 27, 2020. .https://doi.org/10.1101/2020.03.23.20041673doi: medRxiv preprint
All rights reserved. No reuse allowed without permission. perpetuity.
preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for thisthis version posted March 27, 2020. .https://doi.org/10.1101/2020.03.23.20041673doi: medRxiv preprint
Data are median (IQR), n (%), or n/N (%), where N is the total number of patients with available
data. p values comparing survivor with non-survivor were calculated by χ² test, Fisher’s exact test,
or Mann-Whitney U test, as appropriated. Covid-19, coronavirus disease 2019.
All rights reserved. No reuse allowed without permission. perpetuity.
preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for thisthis version posted March 27, 2020. .https://doi.org/10.1101/2020.03.23.20041673doi: medRxiv preprint
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preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for thisthis version posted March 27, 2020. .https://doi.org/10.1101/2020.03.23.20041673doi: medRxiv preprint
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preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for thisthis version posted March 27, 2020. .https://doi.org/10.1101/2020.03.23.20041673doi: medRxiv preprint
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Time between symptom onset and CT scan 4(2.5-5) 5(2-6) 11.5(9-13.25) 18(16-20) 26(24-28)
Data are median (IQR), n (%). χ² test, Mann-Whitney U test and Fisher's exact test were used to compare the values of survivors in Week 1 with those of non-survivors,
and with those of survivors in Week 2, 3, 4, respectively. ****, p < 0.0001; ***, p < 0.001; **, p < 0.01; *, p < 0.05.
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CT findings within the first week after symptom onset
Total severity score* 1.39(1.12-1.72) 0.003 1.544(1.004-2.374) 0.048
<15 1 (ref) .. .. ..
≥15 35.00(3.32-368.57) 0.003 .. ..
Number of involved lung
lobes
1.366(1.003-1.860) 0.048 .. ..
<5 1 (ref) .. .. ..
=5 9.00(1.52-53.40) 0.016 .. ..
OR=odds ratio. *Per 1 unit increase.
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>20 breaths per min 14 (44%) 8 (73%) 6 (29%) 0.017
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Data are median (IQR), n (%), or n/N (%), where N is the total number of patients with available
data. χ² test, Fisher’s exact test, or Mann-Whitney U test were used to compare the values between
survivors and non-survivors as appropriate.
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Prothrombin time, s 11.5-14.5 14.8(13.8-15.4) 15.5(14.8-17.7) 14.3(13.4-15.0) 0.005
<14.5 14 (44%) 2 (18%) 12 (57%) 0.035
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preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for thisthis version posted March 27, 2020. .https://doi.org/10.1101/2020.03.23.20041673doi: medRxiv preprint
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preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for thisthis version posted March 27, 2020. .https://doi.org/10.1101/2020.03.23.20041673doi: medRxiv preprint
Data are median (IQR), n (%), or n/N (%), where N is the total number of patients with available data. χ² test, Fisher’s exact test, or Mann-Whitney U test were used
to compare the values between survivors and non-survivors as appropriate.
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Figure S1. Transverse CT images of a 38-year-old man with Covid-19. A, Normal CT
images on the day when the patient had initial symptoms (day 1). B, day 9 after
symptom onset, bilateral and peripheral ground-grass opacity associated smooth
interlobular and intralobular septal thickening (crazy-paving pattern). C, day 15 after
symptom onset, peripheral predominant consolidation pattern with air bronchograms in
right upper and lower lobes. D, day 23 after symptom onset, previous opacifications
were dissipated into ground-grass opacities and irregular interlobular and intralobular
septal thickening (reticulation pattern). E, day 30 after symptom onset, further
resolution of the lesions, ground-glass opacities and reticulation patterns remained.
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Figure S2. Transverse CT images of a 41-year-old woman with Covid-19. A-C, day 6
after symptom onset, multifocal consolidations and ground-glass opacities affecting the
bilateral, subpleural lung parenchyma associated with crazy-paving pattern. D-F, day
10 after symptom onset, bilateral extensive ground-glass opacities, involving nearly the
entire lower lobes and right middle lobe, and most of the upper lobes, giving a white
lung appearance, with air bronchograms and crazy-paving pattern. The patient died 8
days after this scan.
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KL and GZ conceptualized the study design. KL, SC, DC, YF, CC collected
demographic, clinical, and laboratory data. ZW and NW interpreted the images of CT
scans. KL, DC, YF and GZ analysed the data. KL and GZ interpreted the results. GZ
wrote the manuscript with all authors providing feedback for revision. All authors read
and approved the final report.
Funding
Supported by National Natural Science Foundation of China (grants 81670019,
91742108), National Key Research and Development Program of China
(2016YFC1304400).
Acknowledgement
We are very grateful to all members of the medical, nursing, and support staffs of the
quarantine unit at the Sino-French branch of Tongji Hospital for their support. We are
very grateful to David J. Erle (University of California San Francisco) for the critical
review of the manuscript.
Declaration of interests
The authors have no competing interests to declare.
References
1. World Health Organization. Clinical management of severe acute respiratory
infection when novel coronavirus (2019-nCoV) infection is suspected: interim
guidance. January 28, 2020 (https://www.who.int /docs /default - source/coronaviruse/
clinical-management-of-novel-cov.pdf)
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preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for thisthis version posted March 27, 2020. .https://doi.org/10.1101/2020.03.23.20041673doi: medRxiv preprint