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For a quick reference guide, please see our COVID-19 summary article.

COVID-19 (coronavirus disease 2019) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), previously known as 2019 novel coronavirus (2019-nCoV). The first cases were seen in Wuhan, China in December 2019 before spreading globally ^1,2,10. The current outbreak was recognized as a pandemic on 11 March 2020 ⁴⁴.

The non-specific imaging findings are most commonly of atypical pneumonia, often with a bilateral, peripheral, and basal predominant distribution ³². No effective treatment or vaccine exists currently (March 2020) ²⁰.

Terminology

The WHO originally called this illness "novel coronavirus-infected pneumonia (NCIP)" and the virus itself had been named 2019 novel coronavirus (2019-nCoV) ¹.

On 11 February 2020, the World Health Organisation (WHO) officially renamed the clinical condition COVID-19 (a shortening of COronaVIrus Disease-19), which was announced in a tweet ¹⁵. Coincidentally, on the same day, the Coronavirus Study Group (CSG) of the International Committee on Taxonomy of Viruses renamed the virus "severe acute respiratory syndrome coronavirus 2" (SARS-CoV-2) ^16,22,46.

The names of both the disease and the virus should be fully capitalised, except for the 'o' in the viral name, which is in lower case ^16,22,41.

The WHO has expressed reservations about the official virus name in view of its closeness to the name SARS. It has publicly stated it will not be using it, instead using "COVID-19 virus" or the "virus that causes COVID-19". A group of Chinese virologists also stated in a letter published in The Lancet that the new name was likely to confuse the public due to its similarity to the disease SARS, and they suggested "human coronavirus 2019 (HCoV-19)" ³⁸.

However, the scientific community is already using SARS-CoV-2 and it is likely that this will be gradually accepted by the wider world ²². The WHO has also publicly stated that although they will not be using the term SARS-CoV-2 in their public communications, it remains the official name of the virus ⁴⁵.

Some publications have chosen to use a separate term "novel COVID-19-infected pneumonia (NCIP)" for the pneumonia secondary to COVID-19 ⁴⁰.

Epidemiology

As of 22 March 2020, over 307,200 cases of COVID-19 have been confirmed worldwide, with China now accounting for only 26% of all confirmed cases, according to an online virus tracker created by the medical journal, The Lancet, and hosted by Johns Hopkins University ⁵. Although the percentage of confirmed cases outside China is steadily increasing, the epidemic in China has plateaued ⁵.

Six other countries have over 10,000 cases ⁵:

Italy: 53,578
Iran: 20,610
Spain: 25,496
Germany: 22,364
United States of America: 26,747
France: 14,486

with a further fourteen countries between 1,000-10,000 cases ⁵:

South Korea: 8,897
Switzerland: 6,652
United Kingdom: 5,067
Netherlands: 3,640
Austria: 3,021
Belgium: 2,815
Norway: 2,164
Sweden: 1,770
Denmark: 1,420
Malaysia: 1,183
Portugal: 1,280
Australia: 1,071
Japan: 1,055
Brazil: 1,021

In addition, 717 cases were confirmed on two cruise ships, the Diamond Princess, moored off Japan with 696 cases, and 21 cases on the Grand Princess moored off the Californian coast in the United States ⁵.

On 13 January 2020, the first confirmed case outside China was diagnosed, a Chinese tourist in Thailand ¹⁰. On 20 January, the first infected person in the United States was confirmed to be a man who had recently returned from Wuhan ⁹. The disease has now been diagnosed in over 165 territories, in six continents ^5,13.

The infection was declared a Public Health Emergency of International Concern (PHEIC) on 30 January 2020 by the WHO ⁷. On 28 February 2020, the WHO increased the global risk assessment of COVID-19 to “very high” which is the highest level. On 11 March 2020, COVID-19 was declared a pandemic by the WHO ⁴⁴.

The mortality rate is about 2-3% ⁵ with currently 13,049 confirmed deaths (22 March 2020) ⁵. This includes confirmed deaths in 55 territories including the following ⁵:

4,825 in Italy
3,232 in China
1,556 in Iran
1,381 in Spain
562 in France

In the largest study to date, a paper published by the Chinese Center for Disease Control and Prevention (CCDC) analysed all the cases diagnosed up to 11 February 2020, which came to 44,672 cases. Of these 1.2% were asymptomatic and 80.9% were classed as "mild". The overall mortality rate was found to be 2.3% ²⁵.

In an article examining the first 425 infected cases in Wuhan, 56% of the infected were male and the median age was 59 years ¹². In this early cohort, there were no children under 15 years old. Using this dataset, the group estimated that the R₀ (basic reproduction number) of the novel coronavirus was 2.2, that is each infected individual—on average—causes 2.2 new cases of the disease. The incubation period in this group has been calculated to be 5.2 days on average ¹².

A more recent study, for which researchers reviewed 12 studies of COVID-19, calculated the average R₀ to be higher at 3.28, with the authors estimating the likely R₀ to lie between 2 and 3 ³³.

Interestingly children seem to be relatively unaffected by this virus, or indeed other closely-related coronaviruses ⁴⁷. A Chinese study reviewing the first 31,211 cases in mainland China found that only nine children under one year of age were confirmed with COVID-19. All nine cases were admitted to hospital, and symptoms were mild or absent. None required intensive care or developed severe sequelae ^31,47. A later study of the epidemiology by a case series of over 2,143 Chinese children showed there have been critically ill children, and although the numbers are fewer than in the elderly population, infants under 12 months were more likely to have become critically ill than other pediatric age groups ⁵⁹. In children, male gender does not seem to be a risk factor ⁵⁹.

NB: it is important to appreciate that the known epidemiological parameters of any new disease are likely to change as larger cohorts of infected people are studied, although this will only to some extent reflect a true change in the underlying reality of disease activity (as a disease is studied and understood humans will be simultaneously changing their behaviours to alter transmission or prevalence patterns).

Clinical presentation

COVID-19, when symptomatic, tends to present with respiratory manifestations. However, it is now clear that some individuals remain asymptomatic, whilst others have mild upper respiratory tract symptoms only. Some also experience mild GI or cardiovascular symptoms ^18,50. However, its full spectrum of clinical effects remains to be determined ^1,13. Symptoms and signs are non-specific ⁶⁸:

Common:

fever (85-90%)
cough (65-70%)
fatigue (35-40%)
sputum production (30-35%)
anosmia/hyposmia (30%) ^{reference required}
shortness of breath (15-20%)

Less common:

myalgia/arthralgia (10-15%)
headaches (10-15%)
sore throat (10-15%)
chills (10-12%)
pleuritic pain

Rare:

nausea, vomiting, diarrhea, nasal congestion (<10%)
palpitations, chest tightness ⁵⁰

Diagnosis

The definitive test for SARS-CoV-2 is the real-time reverse transcriptase-polymerase chain reaction (RT-PCR) test and is believed to be highly specific, but with sensitivity reported as low as 60-70% ³² and as high as 95-97% ⁵⁶ depending on the country. Thus, false negatives are a real clinical problem and several negative tests might be required in a single case to be confident about excluding the disease.

Therefore, in many cases, CT findings have been used as a surrogate diagnostic test ^2,³². Indeed, recent work supports the notion that CT is a more sensitive test for the virus than is the confirmatory RT-PCR test. In a cohort of 1,014 patients, with a positive PCR as the diagnostic test, the sensitivity of CT in reaching the same conclusion was 97%. In those patients in whom RT-PCR was negative—yet the CT chest was positive—clinical records were comprehensively re-reviewed and 48% of these cases were deemed to be "highly likely" to be COVID-19, with a further 33% as "probable" ³⁴. On 16 March 2020, an American-Singaporean panel published that CT findings were not part of the diagnostic criteria for COVID-19 ⁵⁶.

The WHO has published official case definitions for COVID-19 surveillance. These definitions remain under constant review.

Laboratory tests

The most common ancillary laboratory findings in a study of 138 hospitalised patients were the following ¹³:

Mild elevations of inflammatory markers (CRP and ESR) and D-dimer are also seen.

Complications

In a study of 138 patients who had been hospitalised, 26% were admitted to the intensive care unit (ICU). The ICU patients tended to be older with more comorbidities ¹³. Common sequelae included the following:

acute respiratory distress syndrome (ARDS)
acute cardiac injury: elevated troponin levels
- myocardial ischaemia
- cardiac arrest
secondary infections
sepsis
multiorgan failure ⁶⁶

In a small subgroup of severe ICU cases:

secondary haemophagocytic lymphohistiocytosis ⁴⁹
- a cytokine storm syndrome

Pathology

Aetiology

The WHO confirmed that SARS-CoV-2 was the cause of COVID-19 on 9 January 2020 (2019-nCoV was the name of the virus at that time) ^14,37. It is a member of the Betacoronavirus genus, one of the genera of the Coronaviridae family of viruses. Coronaviruses are enveloped single-stranded RNA viruses, that are found in humans, many other mammals, and birds. These viruses are responsible for pulmonary, hepatic, CNS, and intestinal disease.

As with many human infections, SARS-CoV-2 is zoonotic. The closest animal coronavirus by genetic sequence is a bat coronavirus, and this is the likely ultimate origin of the virus ^11,19,26. The disease can also be transmitted by snakes ²⁴.

Hitherto, six coronaviruses have been known to be responsible for human diseases. Two are zoonoses: the severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV), both of which may sometimes be fatal. The remaining four viruses are widespread in human society, causing the common cold.

Pathogenesis

The SARS-CoV-2 virus, like the closely-related MERS and SARS coronaviruses, effects cellular entry via attachment of its virion spike protein to the angiotensin-converting enzyme 2 (ACE 2) receptor. This receptor is commonly found on alveolar cells of the lung epithelium, underlying the development of respiratory symptoms as the commonest presentation of COVID-19 ⁵⁰. It is thought that the mediation of the less common cardiovascular effects is also via the same ACE-2 receptor which is also commonly expressed on the cells of the cardiovascular system ⁵⁰.

Transmission

Although originating from animals, COVID-19 is not considered a direct zoonosis as its transmission is now primarily human-to-human. It is primarily transmitted in a similar way to the common cold, via contact with droplets of infected individuals' upper respiratory tract secretions, e.g. from sneezing or coughing ¹⁹.

A recent Bayesian regression model has found that that aerosol and fomite transmission is plausible ⁵⁸.

Orofaecal spread was seen with the SARS epidemic, and although it remains unclear if SARS-CoV-2 can be transmitted in this way, there is some evidence for it ^19,43.

A recent retrospective study of nine pregnant patients infected by SARS-CoV-2 did not show any evidence of vertical/intrauterine infection ²¹.

Considerations for medical imaging departments

Infection precautions

Given staff in the medical imaging department are some of the first parties to be in contact with COVID-19 patients, clear infection control guidelines are imperative. At the time of writing (8 March 2020) droplet-type precautions are in place for COVID-19 patients, that is, medical mask, gown, gloves, and eye protection (aerosol-generating procedures require N95 masks and aprons) ³⁹.

Patients requiring general radiography should receive it portably (to limit transporting patients) or in dedicated auxiliary units. Patients that require transport to departments must wear a mask to and from the unit. Machines, including any ancillary equipment used during examinations, should be cleaned after examinations ⁴⁰. It is recommended that any imaging examinations have two radiographers in attendance using the 'one clean, one in contact with the patient' system to minimize cross-contamination.

Please follow your departmental policies on personal protective equipment (PPE).

CT protocol

Patients requiring CT should receive a non-contrast chest CT (unless iodinated contrast medium is indicated), with reconstructions of the volume at 0.625-mm to 1.5-mm slice thickness (gapless) ⁵⁷.

Radiographic features

The primary findings of COVID-19 on chest radiograph and CT are those of atypical pneumonia ^{3,6,13,17,27,28,32}. A chest radiograph is an insensitive test, and many cases demonstrate normal chest x-rays when mild/early in the disease course. 75% of cases have presented with bilateral ~~pneumonia~~changes ⁶.

CT

The primary findings on CT in adults have been reported ^{13,17,27,28,36}:

ground-glass opacities (GGO) in all hospitalised patients
crazy paving appearance (GGOs and inter-/intra-lobular septal thickening)
air space consolidation
bronchovascular thickening in the lesion
traction bronchiectasis

The ground-glass and/or consolidative opacities are usually bilateral, peripheral, and basal in distribution ^2,³².

A retrospective study of 112 patients found 54% of asymptomatic patients had pneumonic changes on CT ⁶⁷.

A study published in March 2020, evaluated the ability of Chinese and American radiologists to differentiate COVID-19 from other viral pneumonia on CT ⁵¹. The Chinese radiologists demonstrated sensitivities of 72-94% and specificity of 24-94%. The results for the American radiologists were better, including a specificity of 100% for two radiologists; however, the American specialists viewed a much smaller dataset than their Chinese colleagues.

In this study, these chest CT findings had the highest discriminatory value (p<0.001) ⁵¹:

peripheral distribution
ground-glass opacity
vascular thickening

Atypical CT findings

These findings only seen in a small minority of patients should raise concern for superadded bacterial pneumonia or other diagnoses ^2,³²:

mediastinal lymphadenopathy ¹⁷
pleural effusions
- may occur as a complication of COVID-19
multiple tiny pulmonary nodules
- unlike many other viral pneumonias

Temporal CT changes

Up to half of patients with COVID-19 have normal CT scans within 2 days of symptom onset ³². However, the severity of lung abnormalities peaks around 9-13 days ^17,32. Ground-glass opacities dominate early, followed by crazy paving and consolidation ³². With an improvement in the disease course, "fibrous stripes" appear and the abnormalities clear at 1 month and beyond ^24,32.

Paediatric CT

In a small study of five children that had been admitted to hospital with positive COVID-19 RT-PCR tests and who had CT chest performed, only three children had abnormalities. The main abnormality was bilateral patchy ground-glass opacities, similar to the appearances in adults, but less florid, and in all three cases the opacities resolved as they clinically recovered ⁴⁸.

Ultrasound

Initial work on patients in China suggests that lung ultrasound may be useful in the evaluation of critically ill COVID-19 patients ⁵⁵. The following patterns have been observed, tending to have a bilateral and posterobasal predominance:

multiple B-lines
- ranging from focal to diffuse with spared areas ⁶⁴
- representative of thickened subpleural interlobular septa
irregular, thickened pleural line with scattered discontinuities ⁶³
subpleural consolidations
- may be associated with a discrete, localized pleural effusion
- relatively avascular with color flow Doppler interrogation
- pneumonic consolidation typically associated with preservation of flow or hyperemia ⁶⁵
alveolar consolidation
- tissue-like appearance with dynamic and static air bronchograms
- associated with severe, progressive disease
restitution of aeration during recovery
- reappearance of bilateral A-lines

Nuclear medicine

PET-CT

An initial small case series published on 22 February 2020 demonstrated that FDG uptake is increased in ground-glass opacities in those with presumed COVID-19 ⁴².

Treatment and prognosis

Treatment

No specific treatment or vaccine exists for COVID-19 (March 2020). Therefore resources have been concentrated on public health measures, to prevent further interhuman transmission of the virus. This has required a multipronged approach and for individuals includes meticulous personal hygiene, the avoidance of large crowds/crowded environments and where necessary, self-isolation ¹¹.

In healthcare facilities, concerted efforts are required to effect rapid diagnosis, quarantine infected cases and provide effective supportive therapies. This will encompass empirical treatments with antibiotics, antivirals, and supportive measures. Mechanical ventilation and extracorporeal membrane oxygenation (ECMO) have also been used where clinically necessary.

Antiviral therapy

Whilst specific antiviral therapies for SARS-2-CoV do not currently exist, the combination of the protease inhibitors, ritonavir and lopinavir, or a triple combination of these antiviral agents with the addition of ribavirin, showed some success in the treatment of SARS ²⁰, and early reports suggested similar efficacy in the treatment of COVID-19 ²³. However, a more recent randomized, controlled open-label trial failed to demonstrate any added benefit of lopinavir-ritonavir combination therapy ⁶⁶.

Remdesivir, a drug originally developed to treat Ebola virus and shown to be effective against MERS-CoV and SARS-CoV, showed promising in vitro results against SARS-CoV-2 ²⁹ and is being tested in humans ³⁰.

Early reports demonstrated that treatment with two antimalarial drugs, chloroquine, and its analogue hydroxychloroquine have a beneficial effect on the clinical outcome, and it was also shown that they demonstrate anti SARS-2-CoV activity in vitro. This was further corroborated by a recent open label, non-randomized clinical trial, which demonstrated a significant reduction of viral carriage, and a lower average carrying duration in patients treated with hydroxychloroquine. Furthermore, combination with the antibiotic azithromycin resulted in a synergistic effect ⁶⁹.

Vaccines

Vaccines for the coronaviruses have been under development since the SARS outbreak, but none are yet available for humans ^11,26. A phase I trial in humans of a potential vaccine against MERS-CoV has already been performed in the UK ²⁶.

NSAIDs

Emerging expert opinion is that non-steroidal anti-inflammatory drugs (NSAIDs) are relatively contraindicated in those with COVID-19. This is based upon several strands of "evidence" ⁶¹:

since 2019 the French government National Agency for the Safety of Medicines and Health Products, has advised against the routine use of NSAIDs as an antipyretic
previous research has shown that NSAIDs may suppress the immune system
anecdotal reports from France suggest that young patients on NSAIDs, otherwise previously fit and well, developed more severe COVID-19 symptoms

However, it is important to note that there is currently (March 2020) no published scientific evidence showing that NSAIDs increase the risk of developing COVID-19 or worsen established disease. Also, at least one report shows antiviral activity by indomethacin (a NSAID) against SARS-CoV (cause of SARS) ⁶⁰.

Prognosis

Progressive deterioration of imaging changes despite medical treatment is thought to be associated with poor prognosis ²⁷.

Studies have shown an increased risk of ARDS and death in men over the age of 60 years old ⁶².

In the earliest studies, the mortality rate was estimated at 3%, although later data, suggests it as being slightly closer to 2% ⁵. In a study of the first 44,672 diagnosed cases in mainland China, the fatality rate was found to be 2.3% ²⁵.

In a Chinese study looking at 138 hospitalised patients only, in-hospital mortality was higher at 4.3% ¹³.

Early reports show that in some patients the RT-PCR test remains positive despite the apparent clinical recovery. This raises the concern that asymptomatic carriage may occur ³⁵.

History and etymology

The first mention in the medical press about the emerging infection was in the British Medical Journal (BMJ) on 8 January 2020 in a news article, which reported "outbreak of pneumonia of unknown cause in Wuhan, China, has prompted authorities in neighbouring Hong Kong, Macau, and Taiwan to step up border surveillance, amid fears that it could signal the emergence of a new and serious threat to public health" ⁵⁴.

The first scientific article about the new disease, initially termed 2019‐new coronavirus (2019‐nCoV) by the WHO, was published in the Journal of Medical Virology on 16 January 2020 ⁵³.

Resources

These lists are in alphabetical order:

-COVID-19 (coronavirus disease 2019) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), previously known as 2019 novel coronavirus (2019-nCoV). The first cases were seen in Wuhan, China in December 2019 before spreading globally 1,2,10. The current outbreak was recognized as a <a href="/articles/pandemic">pandemic</a> on 11 March 2020 44.The non-specific imaging findings are most commonly of <a href="/articles/pneumonia">pneumonia</a>, often with a bilateral, peripheral, and basal predominant distribution 32. No effective treatment or vaccine exists currently (March 2020) 20.<h4>Terminology</h4>The WHO originally called this illness "novel coronavirus-infected pneumonia (NCIP)" and the virus itself had been named 2019 novel coronavirus (2019-nCoV) 1.On 11 February 2020, the <a href="/articles/world-health-organisation-who">World Health Organisation (WHO)</a> officially renamed the clinical condition COVID-19 (a shortening of COronaVIrus Disease-19), which was announced in a tweet 15. Coincidentally, on the same day, the Coronavirus Study Group (CSG) of the International Committee on Taxonomy of Viruses renamed the virus "severe acute respiratory syndrome coronavirus 2" (SARS-CoV-2) 16,22,46. The names of both the disease and the virus should be fully capitalised, except for the 'o' in the viral name, which is in lower case 16,22,41. The WHO has expressed reservations about the official virus name in view of its closeness to the name SARS. It has publicly stated it will not be using it, instead using "COVID-19 virus" or the "virus that causes COVID-19". A group of Chinese virologists also stated in a letter published in The Lancet that the new name was likely to confuse the public due to its similarity to the disease SARS, and they suggested "human coronavirus 2019 (HCoV-19)" 38.However, the scientific community is already using SARS-CoV-2 and it is likely that this will be gradually accepted by the wider world 22. The WHO has also publicly stated that although they will not be using the term SARS-CoV-2 in their public communications, it remains the official name of the virus 45.Some publications have chosen to use a separate term "novel COVID-19-infected pneumonia (NCIP)" for the pneumonia secondary to COVID-19 40.<h4>Epidemiology</h4>As of 22 March 2020, over 307,200 cases of COVID-19 have been confirmed worldwide, with China now accounting for only 26% of all confirmed cases, according to an online virus tracker created by the medical journal, The Lancet, and hosted by Johns Hopkins University 5. Although the percentage of confirmed cases outside China is steadily increasing, the <a href="/articles/epidemic">epidemic</a> in China has plateaued 5. Six other countries have over 10,000 cases 5:<ul>
+For a quick reference guide, please see our <a title="COVID-19 (summary)" href="/articles/covid-19-summary">COVID-19 summary</a> article.COVID-19 (coronavirus disease 2019) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), previously known as 2019 novel coronavirus (2019-nCoV). The first cases were seen in Wuhan, China in December 2019 before spreading globally 1,2,10. The current outbreak was recognized as a <a href="/articles/pandemic">pandemic</a> on 11 March 2020 44.The non-specific imaging findings are most commonly of <a href="/articles/atypical-pneumonia">atypical pneumonia</a>, often with a bilateral, peripheral, and basal predominant distribution 32. No effective treatment or vaccine exists currently (March 2020) 20.<h4>Terminology</h4>The WHO originally called this illness "novel coronavirus-infected pneumonia (NCIP)" and the virus itself had been named 2019 novel coronavirus (2019-nCoV) 1.On 11 February 2020, the <a href="/articles/world-health-organisation-who">World Health Organisation (WHO)</a> officially renamed the clinical condition COVID-19 (a shortening of COronaVIrus Disease-19), which was announced in a tweet 15. Coincidentally, on the same day, the Coronavirus Study Group (CSG) of the International Committee on Taxonomy of Viruses renamed the virus "severe acute respiratory syndrome coronavirus 2" (SARS-CoV-2) 16,22,46. The names of both the disease and the virus should be fully capitalised, except for the 'o' in the viral name, which is in lower case 16,22,41. The WHO has expressed reservations about the official virus name in view of its closeness to the name SARS. It has publicly stated it will not be using it, instead using "COVID-19 virus" or the "virus that causes COVID-19". A group of Chinese virologists also stated in a letter published in The Lancet that the new name was likely to confuse the public due to its similarity to the disease SARS, and they suggested "human coronavirus 2019 (HCoV-19)" 38.However, the scientific community is already using SARS-CoV-2 and it is likely that this will be gradually accepted by the wider world 22. The WHO has also publicly stated that although they will not be using the term SARS-CoV-2 in their public communications, it remains the official name of the virus 45.Some publications have chosen to use a separate term "novel COVID-19-infected pneumonia (NCIP)" for the pneumonia secondary to COVID-19 40.<h4>Epidemiology</h4>As of 22 March 2020, over 307,200 cases of COVID-19 have been confirmed worldwide, with China now accounting for only 26% of all confirmed cases, according to an online virus tracker created by the medical journal, The Lancet, and hosted by Johns Hopkins University 5. Although the percentage of confirmed cases outside China is steadily increasing, the <a href="/articles/epidemic">epidemic</a> in China has plateaued 5. Six other countries have over 10,000 cases 5:<ul>
-</li></ul><h4>Pathology</h4><h5>Aetiology</h5>The WHO confirmed that SARS-CoV-2 was the cause of COVID-19 on 9 January 2020 (2019-nCoV was the name of the virus at that time) 14,37. It is a member of the Betacoronavirus genus, one of the genera of the Coronaviridae family of viruses. <a href="/articles/human-coronavirus-1">Coronaviruses</a> are enveloped single-stranded RNA viruses, that are found in humans, many other mammals, and birds. These viruses are responsible for pulmonary, hepatic, CNS, and intestinal disease. As with many human infections, SARS-CoV-2 is <a href="/articles/zoonosis">zoonotic</a>. The closest animal coronavirus by genetic sequence is a bat coronavirus, and this is the likely ultimate origin of the virus 11,19,26. The disease can also be transmitted by snakes 24.Hitherto, six coronaviruses have been known to be responsible for human diseases. Two are zoonoses: the <a href="/articles/sars">severe acute respiratory syndrome coronavirus (SARS-CoV)</a> and <a href="/articles/middle-east-respiratory-syndrome-coronavirus-mers-cov-infection">Middle East respiratory syndrome coronavirus (MERS-CoV)</a>, both of which may sometimes be fatal. The remaining four viruses are widespread in human society, causing the <a href="/articles/common-cold">common cold</a>. <h5>Pathogenesis</h5>The SARS-CoV-2 virus, like the closely-related MERS and SARS coronaviruses, effects cellular entry via attachment of its virion spike protein to the angiotensin-converting enzyme 2 (ACE 2) receptor. This receptor is commonly found on alveolar cells of the lung epithelium, underlying the development of respiratory symptoms as the commonest presentation of COVID-19 50. It is thought that the mediation of the less common cardiovascular effects is also via the same ACE-2 receptor which is also commonly expressed on the cells of the cardiovascular system 50.<h5>Transmission</h5>Although originating from animals, COVID-19 is not considered a direct zoonosis as its transmission is now primarily human-to-human. It is primarily transmitted in a similar way to the common cold, via contact with droplets of infected individuals' upper respiratory tract secretions, e.g. from sneezing or coughing 19.A recent Bayesian regression model has found that that aerosol and fomite transmission is plausible 58.Orofaecal spread was seen with the <a href="/articles/severe-acute-respiratory-syndrome-1">SARS</a> epidemic, and although it remains unclear if SARS-CoV-2 can be transmitted in this way, there is some evidence for it 19,43.A recent retrospective study of nine pregnant patients infected by SARS-CoV-2 did not show any evidence of vertical/intrauterine infection 21.<h4>Considerations for medical imaging departments</h4><h5>Infection precautions</h5>Given staff in the medical imaging department are some of the first parties to be in contact with COVID-19 patients, clear infection control guidelines are imperative. At the time of writing (8 March 2020) droplet-type precautions are in place for COVID-19 patients, that is, medical mask, gown, gloves, and eye protection (aerosol-generating procedures require N95 masks and aprons) 39.Patients requiring general radiography should receive it portably (to limit transporting patients) or in dedicated auxiliary units. Patients that require transport to departments must wear a mask to and from the unit. Machines, including any ancillary equipment used during examinations, should be cleaned after examinations 40. It is recommended that any imaging examinations have two radiographers in attendance using the 'one clean, one in contact with the patient' system to minimize cross-contamination.Please follow your departmental policies on <a href="/articles/personal-protective-equipment-ppe">personal protective equipment (PPE)</a>.<h5>CT protocol</h5>Patients requiring CT should receive a <a href="/articles/ct-chest-non-contrast">non-contrast chest CT </a> (unless <a href="/articles/iodinated-contrast-media-1">iodinated contrast medium</a> is indicated), with reconstructions of the volume at 0.625-mm to 1.5-mm slice thickness (gapless) 57. <h4>Radiographic features</h4>The primary findings of COVID-19 on <a href="/articles/chest-radiograph">chest radiograph</a> and <a href="/articles/ct-chest-summary">CT</a> are those of pneumonia 3,6,13,17,27,28,32. A <a href="/articles/chest-radiograph">chest radiograph</a> is an insensitive test, and many cases demonstrate normal chest x-rays when mild/early in the disease course. 75% of cases have presented with bilateral pneumonia 6.<h5>CT</h5>The primary findings on CT in adults have been reported 13,17,27,28,36:<ul>
+</li></ul><h4>Pathology</h4><h5>Aetiology</h5>The WHO confirmed that SARS-CoV-2 was the cause of COVID-19 on 9 January 2020 (2019-nCoV was the name of the virus at that time) 14,37. It is a member of the Betacoronavirus genus, one of the genera of the Coronaviridae family of viruses. <a href="/articles/human-coronavirus-1">Coronaviruses</a> are enveloped single-stranded RNA viruses, that are found in humans, many other mammals, and birds. These viruses are responsible for pulmonary, hepatic, CNS, and intestinal disease. As with many human infections, SARS-CoV-2 is <a href="/articles/zoonosis">zoonotic</a>. The closest animal coronavirus by genetic sequence is a bat coronavirus, and this is the likely ultimate origin of the virus 11,19,26. The disease can also be transmitted by snakes 24.Hitherto, six coronaviruses have been known to be responsible for human diseases. Two are zoonoses: the <a href="/articles/sars">severe acute respiratory syndrome coronavirus (SARS-CoV)</a> and <a href="/articles/middle-east-respiratory-syndrome-coronavirus-mers-cov-infection">Middle East respiratory syndrome coronavirus (MERS-CoV)</a>, both of which may sometimes be fatal. The remaining four viruses are widespread in human society, causing the <a href="/articles/common-cold">common cold</a>. <h5>Pathogenesis</h5>The SARS-CoV-2 virus, like the closely-related MERS and SARS coronaviruses, effects cellular entry via attachment of its virion spike protein to the angiotensin-converting enzyme 2 (ACE 2) receptor. This receptor is commonly found on alveolar cells of the lung epithelium, underlying the development of respiratory symptoms as the commonest presentation of COVID-19 50. It is thought that the mediation of the less common cardiovascular effects is also via the same ACE-2 receptor which is also commonly expressed on the cells of the cardiovascular system 50.<h5>Transmission</h5>Although originating from animals, COVID-19 is not considered a direct zoonosis as its transmission is now primarily human-to-human. It is primarily transmitted in a similar way to the common cold, via contact with droplets of infected individuals' upper respiratory tract secretions, e.g. from sneezing or coughing 19.A recent Bayesian regression model has found that that aerosol and fomite transmission is plausible 58.Orofaecal spread was seen with the <a href="/articles/severe-acute-respiratory-syndrome-1">SARS</a> epidemic, and although it remains unclear if SARS-CoV-2 can be transmitted in this way, there is some evidence for it 19,43.A recent retrospective study of nine pregnant patients infected by SARS-CoV-2 did not show any evidence of vertical/intrauterine infection 21.<h4>Considerations for medical imaging departments</h4><h5>Infection precautions</h5>Given staff in the medical imaging department are some of the first parties to be in contact with COVID-19 patients, clear infection control guidelines are imperative. At the time of writing (8 March 2020) droplet-type precautions are in place for COVID-19 patients, that is, medical mask, gown, gloves, and eye protection (aerosol-generating procedures require N95 masks and aprons) 39.Patients requiring general radiography should receive it portably (to limit transporting patients) or in dedicated auxiliary units. Patients that require transport to departments must wear a mask to and from the unit. Machines, including any ancillary equipment used during examinations, should be cleaned after examinations 40. It is recommended that any imaging examinations have two radiographers in attendance using the 'one clean, one in contact with the patient' system to minimize cross-contamination.Please follow your departmental policies on <a href="/articles/personal-protective-equipment-ppe">personal protective equipment (PPE)</a>.<h5>CT protocol</h5>Patients requiring CT should receive a <a href="/articles/ct-chest-non-contrast">non-contrast chest CT </a> (unless <a href="/articles/iodinated-contrast-media-1">iodinated contrast medium</a> is indicated), with reconstructions of the volume at 0.625-mm to 1.5-mm slice thickness (gapless) 57. <h4>Radiographic features</h4>The primary findings of COVID-19 on <a href="/articles/chest-radiograph">chest radiograph</a> and <a href="/articles/ct-chest-summary">CT</a> are those of <a href="/articles/atypical-pneumonia">atypical pneumonia</a> 3,6,13,17,27,28,32. A <a href="/articles/chest-radiograph">chest radiograph</a> is an insensitive test, and many cases demonstrate normal chest x-rays when mild/early in the disease course. 75% of cases have presented with bilateral changes 6.<h5>CT</h5>The primary findings on CT in adults have been reported 13,17,27,28,36:<ul>

Images Changes:

Image 103 Annotated image (Key findings #1) ( update )

Caption was removed:

~~Case 1: influenza A pneumonia~~

Image 105 CT (lung window) ( create )

Image 108 CT (non-contrast) ( create )

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","thumbnail":"https://prod-images-static.radiopaedia.org/images/52213151/a092a272b78ce7c23e6a490721b750_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52143675,"studyId":85902,"caseSlug":"covid-19-pneumonia-10","caption":"Case 18: with unilateral air space consolidation","thumbnail":"https://prod-images-static.radiopaedia.org/images/52143675/8dcf3c619d4758f020bb7c2b1f6ea0_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52221946,"studyId":86412,"caseSlug":"covid-19-pneumonia-28","caption":"Case 19: bilateral and peripheral alveolar consolidations","thumbnail":"https://prod-images-static.radiopaedia.org/images/52221946/8e98ec22ee304b4fb7b5434276bb79_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52221785,"studyId":86410,"caseSlug":"covid-19-pneumonia-27","caption":"Case 20 ","thumbnail":"https://prod-images-static.radiopaedia.org/images/52221785/78331427ccc2886655edf78d6a7c3e_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52222131,"studyId":86413,"caseSlug":"covid-19-infection-exclusive-gastrointestinal-symptoms","caption":"Case 21: exclusive gastrointestinal symptoms","thumbnail":"https://prod-images-static.radiopaedia.org/images/52222131/0cc8ac00ad4d2c3e8ea3ed4a9c776a_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_unsubstantiated"},{"imageId":52236703,"studyId":86520,"caseSlug":"covid-19-pneumonia-35","caption":"Case 22","thumbnail":"https://prod-images-static.radiopaedia.org/images/52236703/01df189b50ec310cefdd8525478305_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52233361,"studyId":86496,"caseSlug":"covid-19-pneumonia-34","caption":"Case 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","thumbnail":"https://prod-images-static.radiopaedia.org/images/52240880/9451607643d1cd9c4570cdb1c48593_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52252311,"studyId":86708,"caseSlug":"covid-19-pneumonia-43","caption":"Case 33 ","thumbnail":"https://prod-images-static.radiopaedia.org/images/52252311/221a595119abcd1cc91b930f34060e_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52252310,"studyId":86631,"caseSlug":"covid-19-pneumonia-43","caption":"Case 34 ","thumbnail":"https://prod-images-static.radiopaedia.org/images/52252310/d7b08174f3f6151654408d34fb8593_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52286551,"studyId":86789,"caseSlug":"covid-19-pneumonia-52","caption":"Case 35","thumbnail":"https://prod-images-static.radiopaedia.org/images/52286551/6b87133a40a8a4532adf09cacd4657_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52298708,"studyId":86914,"caseSlug":"covid-19-pneumonia-56","caption":"Case 36","thumbnail":"https://prod-images-static.radiopaedia.org/images/52298708/3f71d082fe2b5a944b74890b6d0f2f_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52298472,"studyId":86913,"caseSlug":"covid-19-pneumonia-55","caption":"Case 37","thumbnail":"https://prod-images-static.radiopaedia.org/images/52298472/9a015368b7df8a8fdf1b94ce57d4ac_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52144300,"studyId":85903,"caseSlug":"covid-19-pneumonia-11","caption":"Case 38","thumbnail":"https://prod-images-static.radiopaedia.org/images/52144300/59da2d56def0e71162e58297487fad_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52298341,"studyId":86912,"caseSlug":"covid-19-pneumonia-54","caption":"Case 39 ","thumbnail":"https://prod-images-static.radiopaedia.org/images/52298341/7508066ca6d477788bff6cc3718cc3_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52296787,"studyId":86884,"caseSlug":"covid-19-pneumonia-53","caption":"Case 40 ","thumbnail":"https://prod-images-static.radiopaedia.org/images/52296787/9382428c49dcd870d705e87fdb97ac_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52289131,"studyId":86811,"caseSlug":"post-intubation-pneumomediastinum-and-pneumothorax-background-covid-19-pneumonia","caption":"Case 41: post-intubation pneumomediastinum and pneumothorax with COVID-19 pneumonia","thumbnail":"https://prod-images-static.radiopaedia.org/images/52289131/81af553601a1bc1fdf81c99436a50b_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52196997,"studyId":86262,"caseSlug":"covid-19-rapidly-progressive-acute-respiratory-distress-syndrome-ards","caption":"Case 42: rapidly progressive ARDS","thumbnail":"https://prod-images-static.radiopaedia.org/images/52196997/b1921029beb35ebb6bc80b1bd5c043_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52303343,"studyId":86969,"caseSlug":"covid-19-pneumonia-76","caption":"Case 43","thumbnail":"https://prod-images-static.radiopaedia.org/images/52303343/9f2ed2ef5c343793857faa927b25d8_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52303001,"studyId":86953,"caseSlug":"covid-19-pneumonia-58","caption":"Case 44","thumbnail":"https://prod-images-static.radiopaedia.org/images/52303001/8e12dc985075caacc502f4911006e6_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52307073,"studyId":86987,"caseSlug":"covid-19-pneumonia-62","caption":"Case 45","thumbnail":"https://prod-images-static.radiopaedia.org/images/52307073/38cddebf4af53f3fedb09382690849_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52306583,"studyId":86985,"caseSlug":"early-stage-covid-19-pneumonia-1","caption":"Case 46: mild","thumbnail":"https://prod-images-static.radiopaedia.org/images/52306583/e21992d32cd6b8a2839aa52ffa0150_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52306813,"studyId":86986,"caseSlug":"covid-19-pneumonia-61","caption":"Case 47","thumbnail":"https://prod-images-static.radiopaedia.org/images/52306813/e1c90b0a302b323f5ce7f41b8205e5_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52307997,"studyId":86991,"caseSlug":"covid-19-pneumonia-63","caption":"Case 48","thumbnail":"https://prod-images-static.radiopaedia.org/images/52307997/6b86db9b42cf41fc0d7bca9d80dfee_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52310925,"studyId":87014,"caseSlug":"covid-19-pneumonia-64","caption":"Case 49","thumbnail":"https://prod-images-static.radiopaedia.org/images/52310925/ff8e3e4e11c0a697211a145c7e5442_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52311116,"studyId":87015,"caseSlug":"covid-19-pneumonia-mild","caption":"Case 50: 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53","thumbnail":"https://prod-images-static.radiopaedia.org/images/52306364/b9c3ef54f14af9464b177ce100952c_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52314331,"studyId":87049,"caseSlug":"covid-19-pneumonia-70","caption":"Case 54","thumbnail":"https://prod-images-static.radiopaedia.org/images/52314331/0c73464dd96e9cc99096b45895528d_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52314213,"studyId":87045,"caseSlug":"covid-19-pneumonia-68","caption":"Case 55","thumbnail":"https://prod-images-static.radiopaedia.org/images/52314213/308cc9a9c2a292e40ebbb63bc3c4e2_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52238424,"studyId":86540,"caseSlug":"covid-19-pneumonia-rapidly-progressive-2","caption":"Case 56: rapidly progressive","thumbnail":"https://prod-images-static.radiopaedia.org/images/52238424/f44373474437c99b2740062c914438_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52326148,"studyId":87207,"caseSlug":"covid-19-pneumonia-early-stage","caption":"Case 57: mild","thumbnail":"https://prod-images-static.radiopaedia.org/images/52326148/9296e10c316b5dbd05844c52a2ec4c_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52325481,"studyId":87203,"caseSlug":"covid-19-pneumonia-incidental-finding-in-asymptomatic-patient-2","caption":"Case 58: incidental finding in asymptomatic patient","thumbnail":"https://prod-images-static.radiopaedia.org/images/52325481/5d84691c4bf3b9ddf1c19f2a5e5185_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52320337,"studyId":87130,"caseSlug":"covid-19-pneumonia-73","caption":"Case 59","thumbnail":"https://prod-images-static.radiopaedia.org/images/52320337/f95d56c3815ce6a7efd530f74f0de5_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52347055,"studyId":87461,"caseSlug":"covid-19-pneumonia-75","caption":"Case 60","thumbnail":"https://prod-images-static.radiopaedia.org/images/52347055/213a7402eac2f2ddc57a3a88ca1288_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52351834,"studyId":87486,"caseSlug":"covid-19-pneumonia-45","caption":"Case 61","thumbnail":"https://prod-images-static.radiopaedia.org/images/52351834/aa2c1a6a484ce7aedd53709cfc9579_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52333508,"studyId":87161,"caseSlug":"covid-19-pneumonia-78","caption":"Case 62","thumbnail":"https://prod-images-static.radiopaedia.org/images/52333508/3a7a000f136a331916ab25645c5004_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52366910,"studyId":87677,"caseSlug":"covid-19-pneumonia-80","caption":"Case 63","thumbnail":"https://prod-images-static.radiopaedia.org/images/52366910/14d81f378173b86cc53f21d2d67040_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52419934,"studyId":87991,"caseSlug":"early-stage-covid-19-pneumonia-4","caption":"Case 64: early stage","thumbnail":"https://prod-images-static.radiopaedia.org/images/52419934/7081807bc119bf30645e67567c2743_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52354709,"studyId":87517,"caseSlug":"covid-19-pneumonia-with-superadded-bacterial-infection-1","caption":"Case 65: with superadded bacterial 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68","thumbnail":"https://prod-images-static.radiopaedia.org/images/52379267/7c38367c2b495ceb35e78027ad336a_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52385287,"studyId":87846,"caseSlug":"covid-19-pneumonia-84","caption":"Case 69","thumbnail":"https://prod-images-static.radiopaedia.org/images/52385287/4e71e0f261b2d543e1aa597a697577_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52403451,"studyId":87917,"caseSlug":"covid-19-pneumonia-88","caption":"Case 70","thumbnail":"https://prod-images-static.radiopaedia.org/images/52403451/12c8fcf50208ead88ed27ad30164ee_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52416743,"studyId":87957,"caseSlug":"covid-19-pneumonia-89","caption":"Case 71","thumbnail":"https://prod-images-static.radiopaedia.org/images/52416743/6356848f0c5ab27258bb02b59ccc57_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52420179,"studyId":87992,"caseSlug":"early-stage-covid-19-pneumonia-5","caption":"Case 72: early stage","thumbnail":"https://prod-images-static.radiopaedia.org/images/52420179/c626eb529754e772bdc618f1d777b1_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52420531,"studyId":87993,"caseSlug":"covid-19-pneumonia-96","caption":"Case 73","thumbnail":"https://prod-images-static.radiopaedia.org/images/52420531/bf1ceec74b2f41a172c2063d582558_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52354015,"studyId":87500,"caseSlug":"covid-19-pneumonia-77","caption":"Case 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77","thumbnail":"https://prod-images-static.radiopaedia.org/images/52421212/f62a65e2fe0af5d0bdc164eccf977c_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52421486,"studyId":87998,"caseSlug":"covid-19-pneumonia-in-a-patient-with-old-tuberculosis","caption":"Case 78","thumbnail":"https://prod-images-static.radiopaedia.org/images/52421486/f69ec5050d4e4d10a87db0c339679c_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52450986,"studyId":88332,"caseSlug":"covid-19-pneumonia-115","caption":"Case 79","thumbnail":"https://prod-images-static.radiopaedia.org/images/52450986/2efde068d5850e84b0091f5090264a_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52437263,"studyId":88192,"caseSlug":"covid-19-pneumonia-109","caption":"Case 80","thumbnail":"https://prod-images-static.radiopaedia.org/images/52437263/5cdd68bde3bda88e3261975025fc1e_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52421596,"studyId":87999,"caseSlug":"covid-19-pneumonia-101","caption":"Case 81","thumbnail":"https://prod-images-static.radiopaedia.org/images/52421596/ffad54f999494b9803e5b9ad22386e_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52532612,"studyId":88950,"caseSlug":"covid-19-pneumonia-124","caption":"Case 82","thumbnail":"https://prod-images-static.radiopaedia.org/images/52532612/cb57899d2eccbaef19c314f1642d0e_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52447739,"studyId":88316,"caseSlug":"covid-19-pneumonia-116","caption":"Case 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86","thumbnail":"https://prod-images-static.radiopaedia.org/images/52457924/9a4270f399c571d1fff04168675634_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52468043,"studyId":88485,"caseSlug":"covid-19-pneumonia-117","caption":"Case 87","thumbnail":"https://prod-images-static.radiopaedia.org/images/52468043/41cd7d018ddcf12578a149eec58e002b079a1944a43db98328b6db33387ad93a_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52417152,"studyId":87971,"caseSlug":"covid-19-pneumonia-91","caption":"Case 88","thumbnail":"https://prod-images-static.radiopaedia.org/images/52417152/c63a1e0ab7600a91fd5023e82eaf14_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52437539,"studyId":88193,"caseSlug":"covid-19-pneumonia-110","caption":"Case 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92","thumbnail":"https://prod-images-static.radiopaedia.org/images/52527747/0dd647f4911312e8cf6ac99d1f92b1_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52517963,"studyId":88824,"caseSlug":"covid-19-pneumonia-122","caption":"Case 93","thumbnail":"https://prod-images-static.radiopaedia.org/images/52517963/843d4c110109669834788cab62a803_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_unsubstantiated"},{"imageId":52568054,"studyId":89249,"caseSlug":"covid-19-pneumonia-126","caption":"Case 94","thumbnail":"https://prod-images-static.radiopaedia.org/images/52568054/f3d077ff53b7ef6048841f88c83239_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_unsubstantiated"},{"imageId":52655473,"studyId":89817,"caseSlug":"covid-19-pneumonia-radiological-resolution-1","caption":"Case 95: with radiological 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