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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), a species of coronavirus,. 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) 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 lowercase ^16,22,41.

The official virus name is similar to sudden acute respiratory syndrome (SARS) and its causative virus, SARS-CoV, potentially causing confusion ³⁸. The WHO has stated it will use "COVID-19 virus" or the "virus that causes COVID-19" instead of its official name, SARS-CoV-2, in dealings with the public ⁴⁵.

Epidemiology

As of 23 March 2020, over 339,000 cases of COVID-19 have been confirmed worldwide, having been diagnosed in 169 territories, in six continents according to an online virus tracker created by the medical journal, The Lancet, and hosted by Johns Hopkins University ^5,13. There are seven countries with >10,000 confirmed cases and 18 countries with between 1000 and 10,000 confirmed cases ⁵.

NB: Surveillance methods and capacity vary dramatically between countries, and there is reason to suspect that there may be a significant number of carriers in some countries not diagnosed.

The R₀ (basic reproduction number) of SARS-CoV-2 has been estimated between 2.2 and 3.28 ^12,33, 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.

The mortality rate is about 2-3% ^5,25 with approximately 14,375 confirmed deaths (23 March 2020) in 55 territories ⁵.

A paper published by the Chinese Center for Disease Control and Prevention (CCDC) analysed all 44,672 cases diagnosed up to 11 February 2020. Of these, 1.2% were asymptomatic and 80.9% were classed as "mild" ²⁵.

Another study looked at clinical characteristics in COVID-19 positively tested closed contacts of COVID-19 patients ⁸¹. About 29.2% of those COVID-19 positive closed contacts never ~~developped~~developed any symptoms or changes on chest CT scans. The remainder showed changes on CT, but apparently only 21% ~~developped~~developed symptoms during their hospital course, none of them ~~decelopped~~developed severe disease ⁸¹. This suggests that a high percentage of COVID-19 carriers isare asymptomatic.

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. Children seem to be relatively unaffected by this virus, or indeed other closely-related coronaviruses ^31,47, however, there have been cases of critically-ill children with infants under 12 months likely to be more seriously affected⁵⁹. 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 typically presents with systemic and/or respiratory manifestations. Some individuals infected with SARS-CoV-2 are asymptomatic and can act as carriers ⁷⁰. Some also experience mild gastrointestinal 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%)
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, diarrhoea, nasal congestion (<10%)
palpitations, chest tightness ⁵⁰

Anecdotal reports from ENT specialists in the UK ⁷⁹ suggest that COVID-19 sufferers have high rates of anosmia/hyposmia, however, no peer-reviewed studies supporting this are yet available.

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 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. Bilateral and/or multilobar involvement is common ^6,78.

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 colour 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. A commentary in the same issue of the journal as this paper suggested that those with higher SUVs in lung lesions take longer to heal ⁷⁷. A further single case detailed in a letter to Radiology corroborated the FDG avidity of COVID lung lesions ⁷⁵.

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 undergoing phase III trials ³⁰. Other antivirals in phase III trials include oseltamivir, ASC09F (HIV protease inhibitor), lopinavir, ritonavir, darunavir, and cobicistat ⁸⁰.

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, randomized clinical trial, which demonstrated a significant reduction of viral carriage, and a lower average carrying duration in patients treated with hydroxychloroquine. Furthermore, a combination with the antibiotic azithromycin resulted in a synergistic effect ⁶⁹.

Vaccines

The primary target in developing coronavirus vaccines has been the spike protein (S protein) which is on the surface of the virion particle, and in vivo is the most important antigen for triggering an immune response ⁷⁵.

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 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.

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 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.

Differential diagnoses

viral pneumonia including ^71,72:
- influenza pneumonia A and B
  - distribution more along the bronchovascular bundles
  - bronchial wall thickening
- paramyxovirus pneumonia
- cytomegalovirus (CMV) pneumonia
- adenovirus pneumonia ^71,72
- SARS-CoV pneumonia
- MERS coronavirus
- HSV pneumonia
  - in immunocompromised patients
  - often shows pleural effusions
- respiratory syncytial virus (RSV) pneumonia
atypical bacterial pneumonia
- mycoplasma pneumonia
  - mainly children and adolescents
  - bronchial wall thickening
  - centrilobular nodules
- chlamydia pneumonia
pulmonary oedema ^⁷¹
interstitial lung disease ⁷³
- cryptogenic organizing pneumonia
- chronic eosinophilic pneumonia (CEP)
- acute fibrinous organizing pneumonia
- rheumatic pneumonia ⁷¹

Resources

These lists are in alphabetical order:

-For a quick reference guide, please see our <a 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), a species of <a href="/articles/human-coronavirus-1">coronavirus</a>,. 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) 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 lowercase 16,22,41. The official virus name is similar to <a href="/articles/severe-acute-respiratory-syndrome-1">sudden acute respiratory syndrome (SARS)</a> and its causative virus, SARS-CoV, potentially causing confusion 38. The WHO has stated it will use "COVID-19 virus" or the "virus that causes COVID-19" instead of its official name, SARS-CoV-2, in dealings with the public 45.<h4>Epidemiology</h4>As of 23 March 2020, over 339,000 cases of COVID-19 have been confirmed worldwide, having been diagnosed in 169 territories, in six continents according to an online virus tracker created by the medical journal, The Lancet, and hosted by Johns Hopkins University 5,13. There are seven countries with >10,000 confirmed cases and 18 countries with between 1000 and 10,000 confirmed cases 5. NB: Surveillance methods and capacity vary dramatically between countries, and there is reason to suspect that there may be a significant number of carriers in some countries not diagnosed.The <a href="/articles/basic-reproductive-number">R0 (basic reproduction number)</a> of SARS-CoV-2 has been estimated between 2.2 and 3.28 12,33, that is each infected individual—on average—causes 2.2 new cases of the disease. The <a href="/articles/incubation-period">incubation period</a> in this group has been calculated to be 5.2 days on average 12.The mortality rate is about 2-3% 5,25 with approximately 14,375 confirmed deaths (23 March 2020) in 55 territories 5.A paper published by the Chinese Center for Disease Control and Prevention (CCDC) analysed all 44,672 cases diagnosed up to 11 February 2020. Of these, 1.2% were asymptomatic and 80.9% were classed as "mild" 25. Another study looked at clinical characteristics in COVID-19 positively tested closed contacts of COVID-19 patients 81. About 29.2% of those COVID-19 positive closed contacts never developped any symptoms or changes on chest CT scans. The remainder showed changes on CT, but apparently only 21% developped symptoms during their hospital course, none of them decelopped severe disease 81. This suggests that a high percentage of COVID-19 carriers is asymptomatic.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. Children seem to be relatively unaffected by this virus, or indeed other closely-related coronaviruses 31,47, however, there have been cases of critically-ill children with infants under 12 months likely to be more seriously affected 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).<h4>Clinical presentation</h4>COVID-19 typically presents with systemic and/or respiratory manifestations. Some individuals infected with SARS-CoV-2 are asymptomatic and can act as carriers 70. Some also experience mild gastrointestinal or cardiovascular symptoms 18,50. However, its full spectrum of clinical effects remains to be determined 1,13. Symptoms and signs are <a href="/articles/non-specific">non-specific</a> 68:Common:<ul>
+For a quick reference guide, please see our <a 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), a species of <a href="/articles/human-coronavirus-1">coronavirus</a>,. 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) 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 lowercase 16,22,41. The official virus name is similar to <a href="/articles/severe-acute-respiratory-syndrome-1">sudden acute respiratory syndrome (SARS)</a> and its causative virus, SARS-CoV, potentially causing confusion 38. The WHO has stated it will use "COVID-19 virus" or the "virus that causes COVID-19" instead of its official name, SARS-CoV-2, in dealings with the public 45.<h4>Epidemiology</h4>As of 23 March 2020, over 339,000 cases of COVID-19 have been confirmed worldwide, having been diagnosed in 169 territories, in six continents according to an online virus tracker created by the medical journal, The Lancet, and hosted by Johns Hopkins University 5,13. There are seven countries with >10,000 confirmed cases and 18 countries with between 1000 and 10,000 confirmed cases 5. NB: Surveillance methods and capacity vary dramatically between countries, and there is reason to suspect that there may be a significant number of carriers in some countries not diagnosed.The <a href="/articles/basic-reproductive-number">R0 (basic reproduction number)</a> of SARS-CoV-2 has been estimated between 2.2 and 3.28 12,33, that is each infected individual—on average—causes 2.2 new cases of the disease. The <a href="/articles/incubation-period">incubation period</a> in this group has been calculated to be 5.2 days on average 12.The mortality rate is about 2-3% 5,25 with approximately 14,375 confirmed deaths (23 March 2020) in 55 territories 5.A paper published by the Chinese Center for Disease Control and Prevention (CCDC) analysed all 44,672 cases diagnosed up to 11 February 2020. Of these, 1.2% were asymptomatic and 80.9% were classed as "mild" 25. Another study looked at clinical characteristics in COVID-19 positively tested closed contacts of COVID-19 patients 81. About 29.2% of those COVID-19 positive closed contacts never developed any symptoms or changes on chest CT scans. The remainder showed changes on CT, but apparently only 21% developed symptoms during their hospital course, none of them developed severe disease 81. This suggests that a high percentage of COVID-19 carriers are asymptomatic.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. Children seem to be relatively unaffected by this virus, or indeed other closely-related coronaviruses 31,47, however, there have been cases of critically-ill children with infants under 12 months likely to be more seriously affected 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).<h4>Clinical presentation</h4>COVID-19 typically presents with systemic and/or respiratory manifestations. Some individuals infected with SARS-CoV-2 are asymptomatic and can act as carriers 70. Some also experience mild gastrointestinal or cardiovascular symptoms 18,50. However, its full spectrum of clinical effects remains to be determined 1,13. Symptoms and signs are <a href="/articles/non-specific">non-specific</a> 68:Common:<ul>

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8","thumbnail":"https://prod-images-static.radiopaedia.org/images/52141366/42ce826aeb1f504194f18e4aac1e9b_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_unsubstantiated"},{"imageId":52180311,"studyId":86095,"caseSlug":"covid-19-pneumonia-15","caption":"Case 9","thumbnail":"https://prod-images-static.radiopaedia.org/images/52180311/8549249b763152e944d3ad092a2a2d_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52197344,"studyId":86275,"caseSlug":"covid-19-pneumonia-20","caption":"Case 10","thumbnail":"https://prod-images-static.radiopaedia.org/images/52197344/61c6828be4bb24b9e29e6ebfcfec0a_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52192468,"studyId":86212,"caseSlug":"covid-19-pneumonia-19","caption":"Case 11","thumbnail":"https://prod-images-static.radiopaedia.org/images/52192468/201b87f9902cce6732917d2f292bd3_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52197348,"studyId":86280,"caseSlug":"covid-19-pneumonia-rapidly-progressive","caption":"Case 12","thumbnail":"https://prod-images-static.radiopaedia.org/images/52197348/df1053d3e8896b53ef140773e10e26_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52197350,"studyId":86277,"caseSlug":"covid-19-pneumonia-21","caption":"Case 13","thumbnail":"https://prod-images-static.radiopaedia.org/images/52197350/58cb9263f16e94305c730685358e4e_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52198251,"studyId":86299,"caseSlug":"covid-19-pneumonia-22","caption":"Case 14","thumbnail":"https://prod-images-static.radiopaedia.org/images/52198251/f24a7e3635ec4daf4b9ed18ec1a794f50e6c78764eae871cf5ce5f93514cfb16_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52213036,"studyId":86359,"caseSlug":"covid-19-pneumonia-23","caption":"Case 15: at day 13","thumbnail":"https://prod-images-static.radiopaedia.org/images/52213036/b08b025a70a7e0d7318ad1232a1ff7_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52216853,"studyId":86382,"caseSlug":"covid-19-pneumonia-evolution-over-a-week-1","caption":"Case 16: radiological evolution over 2 weeks","thumbnail":"https://prod-images-static.radiopaedia.org/images/52216853/4d844df58f10acb17fc50351fd9440_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52213151,"studyId":86360,"caseSlug":"covid-19-pneumonia-24","caption":"Case 17 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","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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29","thumbnail":"https://prod-images-static.radiopaedia.org/images/52232380/da8b9198cc02641aaf0f9307e0603d_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52233109,"studyId":86494,"caseSlug":"covid-19-pneumonia-30","caption":"Case 30","thumbnail":"https://prod-images-static.radiopaedia.org/images/52233109/9cd3c1fcd0a55edaf256e4f6ab72af_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52254733,"studyId":86625,"caseSlug":"covid-19-pneumonia-40","caption":"Case 31 ","thumbnail":"https://prod-images-static.radiopaedia.org/images/52254733/b2b57d9a37b3583569176b8a011955_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52240880,"studyId":86561,"caseSlug":"covid-19-pneumonia-49","caption":"Case 32 ","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 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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: mild","thumbnail":"https://prod-images-static.radiopaedia.org/images/52311116/89296bc5c3a3828510c684932858c1_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52311316,"studyId":87017,"caseSlug":"covid-19-pneumonia-66","caption":"Case 51","thumbnail":"https://prod-images-static.radiopaedia.org/images/52311316/60a4164955bda9af96ecebdfca1139_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52306123,"studyId":86983,"caseSlug":"covid-19-pneumonia-59","caption":"Case 52","thumbnail":"https://prod-images-static.radiopaedia.org/images/52306123/b787c7dd6c38586c98aad314115c6c_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52306364,"studyId":86984,"caseSlug":"covid-19-pneumonia-60","caption":"Case 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 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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 89","thumbnail":"https://prod-images-static.radiopaedia.org/images/52437539/7101fa79ffed645f8a0be71f3f9810_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52542650,"studyId":89023,"caseSlug":"covid-19-pneumonia-85","caption":"Case 90","thumbnail":"https://prod-images-static.radiopaedia.org/images/52542650/50c5f109c00b2249fbb833430efa6d_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_unsubstantiated"},{"imageId":52542690,"studyId":88552,"caseSlug":"covid-19-pneumonia-serial-radiographs-1","caption":"Case 91","thumbnail":"https://prod-images-static.radiopaedia.org/images/52542690/2eadbbb367a0366d8c34350d083a83_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52527747,"studyId":88906,"caseSlug":"covid-19-pneumonia-123","caption":"Case 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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