Archives of Academic Emergency Medicine. 2020; 8(1): e46 CA S E RE P O RT COVID-19 Pneumonia in Asymptomatic Trauma Patients; Report of 8 Cases Majid Samsami1, Javad Zebarjadi Bagherpour1∗, Behzad Nematihonar1, Hamed Tahmasbi1 1. Department of General Surgery, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Received: April 2020; Accepted: April 2020; Published online: 6 April 2020 Abstract: We are currently involved in the novel coronavirus 2019 (COVID-19) pandemic. A considerable number of COVID-19 infected cases are asymptomatic but they can transmit the disease to others, especially healthcare workers. In this study, we reported 8 incidentally detected cases of COVID-19 pneumonia in chest computed tomography (CT) scan of patients referred to emergency department following multiple trauma without any respiratory symptoms. Keywords: COVID-19, Pneumonia, injuries Cite this article as: Samsami M, Zebarjadi Bagherpour J, Nematihonar B, Tahmasbi H. COVID-19 Pneumonia in Asymptomatic Trauma Pa- tients; Report of 8 Cases. Arch Acad Emerg Med. 2020; 8(1): e46. 1. Introduction The global incidence of novel coronavirus 2019 (COVID-19) that involves the lower respiratory tract (pneumonia) con- tinues to rise since December 2019 (1). The specific source and the exact primary mode of transmission of 2019-nCoV to humans remain unknown. The clinical features and labora- tory and radiological abnormalities of COVID-19 infections are not specific and are similar to other respiratory tract in- fections (2). It is now evident that most cases of COVID-19 disease develop mild respiratory and constitutional symp- toms such as fever, cough, dyspnea, myalgia, and fatigue (3). A considerable number of COVID-19 infected cases are asymptomatic but they can transmit the disease to others, especially healthcare workers (4). In the study performed by Khazaee et al. (5), several patients had incidental evi- dence of COVID-19 infection on chest CT scans obtained for trauma management. In another study, Hu et al. (6), de- scribed clinical features of 24 asymptomatic patients on their study, five cases (20.8%) developed symptoms (fever, cough, fatigue, etc.) during hospitalization. Twelve (50.0%) cases showed typical CT scan images of ground-glass chest and 5 (20.8%) presented stripe shadowing in the lungs. The re- maining 7 (29.2%) cases had a normal CT image and had no ∗Corresponding Author: Javad Zebarjadi Bagherpour; Department of General Surgery, Imam Hossein Hospital, Shahid Madani Avenue, Imam Hossein Square, Tehran, Iran. Tel: 00989182101497, Email: javad.zebarjady@yahoo.com, symptoms during hospitalization and none of the 24 cases developed severe COVID-19 pneumonia. In this study, we re- port 8 incidentally detected cases of COVID-19 pneumonia in chest computed tomography (CT) scan of patients referred to emergency department following multiple trauma with- out any respiratory symptoms. This cases series study was performed on multiple trauma patients who were referred to emergency department of Imam Hossein Hospital, Tehran, Iran, from 17 to 28 March 2020. Patients who underwent chest CT scan for trauma management and had radiographic manifestations of COVID-19 pneumonia on CT scan were en- rolled. Demographic information (age, gender), mechanism of trauma, as well as chest CT scan and RT-PCR for COVID-19 results were collected and reported for enrolled cases. 2. Case presentation 8 patients with the mean age of 49.71 ± 13.13 (range: 34 – 67) years were studied (62.5% male). The trauma mecha- nism was fall from height in 5 (62.5%) and car accident in 3 (37.5%) cases. None of the patients had symptoms in favor of COVID-19 infection such as fever, dyspnea, headache, cough, etc. at the time of admission. 5 (62.5%) patient had history of close contact with a suspected COVID-19 case. Physical examinations of lungs revealed no signs of pneumonia. A chest CT scan without contrast was performed to evaluate high-energy trauma and the findings strongly were in favor of pneumonia. The results of RT-PCR was positive for COVID- 19 infection in all patients. During the hospital stay, two patients (25%) experienced mild symptoms such as fever, This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem M. Samsami et al. 2 Figure 1: Axial Chest computed tomography (CT) scan without contrast of asymptomatic COVID-19 patients obtained during evaluation for multiple trauma. cough, and myalgia and the rest stayed asymptomatic. In the laboratory results, 4 (50%) patients had a slight increase in C - reactive protein (Maximum 18) and the rest of the lab- oratory findings were normal. Two patients underwent or- thopedic surgery without any respiratory complication. All patients received standard treatment (Hydroxychloroquine with or without Azithromycin). None of the patients required intensive care. All patients were discharged from hospital af- ter completion of treatment and had no mortality. Figure 1 shows axial cuts of the cases’ chest CT scan. 3. Discussion The widespread distribution of COVID-19 is a major concern, globally. Understanding of the transmission risk is incom- plete. Epidemiologic investigation in Wuhan at the begin- ning of the outbreak identified an initial association with a seafood market that sold live animals, where most patients had worked or visited, which was subsequently closed for disinfection (7). With droplet transmission, virus is shed via the respiratory secretions when a person with infection coughs, sneezes, or talks, which can infect another person if it makes direct contact with their mucous membranes. In- fection can also occur if a person touches an infected surface and then touches his or her eyes, nose, or mouth. Droplets typically do not travel more than six feet (about two meters) and do not linger in the air (8). The interval during which an individual with COVID-19 is infectious is uncertain and the maximum incubation period for COVID-19 is thought to be 14 days following exposure, with most cases occurring ap- proximately four to five days after exposure. During the in- cubation period, the patient can pass on the disease to oth- ers (9). In the study performed by Khazaee et al. (5), sev- eral patients had incidental evidence of COVID-19 infection on chest CT scan for trauma management. In the present study, all patients had evidence suggesting COVID-19 in CT scan, which was confirmed by RT-PCR after hospital admis- sion. In this study, only 2 patients experienced mild symp- toms and none of the patients developed severe symptoms. None of the patients in Hu et al. (6), study had severe ill- ness and no death occurred. They observed a typical asymp- tomatic transmission to family members living in the same household, which even caused severe COVID-19 pneumo- nia. Overall, the asymptomatic carriers identified from close contacts were prone to becoming mildly ill during hospital- ization. Physicians and therapists working in trauma centers should treat patients with extreme caution and personal pro- tection. Also, during this pandemic, measures must be taken in trauma emergency departments to prevent transmission of the disease. 4. Conclusion According to the findings of this study, asymptomatic trauma patients can be carriers of the disease and cause transmis- sion. It is important for physicians and staff at trauma centers to know how to use personal protective equipment to prevent catching the disease. 5. Declarations 5.1. Acknowledgements The authors would like to thank the patients and the support- ing staff in this study. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2020; 8(1): e46 5.2. Conflict of interest None. 5.3. Funding There is no funding and support. References 1. Guan W-j, Ni Z-y, Hu Y, Liang W-h, Ou C-q, He J-x, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. New England Journal of Medicine. 2020. 2. Organization WH. Surveillance case definitions for human infection with novel coronavirus ( nCoV ): interim guid- ance v1, January 2020. World Health Organization, 2020. 3. Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72âĂŕ314 Cases From the Chinese Center for Disease Control and Prevention. JAMA. 2020. 4. Yang Y, Lu Q, Liu M, Wang Y, Zhang A, Jalali N, et al. Epi- demiological and clinical features of the 2019 novel coro- navirus outbreak in China. medRxiv. 2020. 5. Khazaei M, Asgari R, Zarei E, Moharramzad Y, Haghigh- atkhah H, Taheri MS. Incidentally Diagnosed COVID- 19 Infection in Trauma Patients; a Clinical Experience. Archives of Academic Emergency Medicine. 2020;8(1):31. 6. Hu Z, Song C, Xu C, Jin G, Chen Y, Xu X, et al. Clinical char- acteristics of 24 asymptomatic infections with COVID-19 screened among close contacts in Nanjing, China. Science China Life Sciences. 2020:1-6. 7. World Health Organization. January 22. . Novel coron- avirus situation report -2. (Accessed on January. 2020) 8. van Doremalen N, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson BN, et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. New England Journal of Medicine. 2020. 9. Chan JF-W, Yuan S, Kok K-H, To KK-W, Chu H, Yang J, et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. The Lancet. 2020;395(10223):514-23. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem Introduction Case presentation Discussion Conclusion Declarations References