Hrev_master [page 28] [Emergency Care Journal 2022; 18:10492] Emergency Care Journal 2022; volume 18:10492 Abstract The gold standard for SARS-CoV-2 pneumonia diagnosis is chest Computed Tomography (CT), but Lung Ultrasound (LUS) is also useful in differential diagnosis and in-hospital monitoring of patients with infection by new Coronavirus 2019 disease (COVID- 19). We present a case of a young man who was infected with SARS-CoV-2 pneumoniae and underwent five steps of chest imag- ing, including LUS aeration scorings and chest CT scans. Each decrease or increase in LUS scoring could accurately predict CT scan changes. Introduction Chest Computed Tomography (CT) is the gold standard for identifying SARS-CoV-2 pneumonia.1 Ground glass opacities, consolidation, reticular and crazy paving patterns are typical CT manifestations.2 Instead, COVID19 pneumonia LUS patterns are irregular pleural lines, coalescent B lines with large “light beams”, patchy distribution, and subpleural mantle consolidation areas.3 These clinic-related patterns enable the identification of probabili- ty levels, which is extremely useful for making a diagnosis.4,5 Despite the fact that LUS has inherent limitations (operator depen- dence, quantification difficulties), many studies have found a strong correlation between the two methods.6,7 Case Report C.S., a forty-year-old man, was admitted to our Emergency Department (ED) on 03/17/20 with a cough, fever, fatigue, malaise, and diarrhoea that had begun eight days prior to the pre- sentation. He didn’t smoke and had no comorbidities. Except for tachy- cardia, mild tachypnoea, and fever, his vital signs were normal (OS 98% without oxygen supplementation, BP 140/93 mmHg: RR 22, HR 115 bpm, BT 38°C). The physical examination revealed only minor inspiratory rales. Based on the symptoms, the differential diagnosis included bacterial or viral upper respiratory tract infection, bacterial pneu- monia caused by Streptococcus pneumoniae or Legionella pneu- mophila, which could cause Gastrointestinal (GI) symptoms, viral pneumonia caused by influenza viruses, or viral or bacterial prima- ry GI infectious. However, due to the timing of the pandemic, the most likely diagnosis was SARS-CoV-2 infection. Investigations and management The arterial blood gas testing without oxygen supplementation did not find respiratory failure (Ph 7,38; pO2 68 mmHg; pCO2 36 mmHg; P/F 324; HCO3- 25 mmol/L). RT-PCR assay from nasopharyngeal swab was diagnostic for SARS-CoV-2 infection. Two instrumental examinations were performed at the same time at the ED: lung ultrasound and chest CT scan. Lung US, executed with topographic scheme and standardized Correspondence: Greta Barbieri, Department of Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Emergency Medicine Department, University Hospital of Pisa, Via Paradisa n.2, 56124, Pisa, Italy. Tel.: 0039.3470104897; Fax: 0039.050997826 E-mail: greta.barbieri@phd.unipi.it Key words: Lung; ultrasound; imaging; SARS-CoV-2. Conflict of interest: GB is member of the editorial board of Emergency Care Journal. The authors have no conflict of interest to declare. Availability of data and materials: All data generated or analyzed during this study are included in this published article. Ethics approval and consent to participate: No ethical committee approval was required for this case report by the Department, because this article does not contain any studies with human participants or ani- mals. Informed consent was obtained from the patient included in this study. Consent for publication: The patient gave his written consent to use his personal data for the publication of this case report and any accompany- ing images. Received for publication: 2 April 2022. Revision received: 18 July 2022. Accepted for publication: 10 August 2022. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2022 Licensee PAGEPress, Italy Emergency Care Journal 2022; 18:10492 doi:10.4081/ecj.2022.10492 Publisher's note: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organiza- tions, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its man- ufacturer is not guaranteed or endorsed by the publisher. A direct comparison between five lung-US and chest-CT-scans in a patient infected by SARS-CoV-2 Valentina Poli,1 Stefano Spinelli,1 Manuela Toscano,1 Francesca Vitale,1 Alessandro Ranalli,1 Michele Tonerini,2 Chiara Romei,3 Annalisa De Liperi,3 Greta Barbieri1,4 1Emergency Medicine Department, Pisa University Hospital; 2Department of Emergency Radiology, Pisa University Hospital; 3Department of Radiology, 2nd Radiology Unit, Pisa University Hospital; 4Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Italy Non -co mmerc ial us e o nly score,8 detected three areas with isolated B-lines and three areas with coalescent B-lines next to intact zones obtaining a final score of 9/45 (L2 region was excluded because it was completely occu- pied by the heart). Chest CT-scan reported areas of ground glass opacities and consolidation bilaterally patchy spread that are typical of chest CT manifestations of new coronavirus 19 disease.1,9 Videoclip n.1 shows each thoracic area explored with ultrasound and CT acqui- sitions performed at the ED, corresponding to the ninth day from the onset of symptoms (Videoclip n.1: First CT and Lung US (03/17/20) LUS score 9/45). The patient was admitted in the Infectious Diseases Department and started an antiviral drug (lopinavir/ritonavir 400/100 mg PO twice daily), hydroxychloroquine (200 mg PO twice daily), antibiotics (ceftriaxone 2 gr IV once daily and doxy- cycline 100 mg PO twice daily) and antithrombotic therapy (enoxaparin 6000 UI SC once daily), according to local protocols available in that period.10 The patient also received supplemental oxygen at the rate of 3 L/min through nasal cannula. During the fourth day of hospitalization (03/21/20) the clinical conditions worsened. The patient presented dyspnoea requiring oxygen therapy with fraction of inspired O2 of 50%. The arterial blood gas testing detected a P/F of 180 (PaO2 90/ FiO2 0.5). A lung US examination was immediately performed detecting large bilateral consolidation in inferior and posterior areas and coa- lescent B-lines11 in the others without defined spared areas. The final Lung Ultrasound (LUS) score was 36/45. Chest-CT scan confirmed bilaterally widespread consolida- tions, some of them with air bronchograms and a crazy paving pat- tern in the superior and medium lobes and in the lingula. Two doses of an interlukin-6 inhibitor (Tocilizumab 400 mg IV) were administered at 12 hours interval of time and the patient started. Considering the respiratory conditions, high flow nasal cannulas (FiO2 60%) were applied in dedicated negative pressure rooms of the infectious disease ward, in line with the indications regarding the ventilatory support of COVID-19 patients.12,13 Videoclip n. 2 shows lung ultrasound and chest CT performed on the fourth day of hospitalization, corresponding to the twelfth day from the onset of symptoms (Videoclip n.2: Second CT and Lung US (03/21/20) LUS score 36/45). After six days (03/27/20) the patient improved, he did not need to use high flow nasal cannulas and had a 95% oxygen saturation with 35% FiO2 delivery set on Venturi mask. The P/F value at arte- rial blood gas testing was 350. Chest imaging exams were repeated to confirm the positive clinical changes. LUS showed regression of the previous large consolidations that gave way to interstitial involvement with several areas of coa- lescent and others of isolated B-lines. Some spread areas also reap- peared. The final LUS score was 25/45. The CT-scan described regression of the consolidations in the inferior lobes occurring in some ground-glass areas. In the superior lobes could be seen a redistribution of the consolidations that remained in the lingula. Videoclip n. 3 shows both instrumental examinations, per- formed on the seventeenth day from the onset of symptoms (Videoclip n.3: Third CT and Lung US (03/27/20) LUS score 25/45). The patient was discharged asymptomatic after nineteen days of hospitalization (04/04/20) with a P/F of 450 without oxygen supplementation. Follow-up After three months (07/25/20) the patient was called to a fol- low-up assessment and performed both LUS and chest CT scan. LUS examination showed a full recovery with no pulmonary areas involved by B-lines or consolidations. LUS score was 0/45. Chest CT-scan confirmed the healing: quite total regression of high-den- sity areas bilaterally barely noticeable in the upper regions of the left superior lobe and right inferior lobe (Videoclip n.4: Follow-up CT and Lung US (07/25/20) LUS score 0/45). Materials and Methods Data for this clinical case were collected during a prospective observational clinical study in accordance with the ethical princi- ples expressed in the Helsinki Declaration, in accordance with the Good Clinical Practice Internationals standards. This research pro- tocol was approved by the local ethics committee on April 7th, 2020. The clinical case in question dates from the first pandemic wave, when validated LUS assessment schemes were not yet avail- able. We used a 16-area scanning scheme (8 for each hemi-thorax) to emphasize posterior chest analysis in order to obtain the most accurate topographical description possible.4 To cover the largest possible surface with a single scan, we used convex probes (fre- quency 2.5-5 MHz) along the intercostal spaces with the transverse approach. The standardized scanning scheme enabled each area to be evaluated and a numerical score based on lung aeration to be assigned. The score is similar to the one used in ARDS,8 with score 0 in case of normal aeration, score 1 in case of 3 or more B-lines or coalescent B-lines occupying ≤50% of the screen, score 2 for B- lines occupying >50% of the screen, score 3 for tissue-like consol- idation. The sum of all values obtained within the 16 areas yields a final LUS score, which indicates a decrease in lung aeration as the score increases. The medical personnel who performed the LUS scans were already experts in LUS and had received addition- al training on COVID-19 pneumoniae. Discussion Approximately 400 cases of SARS-CoV-2 infections were diagnosed by our ED in March and April 2020, with 318 of them requiring hospitalization.10 To stage the severity of lung involve- ment, all patients had an initial lung ultrasound exam and a chest CT-scan, and then patients were monitored using lung ultrasound.10 Additional CT-scans were requested based on clinical conditions. Lung ultrasound was performed in this case using a scanning technique adapted from a previously validated scheme.8,11 We chose four anterior [1-4] and four posterior [5-8] areas per hemithorax, divided vertically by anterior and posterior axillary and scapular lines and horizontally in the middle, from various clinical reports.6 Each lung zone was assigned a score that described lung aeration and ranged from 0 if A-lines were predom- inant or there were three distinct B-lines to 3 if large consolidations (at least > 1 cm) were detected. Score 1 e 2 were characterized by B-lines occupying respectively ≤ 50% or > 50% of the screen. The final score was calculated by adding the scores from each area. This case demonstrates a similar capacity of the two tech- niques in detecting lung involvement, both in severity and distribu- tion, due to the large number of examinations with corresponding timing between ultrasound and CT. During our experience with lung ultrasound in patients infect- Case Report [Emergency Care Journal 2022; 18:10492] [page 29] Non -co mmerc ial us e o nly ed with SARS-CoV-2, we noticed a good ability of this exam to detect lung findings and LUS scores correlated to the severity of clinical conditions,12,14 but we were not often able to compare LUS and CT-scan in such advanced stages of the disease as in this case to understand how precisely LUS can predict CT-scan patterns. Several studies comparing LUS and CT-scan have been pub- lished,3,5 and more will be published in the coming months. This parallel is intriguing not only for monitoring hyperacute phases, but also for imaging performed after disease recovery, with the possibility of promoting lung ultrasound as a remote follow-up tool.15 Why should an emergency physician be aware of this? This clinical case describes an intriguing parallelism between LUS and chest CT-scan, bolstering our efforts to study and perform lung ultrasound and opening the door to future considerations. Clinical judgment was used to perform the examinations (US and CT) in order to shed light on the patient’s course and the underly- ing pathophysiological mechanisms. The presented case demon- strates that LUS can be an accurate and versatile tool for confirm- ing pneumonia progression as the cause of clinical worsening in a patient admitted for COVID-19, with an interesting parallelism with chest CT. References 1. Ye Z, Zhang Y, Wang Y, Huang Z, Song B. Chest CT manifes- tations of new coronavirus disease 2019 (COVID-19): a picto- rial review. Eur Radiol 2020;30:4381-9. 2. Simpson S KF, Abbara S, Bhalla S, et al. Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA - Secondary Publication. J Thorac Imaging 2020:35:219-27. 3. Volpicelli G, Gargani L. Sonographic signs and patterns of COVID-19 pneumonia. Ultrasound J 2020:12:22. 4. Gargani L, Soliman-Aboumarie H, Volpicelli G, et al. Why, when, and how to use lung ultrasound during the COVID-19 pandemic: enthusiasm and caution. Eur Heart J Cardiovasc Imaging 2020;21:941-8. 5. Volpicelli G, Gargani L, Perlini S, et al. Lung ultrasound for the early diagnosis of COVID-19 pneumonia: an international multicenter study. Intensive Care Med 2021;47:444-54. 6. Zieleskiewicz L, Markarian T, Lopez A, et al. Comparative study of lung ultrasound and chest computed tomography scan in the assessment of severity of confirmed COVID-19 pneu- monia. Intensive Care Med 2020;46:1707-13. 7. Nouvenne A, Zani MD, Milanese G, et al. Lung ultrasound in COVID-19 pneumonia: correlations with chest CT on hospital admission. Respiration 2020;99:617-24. 8. Bouhemad B, Mongodi S, Via G, Rouquette I. Ultrasound for “lung monitoring” of ventilated patients. Anesthesiology 2015;122:437-47. 9. Chung M, Bernheim A, Mei X, et al. CT imaging features of 2019 novel coronavirus (2019-nCoV). Radiology 2020;295:202-7. 10. Falcone M, Tiseo G, Barbieri G, et al. Role of low-molecular- weight heparin in hospitalized patients with severe acute respi- ratory syndrome coronavirus 2 pneumonia: a prospective observational study. Open Forum Infect Dis 2020;7:ofaa563. 11. Soldati G SA, Inchingolo R, Buonsenso D, et al. Proposal for international standardization of the use of lung ultrasound for patients with COVID-19: a simple, quantitative, reproducible method. J Ultrasound Med 2020;39:1413-9. 12. Boccatonda A, Grignaschi A, Lanotte AMG, et al. Role of lung ultrasound in the management of patients with suspected SARS-CoV-2 infection in the emergency department. J Clin Med 2022;11:2067 13. Montanari M, De Ciantis P, Boccatonda A, et al. Lung ultra- sound monitoring of CPAP effectiveness on SARS-CoV-2 pneumonia: A case report. Emer Care J 2020;16:9333. 14. Boccatonda A, Cocco G, Ianniello E, et al. One year of SARS- CoV-2 and lung ultrasound: what has been learned and future perspectives. J Ultrasound 2021;24:115-23. 15. Boccatonda A, Cocco G, Sofia S, et al. A new type of outpa- tient: lung ultrasound after covid-19 infection. J Ultrasound Med 2022;41:2113-14. Case Report [page 30] [Emergency Care Journal 2022; 18:10492] Non -co mmerc ial us e o nly