Most commonly used imaging methods for the detection of COVID-19. Literature
review
Métodos de diagnóstico Imagenológico
más empleados para la detección de la COVID-19. Una revisión de la literatura
Jessica Samantha Calle Álvarez*
Heydi Monserrath Calle Arévalo*
Shirley Pamela Lema Remache*
Mayra Vanessa Montesinos-Rivera*
ABSTRACT
The
aim of this study is to comprehensively review the literature on the imaging
techniques most commonly used to diagnose COVID-19. In the present work, a
literature review was conducted, performing a reflexive critical analysis of
the theoretical content of different updated scientific articles, obtained from
PubMed, Cochrane databases. Different inclusion criteria were determined as
year of publication between 2017 and 2023, scientific articles in English and
Spanish, whose content had to be related to the pre-established topic. The
findings show that chest computed tomography, thoracic radiography and lung
ultrasound are the most commonly used imaging methods for the detection of
coronavirus disease. It is concluded that three imaging techniques frequently
used for the detection of COVID-19 were analyzed. Among them are thoracic
radiography, whose devices are easy to handle and disinfect; its price is
accessible and stands out for its careful emission of X-rays in the part of the
body to be examined; computed tomography, which allows an early diagnosis by
evaluating pulmonary involvement and an assessment of the response to
treatment, is sophisticated and provides detailed images to improve the
results; and finally, pulmonary ultrasound, which stands out for its
versatility.
Keywords:
COVID-19, Diagnosis, Imaging, Tomography, Radiography, Ultrasonography.
RESUMEN
El estudio tiene como objetivo
examinar exhaustivamente la literatura sobre las técnicas de diagnóstico por
imágenes más utilizadas para diagnosticar la COVID-19. En el presente trabajo
se realizó una revisión bibliográfica, efectuando un análisis crítico reflexivo
del contenido teórico de diferentes artículos científicos actualizados,
obtenidos en bases de datos PubMed, Cochrane. Se determinaron distintos
criterios de inclusión como año de publicación entre el 2017 y 2023, artículos
científicos en inglés y español, cuyo contenido debían tener relación con la
temática preestablecida. Los hallazgos permiten evidenciar que la tomografía
computarizada de tórax, la radiografía torácica y la ecografía pulmonar son los
métodos imagenológicos más utilizados para la detección de la enfermedad por
coronavirus. Se concluye que tres técnicas imagenológicas frecuentemente son
utilizadas para la detección de COVID-19 fueron analizadas. Entre ellas se
encuentra la radiografía toráxica, cuyos aparatos son fácil de manejo y desinfectar;
su precio es accesible y se destaca por su emisión cuidadosa de rayos X en la
parte del cuerpo han de examinar; la tomografía computarizada, que permite un
diagnóstico temprano al evaluar la afectación pulmonar y una valoración de la
respuesta al tratamiento, es sofisticada y proporcionando imágenes detalladas
para mejorar los resultados; y finalmente, la ecografía pulmonar, que se
destaca por su versatilidad.
Palabras Clave: COVID-19, Diagnóstico,
Imagenología, Tomografía¸ Radiografía, Ecografía.
INTRODUCTION
Since December 2019, there have been documented cases
of a new form of pneumonia that emerged in Wuhan, Hubei Province, China.
Subsequent investigations identified a new strain of coronavirus, classified as
COVID-19, derived from “corona + virus + disease”. This virus, which belongs to
the beta-coronavirus group, was also given the name severe acute respiratory
syndrome (SARS-CoV-2) by the International Committee on Taxonomy of Viruses
(ICTV). The isolated virus belongs to the subfamily Coronavirinae, which
comprises four genera: Alphacoronavirinae, Betacoronavironoronavirinae and
Deltacoronavirinae (Aragón-Nogales et al., 2019).
The virus causes a mutation process due to its
intrinsic nature and host factors, leading to symptomatic or asymptomatic
symptomatology, which represents a diagnostic challenge for health
professionals (Delgado et al., 2020; Rosón et al., 2020) .
The spread of the virus has been facilitated by its easy transmission through
Flugge aerosols or microdroplets, which are expelled when coughing, talking,
sneezing or breathing, and which initially affected Asian countries and
subsequently spread to Europe and worldwide, with an estimated 2 million
deaths. It is worth noting that this virus differs from SARS and MERS, which
caused significant mortality rates in the past ( Escamilla
Llano et al., 2020; Aragón-Nogales et al., 2019; Sánchez-Oro et al., 2020).
Transmission occurs presymptomatically, with an
incubation period of 14 days, although the mortality rate is lower compared to
SARS-CoV or MERS-CoV. The virus has a relatively low mutation rate, but has
evolved to enhance person-to-person transmission and replication rates.
Therefore, efforts are directed to explore complementary methods, particularly
imaging, to assess the impact of this disease on affected individuals (J.
Antonio et al., 2020; Aragón-Nogales et al., 2019; Delgado et al., 2020). This
review aims to comprehensively examine the literature on the imaging techniques
most commonly used to diagnose COVID-19.
Coronaviruses represent a diverse family of viruses
capable of causing disease in both humans and animals. Structurally, they
exhibit a pleomorphic spherical shape ranging from 80 to 120 nanometers, with
spike-like membrane glycoproteins forming a corona-shaped envelope on the
surface and a nucleoprotein that protects the viral RNA from internal
degradation. Viral replication is facilitated by nonstructural proteins such as
helicase and RNA-dependent RNA polymerase, with key structural components
including the spike glycoprotein (S), envelope (E), membrane (M), and
nucleocapsid (N) (Bravo et al., 2018).
Virus replication is initiated by the activity of
non-structural proteins such as helicase and RNA-dependent RNA polymerase,
while at the structural level, notable components include the spike
glycoprotein (S), envelope (E), membrane (M) and nucleocapsid (N). Through
genetic analysis, several human coronaviruses, such as HKU1, NL63, 229E and
OC43, have been identified as causing mild respiratory disease. In contrast,
some coronaviruses enter cells via endosomal or alternative routes and, after
binding to specific host cell protein receptors (angiotensin-converting enzyme,
dipeptidyl peptidase 4, aminopeptidase N and O-acetylsialic
acid), release RNA and nucleocapsid into the cytoplasm, allowing viral
transcription and replication, resulting in the production of new virions.
These virions are then released, causing systemic alterations ranging from
pneumonia to death in patients due to elevated levels of proinflammatory
cytokines that aggravate the disease in different organs and systems (Chen et
al., 2020; Kompatscher et al., 2021).
Clinical manifestations
The clinical presentation of COVID-19 is predominantly
nonspecific and often resembles that of other conditions, making definitive
diagnosis difficult. In particular, mortality and adverse outcomes are more
common among persons with underlying comorbidities (50% to 75% of severe cases)
and the elderly, with hospital mortality rates ranging from 4% to 11% and case
fatality rates between 2% and 3%. The virus is spread mainly through aerosols
and saliva droplets, which are generated during daily activities, resulting in
a pathology characterized by specific features. According to Ibarra et al.
(2020); Jin et al. (2020); Rosón et al. (2020) these
characteristics are:
- Cough: approximately 59% of infected persons present a dry, irritating cough,
with or without sputum production.
- Fever: about 90% of patients present fever; however, the severity may vary
and some cases are asymptomatic.
- Fatigue: weakness and fatigue are observed in up to 69% of infected persons.
- Shortness of breath: 31% of patients report chest tightness and dyspnea.
It is important to note that COVID-19 can manifest asymptomatically or with
severe symptoms, including neurological manifestations such as headache,
vomiting, nausea, diarrhea and abdominal pain. In addition, cardiovascular
symptoms such as chest tightness, palpitations and mild pain in the extremities
have been documented, as well as loss of smell and taste, ophthalmic symptoms
such as conjunctivitis and skin rashes on hands and feet (Ibarra et al., 2020; Rosón et al., 2020).
Importance of imaging in the detection of COVID-19
In the midst of the COVID-19 pandemic, the importance of imaging analysis,
which allows professionals to assess the evolution of internal changes due to
this disease, has been highlighted. Imaging plays a crucial role in identifying
patient complications such as pneumonia, lesions and lung damage. The worldwide
application of imaging aims at diagnosing, monitoring various health
abnormalities and supporting treatment efforts, leading to the establishment
and maintenance of radiological services in several countries (Delgado et al.,
2020; Jawerth, 2020).
Imaging methods used for the detection of COVID-19.
Thoracic Radiography
Currently, the prioritization of imaging modalities to
diagnose COVID-19 depends on laboratory tests, clinical conditions of patients
and availability of radiological equipment in healthcare facilities. Chest
radiography (CXR), in particular, is noted for reducing the risk of infection
among healthcare workers when caring for COVID-19-positive patients, especially
in emergency situations. Chest radiography is critical in assessing lung tissue
in patients with respiratory symptoms, as it aids in treatment decisions and
disease management, especially in acute respiratory cases.
In particular, chest radiographs offer advantages over computed tomography,
such as lower radiation dose, accessibility, ease of use and portability, which
improves the understanding of the characteristics of SARS.COV-2 infection
(Jawerth, 2020; Navarro, 2020; Ortega Garcia, 2020).
Thoracic Computed Tomography
In the case of thoracic computed tomography, the
equipment rotates around the patient and emits X-rays from different body
angles. Specialized detectors capture the X-ray patterns, which are then
processed by a computer to generate detailed 3D images of the thoracic region.
Although more expensive and sophisticated than computed radiographs, chest CT
machines provide comprehensive and valuable information. This imaging method is
recognized for its accessibility and rapidity in detecting COVID-19, and offers
high sensitivity in identifying pulmonary changes during the presymptomatic and
early symptomatic stages.
Research has demonstrated the reliability and
reproducibility of chest CT in detecting COVID-19-related lung disorders,
positioning it as the leading imaging tool in current medical practice ( Escamilla Llano et al., 2020; Gonzalez and Pieri, 2017;
Jin et al., 2020; Mayanga-Sausa et al., 2020).
It has been observed that CT scans can yield negative
results in the early symptomatic phase of COVID-19, so it is recommended that a
negative CT scan should not be used to rule out the disease, especially in
early stages.
Abnormal pulmonary findings have been observed in
asymptomatic individuals, establishing a correlation between radiological
findings and duration since symptom onset. The evolution of COVID-19-related
lung abnormalities is classified into four distinct stages (Mayanga-Sausa et
al., 2020; Rodriguez-Gonzalez, M Espinoza-Rosales, 2016; Yuan et al., 2020):
- Early stage (0-4 days after symptom onset):
tarnished glass pattern predominates, with uni- or bilateral and multifocal
involvement. It may show a rounded morphology.
- Progression phase (5-8 days): ground-glass involvement progresses rapidly in
extent and becomes diffuse, diffuse, with multilobar involvement.
- Peak phase (9-13 days): maximum involvement is
observed, with areas of ground glass that transform into consolidation.
- Resolution phase (>14 days): reabsorption of the
consolidations manifests again as ground glass opacities that may be associated
with bronchial dilatations with subpleural distortion.
Pulmonary Ultrasonography
In the context of COVID-19, lung ultrasound uses
high-frequency sound waves interacting with an ultrasound device, emitting and
receiving billions of sound waves per second to examine the lungs. These waves
generate an echo when they come in contact with fluid, soft tissue or bone. The
device can determine the distance and intensity of the echo, translating this
data into real-time images.
Lung ultrasounds are described as cost-effective,
easily accessible, portable, compact, easy to disinfect, deployable in
ambulances, patient rooms or triage centers, and offer immediate dynamic
visualization on a screen, facilitating rapid patient assessment by healthcare
professionals (Accinelli et al., 2020; Wangüemert Pérez, 2021).
Lung ultrasound represents a valuable modality for evaluating individuals with
respiratory manifestations, as it allows effective visualization of pathology
in the resulting images. This diagnostic approach involves ultrasound capture
using a probe that penetrates to a specific depth, depending on the frequency
of the probe and the target anatomical region.
It takes advantage of discrepancies in tissue
propagation velocities to translate these variations into electrical signals
that are displayed in varying shades of grayscale on a screen (Accinelli et
al., 2020; Gutierrez et al., 2020).
Although lung ultrasound (PE) has historically been considered inadequate due
to poor air conduction of ultrasound, it has gained prominence over time.
Especially in the context of COVID-19, PE has become a crucial diagnostic tool,
allowing bedside evaluations to be performed with minimal delay.
This non-ionizing technique provides rapid insight
into the state of the lung parenchyma, often within minutes, which contributes
significantly to patient care during the pandemic (Jin et al., 2020; Wangüemert Pérez, 2021).
In addition, lung ultrasound is a vital tool for the
accurate diagnosis and detection of lung diseases, facilitating informed
decision making about patients' health status. Individuals with mild lung
involvement or normal results can be discharged, while those with elevated lung
risk should be hospitalized for appropriate intervention. Ultrasonographic
observations include pleural line irregularities (100%), presence of B-lines
and consolidation (64%) (Bravo et al., 2018; Stang, 2020).
MATERIALS
AND METHODS
The study was qualitative, supported by a critical and
reflective review of the literature. The literature search was non-systematic
using specific keywords in databases such as PubMed/Medline and the Cochrane
Library to identify relevant studies on COVID-19 imaging.
Priority was given to high-quality systematic reviews
and critical analyses from authoritative sources, covering primary articles,
reviews, randomized controlled trials, and research studies published in
English and Spanish.
RESULTS
Dr. Elver Leguía clarifies that the identification of
COVID 19 goes beyond mere symptoms such as cough, fever, headache and
respiratory distress, which are discernible only through specific tests, such
as RNA tests that analyze the genetic material of the virus. In addition, CT
scans of the chest, by thoroughly evaluating the thoracic region, can more
accurately identify pulmonary manifestations of coronavirus. Although
accessible, rapid and highly sensitive, this diagnostic method may not yield
optimal results during the early stages of symptom manifestation, which could
lead to unexpected results.
Imaging techniques are time-consuming and require
strict infection control protocols to mitigate the risks of viral transmission
among healthcare workers. Accordingly, he advocates the initial use of
ultrasound and radiography, noting that while radiographs may lack sensitivity
for detecting disease markers, their portability facilitates disease diagnosis
and follow-up. After highlighting the cost-effectiveness and ease of
disinfection of electromagnetic devices, their ability to measure distances,
calculate echo intensities, and translate data into descriptive images, all
without ionizing radiation, is emphasized. However, Ying Hui argues that
premature ejaculation is not universally recognized as a primary diagnostic
tool due to air interference that impedes the clarity of ultrasound images
(Mayanga, 2020).
In addition, Dr. Sayan Manna highlights the valuable
insights provided by echocardiography and lung ultrasound, which can complement
CT findings; however, caution should be exercised to safeguard patient welfare
(Manna et al., 2020).
Regarding imaging technologies, Antonio et al. (2005)
state that computed tomography and chest radiography are among the most
prevalent modalities, with CT scans surpassing rXT in sensitivity. Despite its
cost-effectiveness, accessibility and minimal health risks, rXt reveals
alveolar, interstitial and alveolar interstitial opacities, whereas CT scans
reveal a variety of findings, such as ground-glass opacities, reticular
patterns, consolidations, halo signs, bronchial wall thickening and pulmonary
fibrosis.
DISCUSSION
The Spanish Society of Emergency Radiology (SERAU)
stresses the importance and use of the computed tomography diagnostic technique
for the detection of COVID, particularly in hospitalized patients and when
RT-PCR tests are not available. In contrast, the American College of Radiology
(ACR) points out the high potential risk of contamination in imaging facilities
associated with this method, and stresses the importance of taking
precautionary measures to avoid shared and continuous use that could lead to
harm. In contrast, the Spanish Society of Medical Radiology (SERAM) recommends
minimizing the movement of patients with COVID-19 whenever possible,
emphasizing the use of portable equipment. Finally, the Chilean Society of
Radiology (SOCHRADI) suggests the application of CT scans to resolve
uncertainties in cases of severe pneumonia, hospitalization, slow progression
and cases of respiratory distress.
Jawerth (2020)
the three techniques examined serve as complementary tests that allow systemic
analysis of the impact of COVID-19 in the pulmonary and thoracic regions. While
laboratory tests are accurate diagnostic tools for virus detection, imaging
plays a crucial role not only in identifying and assessing pathology, but also
in understanding its behavior. Consequently, X-ray devices are indispensable
during this pandemic because of their light weight, ease of use, portability
and simple decontamination procedures, which facilitate a thorough examination
of lung tissue.
While alternative diagnostic approaches exist, such as
molecular and serological tests for antigen detection, imaging modalities have
proven to be essential in monitoring disease progression in infected
individuals. Among these, chest radiography stands out as a viable option due
to its affordability and availability and the efficacy of disinfecting
equipment after use, while chest CT scanning is recommended for patients
diagnosed with pneumonia by COVID-19(Varadarajan et al., 2021).
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*Estudiante de la
Carrera de odontología, Universidad Católica de Cuenca, jessica.calle.04@est.ucacue.edu.ec
https://orcid.org/0000-0002-9276-8636
*Estudiante de la
Carrera de odontología, Universidad Católica de Cuenca, heydi.calle.11@est.ucacue.edu.ec
https://orcid.org/0000-0002-3065-2849
*Estudiante de la
Carrera de odontología Universidad Católica de Cuenca, shirley.lema.94@est.ucacue.edu.ec
https://orcid.org/0000-0003-4647-2639
*Especialista en
Endodoncia. Magister en Educación, Tecnología e Innovación, Docente de la
Carrera de Odontología, Universidad Católica de Cuenca
https://orcid.org/0000-0001-7991-366X