• Users Online: 269
  • Print this page
  • Email this page

 Table of Contents  
Year : 2021  |  Volume : 2  |  Issue : 2  |  Page : 55-60

Plain chest radiographic findings among COVID-19 patients in sub-saharan Africa

Department of Radiology, University of Teaching Hospital, Abuja, Nigeria

Date of Submission12-Feb-2021
Date of Decision05-Jun-2021
Date of Acceptance28-Sep-2021
Date of Web Publication30-Nov-2021

Correspondence Address:
Donald Amasike Nzeh
Department of Radiology, University of Abuja Teaching Hospital, Abuja
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jrmt.jrmt_4_21

Rights and Permissions

Background: Coronavirus disease (COVID-19) is a pandemic that is ravaging the world. Chest imaging plays an important role in the diagnosis and management of patients with COVID-19-related chest infections. This study determined the pattern of chest radiographic features among confirmed COVID-19 patients in Abuja, Nigeria. Materials and Methods: Chest radiographs (CXR) of COVID-19 patients were reviewed, and the radiological features of the lesions were recorded based on the type of opacities, pattern of distribution in the lung fields, side of lesions, and severity of pulmonary abnormalities. Results: The radiographs of 77 patients were analyzed. Their age range was 15–88 years with a mean of 47.4 years and peak age group of 51–60 years. Gender distribution of the patients was 58 (75.3%) males and 19 (24.7%) females giving a male-to-female ratio of 3.1: 1. Fifty-five (71.4%) of the patients had normal CXRs, whereas 22 (28.6%) patients had abnormal pulmonary appearances. Seven (58.3%) out of 12 patients with mild interstitial pneumonia had unilateral disease, whereas 5 (41.7%) had bilateral disease. Combined total of ten patients with moderate and severe interstitial pneumonia all had bilateral disease. Conclusion: Plain CXR gives reliable diagnosis about the presence and degree of interstitial pneumonia in COVID-19 patients. CXR should be routinely done as a baseline diagnostic tool in patients positive for reverse-transcription polymerase chain reaction test. The findings in the CXRs of COVID-19 patients in sub-Saharan Africa are similar to those reported from the other parts of the world.

Keywords: Chest radiographic findings, coronavirus disease-19, sub-Saharan Africa

How to cite this article:
Nzeh DA, Kolade-Yunusa HO, Shalangwa I, Ekele BA, Anumah F, Isaac U, Ogbonyomi P, Yunusa T, Kwaghe VG, Habib Z, Akor AA, Bawa A, Adebayo F, Idoko G, Akintola O. Plain chest radiographic findings among COVID-19 patients in sub-saharan Africa. J Radiat Med Trop 2021;2:55-60

How to cite this URL:
Nzeh DA, Kolade-Yunusa HO, Shalangwa I, Ekele BA, Anumah F, Isaac U, Ogbonyomi P, Yunusa T, Kwaghe VG, Habib Z, Akor AA, Bawa A, Adebayo F, Idoko G, Akintola O. Plain chest radiographic findings among COVID-19 patients in sub-saharan Africa. J Radiat Med Trop [serial online] 2021 [cited 2023 Jun 3];2:55-60. Available from: http://www.jrmt.org/text.asp?2021/2/2/55/331525

  Introduction Top

Coronavirus disease 2019 (COVID-19) has caused a global pandemic that is ravaging the whole world. This disease is caused by a virus called severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2 virus) that was first reported in Wuhan, Hubei Province, China, in December 2019 and has since then spread to the other parts of the world.[1] The virus is highly contagious and is transmitted through close contact, respiratory droplets, and it is also airborne.[2],[3] Affected patients present clinically with fever, dry cough, dyspnea, fatigue, anosmia, and loss of the sense of taste (ageusia) among others.[3],[4],[5],[6] The first case was reported in Nigeria on February 27, 2020,[3] while Abuja the federal capital territory (FCT) of Nigeria had its first case in March 2020. A mutant and more infectious variant of the virus was first identified in the United Kingdom in September 2020 and has spread to more than thirty countries as at the end of 2020. A second wave of the pandemic has set in since the last quarter of 2020, with associated second and even the third phase of national lockdowns, by some countries, especially in Europe by January 2021, with adverse social and economic consequences on the citizens of these countries. However, the recent development of vaccines against COVID-19 disease and commencement of inoculation of persons against the virus means that the pandemic would eventually be contained. As at February 11, 2021, Nigeria has had a total of 142,578 confirmed cases, of which 116,947 had recovered and 1,702 had died from the infection.[7]

Chest imaging plays an important role in the diagnosis and management of patients with COVID-19-related pulmonary infections. Although computed tomography (CT) is more sensitive than chest radiograph (CXR) in detecting COVID-19-related pulmonary changes, its use as a first-line imaging modality for COVID-19 patients is not recommended by the American College of Radiology, because CT poses a great burden in infection prevention and control in the CT suite.[8] The process of decontaminating the machine after each use on a COVID-19 patient can be quite tasking and makes the routine use of CT impracticable, and there is also the possibility of cross infection among staff and patients.[8] This is even more pertinent in Nigeria, where a number of the tertiary hospitals in the country have only one functional CT scanner, to cater for all the hospital patients. CXR is recommended as the baseline radiological investigative tool for COVID-19 cases who are in need of chest imaging in the triage of patients.[8]

The findings on the CXR of COVID-19 patients is that of atypical or organizing pneumonia with bilateral, peripheral, and basal distribution.[5],[9],[10],[11],[12] The commonly reported imaging features of COVID-19 on plain chest are ground-glass opacities (GGO), patchy opacities which are usually bilateral with peripheral and predominantly basal distribution.[10],[12],[13],[14] Pulmonary fibrosis is now a recognized sequelae of advanced pulmonary involvement in severe COVID-19 disease, although it is not usually present in the mild or moderate forms of the disease.[15],[16] Other findings include lymphadenopathy and pleural effusion which are less frequently encountered findings on CXR.[13],[17]

Some studies have evaluated chest radiographic findings in patients with COVID-19.[7],[13],[14],[17],[18] However, most of these studies are from developed countries. There has been an increase in the number of confirmed COVID-19 cases in Nigeria, especially with the onset of the second wave of the pandemic, but there is a paucity of data on the pattern of chest radiographic findings among these patients. Hence, there is the need to determine the pattern of chest radiographic findings of this novel disease in the Abuja, FCT of Nigeria and to compare the findings with those reported from other places.

  Materials and Methods Top

This was a retrospective study approved by the institutional human research and ethics committee and conducted at the Infectious Diseases Centre (IDC) of the University of Abuja Teaching Hospital (UATH), Gwagwalada, Abuja. The patients were confirmed to be COVID-19 positive through the reverse-transcription polymerase chain reaction test. This study was conducted from April–July 2020.

CXRs were done on 77 consecutive confirmed COVID-19 patients admitted at IDC. The chest radiographic examinations were performed using a mobile Philips X-ray machine model XD4 manufactured in England, dedicated to the center. Erect postero-anterior CXRs were taken with focus-film distance of 100 cm for stable patients while very ill patients had supine anteroposterior CXRs done. Computed radiography images were processed using a FUJI® digitizer to generate digital radiographs. The digital radiographs were jointly interpreted on computer monitors, by three consultant radiologists (DN, IS, HKY), two of whom have experience of at least 15 years, in the interpretation of CXRs and a consensus was reached on the findings on each radiograph, by the three radiologists. The findings on the radiographs were recorded based on the type of lesions seen, pattern of distribution within the lungs (upper, middle, and lower lobes), side of lesion, and degree of severity of the pulmonary findings (mild, moderate, and severe). A well-structured questionnaire was deployed to record sociodemographic data, clinical presentation, and chest radiographic findings.

Data were collated and analyzed using the Statistical Package for the Social Sciences (SPSS) version 19.0 software 2010 by IBM® USA. Descriptive variables were generated using frequency and means.

  Results Top

A total of 77 COVID-19-positive patients had CXRs done. The mean age of the patients was 47.4 ± 17 years (range 15–88 years). The peak age group was 51–60 years [Table 1].
Table 1: Age distribution of patients

Click here to view

There were 58/77 male (75.3%) and 19/77 female (24.7%) patients who had CXRs done giving a male:female ratio of 3.1: 1 [Table 2].
Table 2: Sex distribution of patients in the study

Click here to view

55/77 (71.4%) of the patients had normal CXRs while 22/77 (28.6%) of the patients had abnormal pulmonary findings. Among the patients with abnormal features in the chest, 19/22 (86.4%) were male and 3/22 (13.6%) were female [Table 3].
Table 3: Sex distribution of patients with abnormal chest radiographs

Click here to view

The youngest patient with abnormal CXR was in the 31–40 years age group while the oldest patient with abnormal CXR was in the 81–90 years age group [Table 4].
Table 4: Age distribution of patients with abnormal chest radiographs

Click here to view

7/12 (58.3%) of patients with mild interstitial pneumonia had unilateral disease [Table 5] while 5/12 (41.7%) had bilateral disease. 8/8 (100%) of the patients with moderate and 2/2 (100%) of the patients with severe interstitial pneumonia had bilateral disease.
Table 5: Distribution of chest findings among patients

Click here to view

The types of pulmonary lesions seen and their distribution on CXR are shown in [Table 5] and [Table 6]. Clinical conditions that were comorbidities among the patients studied included hypertension, diabetes mellitus, heart failure, and obesity.
Table 6: Types of abnormal chest findings among patients

Click here to view

The examples of mild, moderate, and severe pulmonary disease are shown in [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6].
Figure 1: Chest radiograph of a 60-year-old man with coronavirus disease-19 showing ground glass opacity in the left lung base that is causing obliteration of the shadow of the left hemidiaphragm due to mild interstitial pneumonia

Click here to view
Figure 2: Chest radiograph of a 70-year-old male with coronavirus disease-19 showing bilateral basal patchy opacities that have predominantly peripheral distribution and extension into the middle zones due to moderate interstitial pneumonia. The right hemidiaphragm is elevated

Click here to view
Figure 3: Chest radiograph of a 62-year-old man with coronavirus disease-19 showing left sided basal ground glass opacities and right sided patchy opacities extending to the right middle zone due to moderate interstitial pneumonia. The patient also had cardiomegaly from hypertensive heart disease

Click here to view
Figure 4: Chest radiograph of a 60-year-old coronavirus disease-19 patient showing moderate interstitial pneumonia with predominantly basal and peripheral distribution

Click here to view
Figure 5: Chest radiograph of the same patient as in Figure 5 taken at an interval of 2 weeks showing progression from moderate to severe interstitial pneumonia with predominantly basal and peripheral distribution

Click here to view
Figure 6: Chest radiograph of a 53-year-old man with coronavirus disease-19 showing bilateral severe interstitial pneumonia giving coalescent patchy opacities in both lungs with predominantly peripheral and basal distribution. Horizontal linear processing artefacts are present on the radiograph

Click here to view

  Discussion Top

The management of COVID-19 patients has continued to pose serious challenges to clinicians worldwide. By the end of 2020, a second wave of the disease had set in. A new and more infectious mutant variant of the virus emerged in Southern England, in the United Kingdom in September 2020, and is spreading rapidly across the globe; it had reached more than 30 countries as at the end of December 2020. South Africa has also reported a mutant variant of the virus which is resistant to some of the currently available vaccines.

The symptoms and signs of coronavirus disease are well recognized globally as fever, dry cough, dyspnea, anosmia, and loss of the sense of taste (ageusia).[3],[4],[6],[18] The continent of Africa, especially the tropical sub-Saharan region has been relatively spared of the devastation of large populations by the disease, despite low resources of these countries and less compliance with the nonpharmaceutical COVID-19 protocols, such as wearing of face mask, regular washing of hands, and physical distancing. Interestingly, even the overcrowded inner city areas of Africa have not recorded the level of havoc caused by the disease that has been seen in temperate countries of the northern hemisphere in Europe, Asia as well as North and South America.[19] Explanation for this relative sparing of tropical Africa from the ravages of the COVID-19 pandemic has remained essentially speculative and attributed in large measure to hotness of the tropical climate and exposure to long hours of bright sunlight which promotes production of Vitamin D that has protective effect on the disease. Another assumption is that circulating blood immunity from exposure to endemic pathogens protects against the virus. A study on the first 32 cases of COVID-19 in Nigeria reported that most of the patients had mild or moderate forms of the disease.[3]

Research studies on pulmonary features of COVID-19 on CXR in Africa are few. Although CXR is a complementary diagnostic tool to clinical examination and laboratory tests, it is helpful for patient triage and to determine the extent of lung involvement and also to monitor response to treatment especially when there is shortage of serological testing.[9]

The peak age group in the present study was the sixth decade which is similar to the 50–59 years peak age group reported in studies from Ibadan and Kano in Nigeria.[15],[20] Previous studies[3],[16],[21] showed a male preponderance for COVID-19 and this agrees with findings from the present study with male-to-female ratio of 3.1:1. However, the studies in New Orleans, USA, and Hong Kong showed preponderance of females.[9],[14] Patients with positive pulmonary findings in the current study also showed a higher predilection for males (86.4%) as compared to females (13.6%).

In the present study, 71.4% of the patients had normal CXR while 28.9% had abnormal pulmonary appearances. This is in contrast to 80.8% positive findings and 19.2% normal features of CXR in the report from Kano, Nigeria by Lawal et al.[18] The findings from the study by Smith et al. in New Orleans, USA which reported 33% normal CXR, 10% cases with classical COVID-19 CXR appearance and 57% nonspecific chest radiographic features is also at variance with the present study.[9] Wong et al.[14] in a Hong Kong study found normal CXR features in 20/64 (31%) of the patients while 51/64 (79.7%) of the patients had abnormal appearances which differs from the results obtained in the current study. Pulmonary changes in COVID-19 on CXR are less sensitive than on CT scan.[9],[11],[17],[22],[23] Lomoro et al.[17] in Italy combined CXR and CT scan to investigate a group of patients and reported that 5/32 (15.6%) of the patients who had CXR and CT scan done the same day showed normal appearance of the lungs on CXR but CT demonstrated mild bilateral hyperdensities which should correspond to GGO on CXR. Ibrahim et al.[24] studied a case series of five COVID-19-positive children in Katsina, Nigeria, four of whom had CXR, and reported that 2/4 (50%) of the children had mild bilateral pulmonary opacities. These differences could be explained by the fact that most of the patients at the IDC, UATH presented with mild or moderate COVID-19 illness clinically and all the patients on admission at IDC, UATH who developed pulmonary symptoms had CXR done as soon as possible.

GGO was the most common abnormal finding on CXR in the current study and constituted 12/22 (54.5%) of the abnormalities on CXR. This is lower than the report of 69% GGO as abnormal finding in the study by Lawal et al.[18] In the study by Wong et al.,[14] 26/64 (41%) had mild changes on CXR while 13/64 (20%) of cases had moderate changes and 5/64 (8%) had severe pulmonary features, respectively, on CXR. Lawal et al.[18] reported that all the cases studied had bilateral distribution of pulmonary abnormalities. A study from Italy reported that 2/32 (6.2%) of the patients had unilateral abnormalities on CXR while 25/32 (78.1%) of the patients had bilateral pulmonary disease.[17] In the current study, 7/22 (31.8%) of the abnormal CXR had unilateral pulmonary disease, whereas 15/22 (61.2%) of the abnormal CXR showed bilateral involvement, which differs slightly from the reports of earlier studies.

Smith et al.[9] stated in the study from New Orleans, USA that the presence of bilateral ground glass opacity or consolidation that is patchy or confluent in nature, accompanied by peripheral and mid-to-lower zone distribution on CXR, in the setting of COVID-19 pandemic, is highly suggestive of SARS-CoV-2 pulmonary infection. This assertion is corroborated by the results from the present study.

  Conclusion Top

The present study has shown that plain CXR is useful in the detection of pulmonary changes in COVID-19-positive patients and it should be utilized as a baseline diagnostic tool in the management of this disease.


The authors express their appreciation to the health-care workers at the University of Abuja Teaching Hospital and Abuja, FCT, Nigeria for their dedication to duty and selfless service during this COVID-19 pandemic.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med 2020;382:727-33.  Back to cited text no. 1
Perlman S. Another decade, another coronavirus. N Engl J Med 2020;382:760-2.  Back to cited text no. 2
Bowale A, Abayomi A, Idris J, Omilabu S, Abdus-Salam I, Adebayo B, et al. Clinical presentation, case management and outcomes for the first 32 COVID-19 patients in Nigeria. Pan Afr Med J 2020;35:24.  Back to cited text no. 3
Xydakis MS, Dehgani-Mobaraki P, Holbrook EH, Geisthoff UW, Bauer C, Hautefort C, et al. Smell and taste dysfunction in patients with COVID-19. Lancet Infect Dis 2020;20:1015-6.  Back to cited text no. 4
Kanne JP. Chest CT findings in 2019 novel coronavirus (2019-nCoV) infections from Wuhan, China: Key points for the radiologist. Radiology 2020;295:16-7.  Back to cited text no. 5
Nzeh DA. COVID-19 pandemic and a new reality for radiologists in the workplace. J Rad Med Trop 2020;1:1-2.  Back to cited text no. 6
Worldometers COVID-19 Corona Virus Pandemic; 2020. Available from: https\\www.worldometers.info Nigeria. [Last accessed 2021 Feb 11].  Back to cited text no. 7
ACR Recommendations for the Use of Chest Radiography and Computed Tomography (CT) for Suspected COVID-19 Infection | American College of Radiology. Available from: https://www.acr.org/Advocacy-and-Economics/ACR-PositionStatements/Recommendations-for-Chest -Radiography-and-CT-for-Suspected-COVID19-Infection. [Last accessed on 2020 Dec 28].  Back to cited text no. 8
Smith DL, Grenier JP, Batte C, Spieler B. A characteristic chest radiographic pattern in the setting of COVID-19 pandemic. Radiol Cardiothorac Imaging 2020;2:e200280.  Back to cited text no. 9
Cleverley J, Piper J, Jones MM. The role of chest radiography in confirming covid-19 pneumonia. BMJ 2020;370:m2426.  Back to cited text no. 10
Ai T, Yang Z, Hou H, Zhan C, Chen C, Lv W, et al. Correlation of chest CT and RT-PCR testing for coronavirus disease 2019 (COVID-19) in China: A report of 1014 cases. Radiology 2020;296:E32-40.  Back to cited text no. 11
Kong W, Agarwal PP. Chest imaging appearance of COVID-19 infection. Radiol Cardiothorac Imaging 2020;2:e200028.  Back to cited text no. 12
Weinstock MB, Echenique A, Russell JW, Leib A, Miller JA, Cohen DJ, et al. Chest X-ray findings in 636 ambulatory patients with COVID-19 presenting to an urgent care center: A normal chest X-ray Is no guarantee. J Urgent Care Med 2020;14:19-21. Available from: https: \\www.jucm.com. [Last accessed on 2021 Nov 14].  Back to cited text no. 13
Wong HY, Lam HY, Fong AH, Leung ST, Chin TW, Lo CS, et al. Frequency and distribution of chest radiographic findings in patients positive for COVID-19. Radiology 2020;296:E72-8.  Back to cited text no. 14
Letellier A, Gibelin A, Voiriot G, Fartoukh M, Djibré M. Destructive pulmonary fibrosis after severe COVID-19 pneumonia. Int J Infect Dis 2020;100:377-8.  Back to cited text no. 15
Rogliani P, Calzetta L, Coppola A, Puxeddu E, Sergiacomi G, D'Amato D, et al. Are there pulmonary sequelae in patients recovering from COVID-19? Respir Res 2020;21:286.  Back to cited text no. 16
Lomoro P, Verde F, Zerboni F, Simonetti I, Borghi C, Fachinetti C, et al. COVID-19 pneumonia manifestations at the admission on chest ultrasound, radiographs, and CT: Single-center study and comprehensive radiologic literature review. Eur J Radiol 2020;7:100231.  Back to cited text no. 17
Lawal Y, Hikima MS, Suwaid MA, Saleh MK, Ismail A, Yahuza MA, et al. Radiographic manifestations of COVID-19: Initial experience from an epicentre in North-Western Nigeria. J Rad Med Trop 2020;1:61-6.  Back to cited text no. 18
Attiah K. Africa Has Defied the COVID-19 Nightmare Scenarios: We Shouldn't Be Surprised. The Washington Post; September 22, 2020.  Back to cited text no. 19
Usman AB, Ayinde O, Akinyode A, Gbolahan A, Bello B. Epidemiology of coronavirus disease 2019 (COVD-19) outbreak cases in Oyo State South West Nigeria, March-April 2020. Pan Afr Med J 2020;35:88.  Back to cited text no. 20
Percivale I, Danna PS, Falasci Z, Berardo S, Gangi S, Tricca S. Men and women affected by Sars-CoV-2 pneumonia: Same CT features but different outcome. Clin Radiol 2021;76:235.e25-34.  Back to cited text no. 21
Salehi S, Abedi A, Balakrishnan S, Gholamrezanezhad A. Coronavirus disease 2019 (COVID-19): A systematic review of imaging findings in 919 patients. AJR Am J Roentgenol 2020;215:87-93.  Back to cited text no. 22
Li Y, Xia L. Coronavirus disease 2019 (COVID-19): Role of chest CT in diagnosis and management. AJR Am J Roentgenol 2020;214:1280-6.  Back to cited text no. 23
Ibrahim OR, Suleiman BM, Sanda A, Oloyede T, Bello SO, Bello UI, et al. COVID-19 in children: A case series from Nigeria. Pan Afr Med J 2020;35:53.  Back to cited text no. 24


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Materials and Me...
Article Figures
Article Tables

 Article Access Statistics
    PDF Downloaded101    
    Comments [Add]    

Recommend this journal