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| ORIGINAL ARTICLE |
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| Year : 2021 | Volume
: 2
| Issue : 2 | Page : 55-60 |
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Plain chest radiographic findings among COVID-19 patients in sub-saharan Africa
Donald Amasike Nzeh, Hadijat Oluseyi Kolade-Yunusa, Ibrahim Shalangwa, Bisallah Ahmed Ekele, Felicia Anumah, Udugh Isaac, Paul Ogbonyomi, Thairu Yunusa, Vivian Gga Kwaghe, Zaiyad Habib, Alexander Agada Akor, Anthony Bawa, Francis Adebayo, Godwin Idoko, Olusegun Akintola
Department of Radiology, University of Teaching Hospital, Abuja, Nigeria
| Date of Submission | 12-Feb-2021 |
| Date of Decision | 05-Jun-2021 |
| Date of Acceptance | 28-Sep-2021 |
| Date of Web Publication | 30-Nov-2021 |
Correspondence Address:
Donald Amasike Nzeh
Department of Radiology, University of Abuja Teaching Hospital, Abuja
Nigeria
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jrmt.jrmt_4_21
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 | |  |
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 | | |
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 | | |
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].
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].
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].
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].
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.
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.
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
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 | 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
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 | 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
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 | Figure 4: Chest radiograph of a 60-year-old coronavirus disease-19 patient showing moderate interstitial pneumonia with predominantly basal and peripheral distribution
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 | 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
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 | 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
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| Discussion | | |
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 | | |
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.
Acknowledgments
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
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
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