Imaging of Covid 19 infection in children

Imaging of Covid 19 infection in children

Dr. Paolo Tomà

Head of Imaging Department

Bambino Gesù Children’s Hospitals

Background

Classic CXR and CT appearences of COVID-19 described in adults

Literature on chest imaging of children with COVID-19 is limited

CT widely used in adults, & in children in some centres

Children with COVID-19 experience milder illness than adults

• New studies: higher than previously recognized rate of severe illness and MIS-C in pediatric COVID-19

• Infants (< 1yr) more vulnerable to severe infection

Royal College of Physicians. Every breath we take: the lifelong impact of air pollution. Report of a working party. London: RCP, 2016.

Due to immature lung anatomy & developing immune system, pediatric patients are often particularly susceptible

COVID-19 Chest Pediatric Imaging Pubblications

Small sample size

CT CXR

Consolidation 35%

Collapse 3%

PeriBronchial thickening

51%

Hyperexpansion 7%

Effusion 4%

Chlamydia

Acute Pediatric COVID-19: CT

3 Phases

Early: "Halo" sign

Local infection

Progressive: Diffuse GGO

Developed: Consolidation

Surr vasc congestion

Inflammation - adj alveoli

Alveoli fill with fluid/cells

Early: "Halo" sign

Apicale sinistraa Medio -Basale sinistra

Basale sinistra Basale sinistra

Lung Disorders CXR

COVID 19

• Patchy bilateral GGO, Consolidations or both

• Peripheral and lower lung zone predominance

H1N1

• Bilateral & hyperinflation (early)

• GGO +/- consolidation

• Bilateral, central, & symmetric distribution

EVALI

• Bilateral multifocal GGO consolidation or both

• Lower lung zone predominance

CT

• Bilateral & multifocal GGO, +/Consolidations or both

• Halo sign

• Peripheral and subpleural

• Bronchovascular thickening

• GGO +/- consolidation

• Central lung predominance

Helpful Imaging Features

• Halo sign (Early)

CMV

Adenovirus

• Bilateral & symmetric GGO +/consolidation

• Subpleural sparing

• Atoll sign

• Diffuse

• Consolidation

• GGO

• Nodules

• Multifocal

• Consolidation

• GGO

• Centrilobular Nodules

Varicella zoster virus

• Multifocal

• Surrounding halo GGO

• 1–10 mm (in late phase, calcification)

Influenza

• Hyperinflation

• Bronchovascular thickening (early)

• GGO +/- consolidation (later)

• Central

• Subpleural spacing

• Atoll sign

RSV

• Airway, multifocal

• Consolidations

• GGO

• Nodules

• Bronchial Wall Thickening

• Airway, multifocal

• Centrilobular Nodules

• Bronchial Wall Thickening

Lung Disorders CXR CT Helpful Imaging Features

COVID 19

• Patchy bilateral GGO, Consolidations or both

• Bilateral & multifocal GGO, +/Consolidations or both

• Halo sign (Early)

COVID 19

H1N1

EVALI

CMV

Adenovirus

Varicella zoster virus

Influenza

RSV

• Peripheral and lower lung zone predominance

• Bilateral & hyperinflation (early)

• GGO +/- consolidation

• Patchy bilateral GGO, Consolidations or both

• Bilateral, central, & symmetric distribution

• Bilateral multifocal GGO consolidation or both

• Lower lung zone predominance

• Peripheral and lower lung zone predominance

• Halo sign

• Peripheral and subpleural

• Bronchovascular thickening

• GGO +/- consolidation

• Central lung predominance

• Bilateral & multifocal GGO, +/Consolidations or both

• Halo sign

• Bilateral & symmetric GGO +/consolidation

• Halo sign (Early)

• Hyperinflation

• Bronchovascular thickening (early)

• GGO +/- consolidation (later)

• Central

• Subpleural spacing

• Atoll sign

• Subpleural sparing

• Atoll sign

• Peripheral and subpleural

• Diffuse

• Consolidation

• GGO

• Nodules

• Multifocal

• Consolidation

• GGO

• Centrilobular Nodules

• Multifocal

• Surrounding halo GGO

• 1–10 mm (in late phase, calcification)

• Airway, multifocal

• Consolidations

• GGO

• Nodules

• Bronchial Wall Thickening

• Airway, multifocal

• Centrilobular Nodules

• Bronchial Wall Thickening

Imaging of Covid 19 infection in children

Lung Disorders CXR

COVID 19

• Patchy bilateral GGO, Consolidations or both

• Peripheral and lower lung zone predominance

EVALI

CT

• Bilateral & multifocal GGO, +/Consolidations or both

• Halo sign

• Peripheral and subpleural

• Bilateral multifocal GGO consolidation or both

• Lower lung zone predominance

H1N1

• Bilateral & symmetric GGO +/- consolidation

• Subpleural sparing

• Atoll sign

Helpful Imaging Features

• Halo sign (Early)

CMV

• Bilateral & hyperinflation (early)

• GGO +/consolidation

• Bilateral, central, & symmetric distribution

• Bronchovascular thickening

• GGO +/- consolidation

• Central lung predominance

• Subpleural spacing

• Atoll sign

• Diffuse

• Consolidation

• GGO

• Nodules

• Hyperinflation

• Bronchovascular thickening (early)

• GGO +/consolidation (later)

• Central

EVALI

E-cigarette, or Vaping, product use–Associated Lung Injury

Lung

COVID 19

• Patchy bilateral GGO, Consolidations or both

• Peripheral and lower lung zone predominance

Adenovirus

Helpful Imaging Features

• Bilateral & multifocal GGO, +/Consolidations or both

• Halo sign

• Peripheral and subpleural

• Multifocal

• Consolidation

• GGO

• Centrilobular Nodules

Varicella

zoster virus

• Multifocal

• Surrounding halo GGO

• 1–10 mm (in late phase, calcification)

Influenza

• Halo sign (Early)

RSV

• Airway, multifocal

• Consolidations

• GGO

• Nodules

• Bronchial Wall Thickening

• Airway, multifocal

• Centrilobular Nodules

• Bronchial Wall Thickening

ADENOVIRUS

Bronchiolar and alveolar damage

Chickenpox

Pediatric COVID-19: MIS-C (Multisystem inflammatory syndrome –Covid)

• Serious condition where different body parts can be inflamed

• Characterized by severe, febrile inflammatory illness

• Elevated inflammatory markers

• "Cytokine storm

• 2 - 4 weeks after infection or exposure

• 80 - 100% + SARS-CoV-2 antibodies

• School-age children

Inflammatory Syndrome in Children in the Context of Global SARS

CoV-2 Pandemic, Volume: 142, Issue: 5, Pages: 429-436, DOI: (10.1161/CIRCULATIONAHA.120.048360)

© 2020 American Heart Association, Inc.

CF ARDS Emboli

MIS-C Main signs

Pediatric COVID-19: MIS-C

Thoracic abnormalities

Cardiovascular abnormalities

Cardiomegaly

CHF or cardiogenic edema

Pulmonary parenchymal abnormalities

Lower lobe atelectasis

Bilateral opacities( ARDS)

Consolidation

Pleural abnormalities

Small pleural effusion

Mediastinal and hilar lymphadenopathy

Abdominal abnormalities

Solid viscera abnormalities

Hepatomegaly

Echogenic kidneys

Splenomegaly

Hollow viscera abnormalities

Gallbladder wall thickening

Bowel wall thickening

Bowel dilation

Gastric distention

Urinary bladder thickening

Peritoneal abnormalities

Small ascites

Mesenteric abnormalities

Mesenteric lymphadenopathy

Intramural lymphocytic infiltrate

Chilblain-like lesions

19 cases

El Hachem JDV 2020

Perineural dermal inflammatory infiltrate

Thrombus

MIS-C Embolism

Imaging of Covid 19 infection in children

MIS-C: Heart failure

Imaging of Covid 19 infection in children

• Gastrointestinal (GI) symptoms (abdominal pain, diarrhoea and vomiting) are prevalent in MIS-C

• Abdominal pain in 62%

• Up to 90% any GI symptom

• Anumber of studies have described abdominal imaging findings including ascites, bowel wall thickening and mesenteric lymphadenopathy

Pediatric COVID-19

Relapsing Polychondritis