COVID on chest X-ray

The recent wave of Covid infections with omicron variant has resulted in a large number of patients presenting to the emergency room and hospital with covid infection.  Many of these patients get preliminary imaging with chest X-ray because of shortness of breath and low oxygen readings in the blood.

The most common finding I have been seeing is mid to lower lung zone and peripheral predominant airspace opacities in those presenting to the emergency room.  These are white fluffy areas in the normally dark lungs.  Some patients have normal looking x rays but than have a chest CT which shows pneumonia.

Chest X-rays do not show all COVID pneumonias.  This is especially true for ground glass pneumonias.  Ground glass on CT means that the pneumonia does not completely white the lung out but is fainter.  These types of pneumonias are also more along the periphery of the lung.  I have seen these progress to denser pneumonias over time.

I have also been seeing more pneumomediastinum and subcutaneous emphysema in this recent wave or infections.  This means that there is spread of air under the skin in the chest and neck.  There is air in the mediastinum or the space between the lungs where the heart and great vessels are.

Some of these patients that get chest CTs show that chest X-ray often underestimates the severity of pneumonia.  Some patients I have seen have more modular or round spots in the lungs.  I have even seen some with cavitation or small air within.

CT also best show the air under the skin and in the mediastinum.  I have also been seeing more pulmonary emboli or clots in the arteries than with previous waves.  Patients also have been showing enlarged lymph nodes in the chest as a response to the infection.

My informal survey of patients show that many are unvaccinated amongst those who present to the ER and hospital with more severe disease.   Vaccines work even with the latest variant.   The newest variant shows many imaging features in common with part variants but some new features as well.

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