key: cord-0720100-flg2nhjk
authors: Zieleskiewicz, Laurent; Duclos, Gary; Dransart-Rayé, Ophélie; Nowobilski, Nicolas; Bouhemad, Belaid
title: Ultrasound findings in patients with COVID-19 pneumonia in early and late stages: Two case-reports
date: 2020-05-04
journal: Anaesth Crit Care Pain Med
DOI: 10.1016/j.accpm.2020.04.015
sha: 2acceb1dab1ee254054de41f41a6685d2c24f982
doc_id: 720100
cord_uid: flg2nhjk

nan

Morphology assessment of COVID-19 pneumonia may be crucial for its diagnosis and management. Chest computed tomography (CT) scan has high diagnostic accuracy and may be associated with patient clinical condition [1] . However, during a pandemic the safe use of CT is questionable. Given its characteristics, CT scan cannot be considered as a screening tool (too wide target population) or a monitoring tool (intra hospital transfer, radiation, availability).

Lung ultrasound (LUS) has been validated for the diagnosis and the management of acute respiratory failure, pneumonia, [2] even during viral pandemic [3] . LUS has high diagnostic accuracy for interstitial syndrome and alveolar consolidations, which are the commonest radiological signs of COVID-19 pneumonia. [4] Moreover, preliminary reports are in favour of a predominant involvement of the pulmonary periphery, which could reinforce LUS interest in the actual pandemic.

Here we described two cases of confirmed COVID-19 patients at early and late stages of the disease. We compared the CT scan and ultrasound features performed at the same time.

In a 70-year-old woman, at admission, CT scan showed the typical pattern of COVID-19 with peripheral ground-glass opacities that were bilateral and multilobar (Fig 1A and 1B) .

Ground-glass opacities appear as coalescent B-line areas and are associated with irregularities of pleural line (white arrows, Fig 1A, 1B and Fig 1C) . This pattern alternates with normal area.

Nodular or mass-like ground-glass opacities can also reach the periphery and be depicted as small consolidation in subpleural areas (red arrows, Fig 1A, 1B and Fig 1D, 1E ) or consolidation (yellow arrows, Fig 1A, 1B and Fig 1E) .

A 65-year-old male, after 25 days of mechanical ventilation for acute respiratory distress syndrome, developed on the CT scan fibrosis (Fig 2A, 2B) consisting on subpleural fibrosis, honeycombing, traction bronchiectasis with anterior distribution and thickened interlobular septal [5] . These abnormalities using LUS were reported as irregularities of pleural line associated with coalescent B-lines (red arrows Fig 2A and Fig 2C, 2D ) or multifocal subpleural consolidation (red arrows, Fig 2C,D) . Thickened interlobular septal seen as regularly spaced B-lines (yellow arrows Fig 2E) combined with thickened pleural line allows the visualisation of secondary pulmonary lobules (white arrow; Fig 2E) . Thickened interlobular septal and small subpleural consolidations evidenced the major fissure (red arrows Fig 2B and   2E ).

These two suggestive cases underline the potential of LUS for COVID-19 pneumonia assessment at different stages of the disease. Even if all LUS signs are not specific, presence of these various pattern in a clinical context is very suggestive of viral pneumonia. Thus LUS, when the clinical context is evocative, may help physicians to identify COVID-19 patients. After a proper validation of LUS against chest CT scan, one can believe that LUS could serve as a diagnostic and a triage tool detecting at risk patients, thus allowing a better allocation of ICU resources as previously described in another context [6] . Finally, it seems important to underline that LUS should also be associated with multiorgan point of care ultrasound. In particular, COVID-19 infection is associated with myocarditis and an elevated incidence of thromboembolic events. Thus, multiorgan point of care ultrasound could therefore be of high 

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