Normal Chest X-ray Doesn't Rule Out COVID-19
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Patients presenting at urgent care centers with symptoms that warrant suspicion of COVID-19 may have normal chest X-rays yet still be infected with SARS-CoV-2, according to findings of a study published in the Journal of Urgent Care Medicine (JUCM).

"Providers ordering a chest X-ray in the outpatient setting should be aware that a patient with symptoms of COVID-19 may have a negative chest X-ray and should manage the patient based on their symptoms. Doctors should not be reassured by a negative chest X-ray," said an expert.

Many early imaging studies of COVID-19 used CT to characterize the peculiarities of SARS-CoV-2 infection. However, CT is too costly and cumbersome to be part of a COVID-19 work-up in the urgent care setting. By contrast, chest X-ray is less sensitive, but widely available in urgent care centers and may help with COVID-19 diagnosis.

Therefore, to quantify how often chest X-ray reveals abnormalities consistent with COVID-19 in the urgent care setting, Weinstock and colleagues asked board-certified radiologists to re-read chest X-rays taken at more than 100 urgent care facilities in urban New York and New Jersey between March 9 and March 24.

Eleven radiologists re-read 47 to 100 chest x-rays each, totaling 636 images, from patients who were eventually confirmed to have symptomatic COVID-19. The radiologists who had initially read the films did not know the diagnostic status of the patients because of limited testing in March. The radiologists were instructed to disregard the initial interpretations and to classify each film as indicating normal, mild, moderate, or severe disease.

Of the 636 X-rayed patients, 363 (57.1%) were male. They ranged in age from 18 to 90 years.

Upon second inspection, 371 (58.3%) of the 636 chest X-rays were classified as normal. Of the 265 (41.7%) re-read as abnormal, 195 were classified as mild disease, 65 as moderate, and 5 as severe. That is, 89% (566 of 636) of the scans were re-read as normal or mildly abnormal.

The radiologists who initially read the films had classified a greater percentage as normal — 468 (73.6%) of the 636. The second scrutiny reclassified 97 of the films initially deemed normal as abnormal.

On the chest X-rays, interstitial changes were most common, seen in 151 (23.7%), and ground-glass opacities predominated in 120 (18.9%). The abnormalities were in the lower lobe in 215 (33.8%) of the images, bilateral in 133 (20.9%), and multifocal in 154 (24.2%).

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