Differential Diagnosis of New-Onset Pulmonary Ground Glass Changes During the COVID-19 Pandemic: a Case Report

The paper describes a clinical case of hypersensitivity pneumonitis in a young patient during the COVID-19 pandemic when the patient having complaints of dyspnea and interstitial lung changes as ground glass opacity was initially unambiguously diagnosed with viral COVID-related bilateral pneumonia. The chief computed tomography manifestations in the lung were infiltrative inflammatory changes as numerous areas of predominantly interstitial infiltration by the type of ground glass, with consolidation areas and reticular changes, varying in extent, peripheral localization, mainly in the lower lobes and with the 25–50% involvement of the right and left lung parenchyma. The diagnosis of hypersensitivity pneumonitis was confirmed by cytological and histological examinations of the biopsy material obtained during bronchoscopy using a set of biopsies and endobronchial cryobiopsy.
This clinical case demonstrates that the chest computed tomography detection of pulmonary ground glasstype changes is a reason for further patient examinations and requires morphological verification of the diagnosis, since the cost of a diagnostic error is the life of a patient.

1. Temporary methodical recommendations. Prevention, diagnosis and treatment of new coronavirus infection (COVID-19). Version 7 (03.06.20). URL: https://static-0.rosminzdrav.ru/system/attachments/attaches/000/050/584/original/03062020_%D0%9CR_COVID-19_v7.pdf (accessed December 13, 2020) (in Russian).

2. Morozov S., Prozenko DN, Smetanina SV, Andreychenko АЕ, Ambrosi ОЕ, Balanyuk EА, et al. Radiation diagnostics of coronavirus disease (COVID-19): organization, methodology, interpretation of results. Version 2 (17.04.2020). Мoscow; 2020 (in Russian).

3. Temporary methodical recommendations. Prevention, diagnosis and treatment of new coronavirus infection (COVID-19). Version 8 (03.09.2020). URL: https://static-0.minzdrav.gov.ru/system/attachments/attaches/000/051/777/original/030902020_COVID-19_v8.pdf (accessed 13.12.2020) (in Russian).

4. Khristenko EA, von Stackelberg O, Kauczor HU, Layer G, Rieden TB. CT-patterns in COVID-19 associated pneumonia – unification of radiological reports based on glossary of Fleischner Society. Russian Electronic Journal of Radiology. 2020; 10(1): 16–26 (in Russian). doi: 10.21569/2222-7415-2020-10-1-16-26

5. Speranskaya AA. Radiological signs of a new coronavirus infection COVID-19. Diagnostic Radiology and Radiotherapy. 2020; 11(1): 18–25 (in Russian). doi: 10.22328/2079-5343-2020-11-1-18-25

6. Lin X, Gong Z, Xiao Z, Xiong J, Fan B, Liu J. Novel coronavirus pneumonia outbreak in 2019: computed tomographic findings in two cases. Korean J Radiol. 2020; 21(3): 365–8. doi: 10.3348/kjr.2020.0078

7. Xie X, Zhong Z, Zhao W, Zheng C, Wang F, Liu J. Chest CT for typical coronavirus disease 2019 (COVID-19) pneumonia: relationship to negative RT-PCR testing. Radiology. 2020; 296(2). doi: 10.1148/radiol.2020200343

8. Pan F, Ye T, Sun P, Gui S, Liang B, Li L, et al. Time course of lung changes on chest CT during recovery from 2019 novel coronavirus (COVID-19) pneumonia. Radiology. 2020; 295(3). doi: 10.1148/radiol.2020200370

9. Lei J, Li J, Li X, Qi X. CT imaging of the 2019 novel coronavirus (2019-nCoV) pneumonia. Radiology. 2020; 295(1). doi: 10.1148/radiol.2020200236

10. Chung М, Bernheim А, Mei Х, Zhang N, Huang M, Zeng X, et al. CT imaging features of 2019 novel coronavirus (2019-nCoV). Radiology. 2020; 295(1). doi: 10.1148/radiol.2020200230

11. Makar’yants NN, Amansakhedov RB, Lepekha LN, Semenova AK, Shmelev EI, Dem’yanenko NG. Clinical and radiological features of various variants of extrinsic allergic alveolitis. Journal of Radiology and Nuclear Medicine. 2019; 100(3): 136–44 (in Russian). doi: 10.20862/0042-4676-2019-100-3-136-144

12. Aver’yanov АV (Ed.) Rare lung diseases. Мoscow: МIA; 2016 (in Russian).

13. Pan Y, Guan H, Zhou S, Wang Y, Li Q, Zhu T, et al. Initial CT findings and temporal changes in patients with the novel coronavirus pneumonia (2019-nCoV): a study of 63 patients in Wuhan, China. Eur Radiol. 2020; 30(6): 3306–9. doi: 10.1007/s00330-020-06731-x

14. Ai T, Yang Z, Hou H, Zhan C, Chen C, Lv W, et al. Correlation of chest CT and RT-PCR testing in coronavirus disease 2019 (COVID-19) in China: a report of 1014 cases. Radiology. 2020; 296(2): E32–40. doi: 10.1148/radiol.2020200642

15. Al-Tawfiq JA, Memish ZA. Diagnosis of SARS-CoV-2 infection based on CT scan vs RT-PCR: reflecting on experience from MERS-CoV. J Hosp Infect. 2020; 105(2): 154–5. doi: 10.1016/j.jhin.2020.03.001

16. Araujo-Filho JAB, Sawamura MVY, Costa AN, Cerri GG, Nomura CH. COVID-19 pneumonia: what is the role of imaging in diagnosis? J Bras Pneumol. 2020; 46(2): e20200114. doi: 10.36416/1806-3756/e20200114