Most COVID-19-Positive Children Have Negative Chest CT Scans

8-year-old boy with coronavirus disease. A, Unenhanced chest CT scans show minimal ground-glass opacities (in right lower and left upper lobes) (arrows) and no consolidation. Only two lobes were affected, and CT findings were assigned CT severity score of 2. Courtesy: American Journal of Roentgenology

Most children who are confirmed positive for COVID-19 with the RT-PCR test have chest CT scans that show no findings of viral infection, according to newly published research.

In the American Journal of Roentgenology, a research team, led by Sharon Steinberger, M.D., cardiothoracic imaging fellow at Icahn School of Medicine at Mount Sinai, revealed that 77 percent of children who have laboratory-confirmed disease also have negative chest CT scans. These findings cast doubt on the true usefulness of these images in identifying and managing patients positive for viral infection.

“Our early study investigating pediatric patients with known infection raises questions about the widespread utilization of chest CT in children,” the team wrote, noting this study is the largest series to date that describes imaging findings in children. “Our findings show the limited sensitivity and poor negative predictive value of chest CT for the detection of suspected COVID-19 in children and highlight that normal chest CT findings do not exclude disease.”

Currently, children – patients ages 18 and under – account for 2 percent of reported cases, and they present with milder symptoms than adults. In fact, 30 percent of the cohort had no clinical symptoms at the time of diagnosis, making their cases simultaneously harder to recognize and more critical to diagnose. The team did discover that older children had more severe CT scores.

To determine the efficacy and reliability of chest CT scans in children with suspected viral infection, Steinberger’s team analyzed images from 30 pediatric patients between the ages of 10 months and 18 years who had RT-PCR-positive test results. The children were treated in six hospitals in China between Jan. 23, 2020, and Feb. 8, 2020. All remained in stable condition during their hospitalization.

The Results

Based on the study analysis, 23 patients – 77 percent – had normal CT findings with no evidence of ground-glass opacities or consolidation. Among the seven who had abnormal scans, six (86 percent) had ground-glass opacities alone, and one had ground-glass opacities and consolidation. Crazy waving pattern, reverse halo sign, and halo sign were identified in two patients each (29 percent). In addition, six patients also had peripheral lung distribution.

Lower lobes were most commonly involved, affecting six of the seven patients, and most (71 percent) had bilateral disease. Two (29 percent) had opacities in one lobe; three (43 percent) in two lobes; one (14 percent) in three lobes; and one in four lobes.

Follow-up scans did not improve CT performance, the team said. Ten out of 11 patients scanned again showed no change in their findings.

What It Means

The high inaccuracy rate of the scans, coupled with the fact that these findings are not specific to COVID-19, should give providers pause about the actual diagnostic and disease management utility of the images, the team said.

“For children with suspected infection, but without suspicion of complication, in light of the low sensitivity of CT, its benefits may not outweigh the potential harm of radiation exposure,” the team said. “However, when these findings are encountered in a pediatric patient who has a suspicious clinical history or lives in an area with a high prevalence of COVID-19, they should alert the radiologist to consider a diagnosis of COVID-19.”

Providers should also consider the lower incidence of severe disease in children when deciding whether to order a chest CT, they said. It is important to note, though, that CT can be used to effectively assess possible complications, including other infections, pulmonary emboli, or other pre-existing conditions that might be negatively impacted by the virus.

Ultimately, they said, even though more research is needed to fully elucidate clinical symptoms and imaging findings associated with COVID-19, their findings highlight the need for radiologists to understand how COVID-19 affects the pediatric population.

“Recognizing the common CT pattern and distribution of findings of COVID-19 in children is crucial for prompt isolation and disease containment. Although children had milder symptoms overall, severe cases do occur in the pediatric population, and deaths have been reported,” the team said. “Identifying these patterns and signs can help radiologists to distinguish COVID-19 pneumonia from other diseases.”