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Severe Acute Respiratory Syndrome: Prognostic Implications of Chest Radiographic Findings in 52 Patients¹

¹ From the Department of Radiology (S.F.K., T.Y.L., C.C.H., Y.F.C., S.H.N., Y.L.K.), Department of Internal Medicine, Divisions of Pulmonary and Critical Care Medicine (M.C.L.) and Infectious Diseases (J.W.L.), Department of Medical Research (K.D.Y.), Department of Public Health and Biostatistics (M.C.C.), and Department of Surgery (C.L.C.), Chang Gung University, Chang Gung Memorial Hospital at Kaouhsiung, 123 Ta-Pei Rd, Niao-Sung Hsiang, Kaohsiung Hsien 833, Taiwan. Received September 24, 2003; revision requested December 4; revision received December 11; accepted January 30, 2004. Address correspondence to S.F.K. (e-mail: sfatko@adm.cgmh.org.tw).

View larger version (142K): [in a new window]   Figure 1a. Category I SARS-related lesion. Serial radiographic changes in a 26-year-old man with SARS. (a) Frontal chest radiograph obtained 2 days after fever onset shows a somewhat nodular air-space opacity (arrow) involving one-third of the right upper lung zone (category I, extent score of 1). (b) Follow-up frontal chest radiograph obtained 7 days later shows maximal progression of the opacity (arrows) to involve less than two-thirds of the right upper lung zone (category I, extent score of 2). The patient recovered 6 days later.

View larger version (146K): [in a new window]   Figure 1b. Category I SARS-related lesion. Serial radiographic changes in a 26-year-old man with SARS. (a) Frontal chest radiograph obtained 2 days after fever onset shows a somewhat nodular air-space opacity (arrow) involving one-third of the right upper lung zone (category I, extent score of 1). (b) Follow-up frontal chest radiograph obtained 7 days later shows maximal progression of the opacity (arrows) to involve less than two-thirds of the right upper lung zone (category I, extent score of 2). The patient recovered 6 days later.

View larger version (145K): [in a new window]   Figure 2a. Initial SARS-related lesion distribution of category II and maximal category III serial radiographic changes in a 28-year-old woman with SARS. (a) Frontal chest radiograph obtained 6 days after fever onset shows a focal air-space opacity (solid arrow) involving less than one-third of the left lower lung zone. Note partial obliteration of the right upper heart border (open arrow) by adjacent air-space opacity, involving less than one-third of the right middle lung zone (category II, extent score of 2). (b) Follow-up chest radiograph obtained 5 days later shows maximal progression of the lesions with extension of air-space opacity (solid arrow) involving more than two-thirds of the left lower lung zone and less than one-third of the right middle and lower lung zones (open arrows) (category III, extent score of 5). The patient recovered 11 days later.

View larger version (136K): [in a new window]   Figure 2b. Initial SARS-related lesion distribution of category II and maximal category III serial radiographic changes in a 28-year-old woman with SARS. (a) Frontal chest radiograph obtained 6 days after fever onset shows a focal air-space opacity (solid arrow) involving less than one-third of the left lower lung zone. Note partial obliteration of the right upper heart border (open arrow) by adjacent air-space opacity, involving less than one-third of the right middle lung zone (category II, extent score of 2). (b) Follow-up chest radiograph obtained 5 days later shows maximal progression of the lesions with extension of air-space opacity (solid arrow) involving more than two-thirds of the left lower lung zone and less than one-third of the right middle and lower lung zones (open arrows) (category III, extent score of 5). The patient recovered 11 days later.

View larger version (120K): [in a new window]   Figure 3a. Serial radiographic changes in a 45-year-old man with SARS with initial category III and maximal category VI distribution of SARS-related lesions. (a) Frontal chest radiograph obtained 2 days after fever onset shows air-space opacities involving less than one-third of the bilateral middle and left upper lung zones (arrows) (category III, extent score of 3). (b) Follow-up chest radiograph obtained 3 days later shows marked progression of the SARS-related opacities (arrows) in both lungs, involving more than two-thirds of the bilateral middle lung, less than two-thirds of the bilateral upper lung, and less than one-third of the bilateral lower lung. (category VI, extent score of 12). The patient died 6 days later.

View larger version (118K): [in a new window]   Figure 3b. Serial radiographic changes in a 45-year-old man with SARS with initial category III and maximal category VI distribution of SARS-related lesions. (a) Frontal chest radiograph obtained 2 days after fever onset shows air-space opacities involving less than one-third of the bilateral middle and left upper lung zones (arrows) (category III, extent score of 3). (b) Follow-up chest radiograph obtained 3 days later shows marked progression of the SARS-related opacities (arrows) in both lungs, involving more than two-thirds of the bilateral middle lung, less than two-thirds of the bilateral upper lung, and less than one-third of the bilateral lower lung. (category VI, extent score of 12). The patient died 6 days later.

View larger version (135K): [in a new window]   Figure 4a. SARS-related lesion with shifting. Serial radiographic changes in a 26-year-old woman with SARS. (a) Frontal chest radiograph obtained 8 days after fever onset shows a large air-space opacity (arrows) confined to the right middle lung. (b) Follow-up chest radiograph obtained 5 days later shows marked regression of the original air-space opacity (solid arrow) but development of a laterally located new opacity (open arrow). The patient recovered 6 days later.

View larger version (130K): [in a new window]   Figure 4b. SARS-related lesion with shifting. Serial radiographic changes in a 26-year-old woman with SARS. (a) Frontal chest radiograph obtained 8 days after fever onset shows a large air-space opacity (arrows) confined to the right middle lung. (b) Follow-up chest radiograph obtained 5 days later shows marked regression of the original air-space opacity (solid arrow) but development of a laterally located new opacity (open arrow). The patient recovered 6 days later.

View larger version (19K): [in a new window]   Figure 5a. (a) Bar graph shows correlation of number of patients with maximal lesion extent score lower than 7 versus lesion distribution categories. Twenty-seven patients who survived and had an extent score lower than 7 belonged to categories I-III, with involvement of three or fewer lung zones. (b) Bar graph shows correlation of number of patients with maximal lesion extent score of 7 or higher versus lesion distribution categories. The patients with a lesion extent score of 7 or higher (25 patients) had a high mortality rate (20 of the 25 died), especially those patients with lesion distributions in categories IV-VI. Note that all three patients with category III lesion distributions who died had thoracic malignancies.

View larger version (20K): [in a new window]   Figure 5b. (a) Bar graph shows correlation of number of patients with maximal lesion extent score lower than 7 versus lesion distribution categories. Twenty-seven patients who survived and had an extent score lower than 7 belonged to categories I-III, with involvement of three or fewer lung zones. (b) Bar graph shows correlation of number of patients with maximal lesion extent score of 7 or higher versus lesion distribution categories. The patients with a lesion extent score of 7 or higher (25 patients) had a high mortality rate (20 of the 25 died), especially those patients with lesion distributions in categories IV-VI. Note that all three patients with category III lesion distributions who died had thoracic malignancies.

View larger version (17K): [in a new window]   Figure 6. Box plot shows percentages of lung involvement area of SARS-related lesions measured on chest radiographs in relation to survival and mortality groups at initial and maximal stages of involvement. Survival and mortality groups had significantly different initial (7.7% ± 5.5 vs 4.0% ± 2.5, P < .007) and maximal (41.5% ± 8.6 vs 16.4% ± 10.0, P < .001) percentages of area of lung involvement. GpM-I = mortality group at initial stage, GpM-M = mortality group at maximal stage, GpS-I = survival group at initial stage, GpS-M = survival group at maximal stage.