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Radiographic-Clinical Correlation in Severe Acute Respiratory Syndrome: Study of 1373 Patients in Hong Kong¹

¹ From the Dept of Diagnostic Radiology and Organ Imaging, Chinese Univ of Hong Kong, Prince of Wales Hosp, Shatin, Hong Kong (G.E.A., A.T.A.); Dept of Diagnostic Radiology, Univ of Hong Kong, Hong Kong (C.G.C.O.); Dept of Diagnostic Radiology and Organ Imaging, Prince of Wales Hosp, Hong Kong (K.T.W.); Statistics and Research Unit (E.L.H.T.), Professional Services and Medical Development Div (J.C.K.C.), Hosp Authority Head Office, Hong Kong; Dept of Radiology, Queen Mary Hosp, Hong Kong (J.S.W.W., A.N.L.S., L.L.Y.L.); Dept of Radiology and Organ Imaging, United Christian Hosp, Hong Kong (J.Y.H.H.); Dept of Diagnostic Radiology and Nuclear Medicine, Tuen Mun Hosp, Hong Kong (C.Y.C.); Dept of Radiology, Tseung Kwan O Hosp, Hong Kong (H.Y.H.H.); and Dept of Radiology, Pamela Youde Nethersole Eastern Hosp, Hong Kong (Y.F.C., T.P.W.). Received Nov 26, 2004; revision requested Jan 31, 2005; revision received Apr 29; accepted May 31. Address correspondence to G.E.A. (e-mail: gregantonio{at}cuhk.edu.hk).

View larger version (155K): [in a new window]   Figure 1a. Selected serial frontal chest radiographs in 44-year-old man with laboratory-confirmed SARS at each of five milestones. (a) On radiograph acquired at admission (first milestone, 3 days after symptom onset), there was an area of opacification in the right lower zone. (b) On radiograph acquired at the start of ribavirin (second milestone, 5 days after symptom onset), a new area of opacification is seen to have developed in the left lower zone. (c) On radiograph acquired at first pulse of corticosteroid (third milestone, 8 days after symptom onset), new involvement of the right upper zone is seen. The other areas of opacification have enlarged and become less well defined. (d) Worst radiograph (fourth milestone, 11 days after symptom onset) shows widespread lung opacification affecting middle and lower zones bilaterally that is worse on the right. (e) Radiograph obtained before hospital discharge (fifth milestone, 24 days after symptom onset) shows that opacification has largely resolved. Reticulations were present in both the middle and lower zones.

View larger version (145K): [in a new window]   Figure 1b. Selected serial frontal chest radiographs in 44-year-old man with laboratory-confirmed SARS at each of five milestones. (a) On radiograph acquired at admission (first milestone, 3 days after symptom onset), there was an area of opacification in the right lower zone. (b) On radiograph acquired at the start of ribavirin (second milestone, 5 days after symptom onset), a new area of opacification is seen to have developed in the left lower zone. (c) On radiograph acquired at first pulse of corticosteroid (third milestone, 8 days after symptom onset), new involvement of the right upper zone is seen. The other areas of opacification have enlarged and become less well defined. (d) Worst radiograph (fourth milestone, 11 days after symptom onset) shows widespread lung opacification affecting middle and lower zones bilaterally that is worse on the right. (e) Radiograph obtained before hospital discharge (fifth milestone, 24 days after symptom onset) shows that opacification has largely resolved. Reticulations were present in both the middle and lower zones.

View larger version (134K): [in a new window]   Figure 1c. Selected serial frontal chest radiographs in 44-year-old man with laboratory-confirmed SARS at each of five milestones. (a) On radiograph acquired at admission (first milestone, 3 days after symptom onset), there was an area of opacification in the right lower zone. (b) On radiograph acquired at the start of ribavirin (second milestone, 5 days after symptom onset), a new area of opacification is seen to have developed in the left lower zone. (c) On radiograph acquired at first pulse of corticosteroid (third milestone, 8 days after symptom onset), new involvement of the right upper zone is seen. The other areas of opacification have enlarged and become less well defined. (d) Worst radiograph (fourth milestone, 11 days after symptom onset) shows widespread lung opacification affecting middle and lower zones bilaterally that is worse on the right. (e) Radiograph obtained before hospital discharge (fifth milestone, 24 days after symptom onset) shows that opacification has largely resolved. Reticulations were present in both the middle and lower zones.

View larger version (134K): [in a new window]   Figure 1d. Selected serial frontal chest radiographs in 44-year-old man with laboratory-confirmed SARS at each of five milestones. (a) On radiograph acquired at admission (first milestone, 3 days after symptom onset), there was an area of opacification in the right lower zone. (b) On radiograph acquired at the start of ribavirin (second milestone, 5 days after symptom onset), a new area of opacification is seen to have developed in the left lower zone. (c) On radiograph acquired at first pulse of corticosteroid (third milestone, 8 days after symptom onset), new involvement of the right upper zone is seen. The other areas of opacification have enlarged and become less well defined. (d) Worst radiograph (fourth milestone, 11 days after symptom onset) shows widespread lung opacification affecting middle and lower zones bilaterally that is worse on the right. (e) Radiograph obtained before hospital discharge (fifth milestone, 24 days after symptom onset) shows that opacification has largely resolved. Reticulations were present in both the middle and lower zones.

View larger version (151K): [in a new window]   Figure 1e. Selected serial frontal chest radiographs in 44-year-old man with laboratory-confirmed SARS at each of five milestones. (a) On radiograph acquired at admission (first milestone, 3 days after symptom onset), there was an area of opacification in the right lower zone. (b) On radiograph acquired at the start of ribavirin (second milestone, 5 days after symptom onset), a new area of opacification is seen to have developed in the left lower zone. (c) On radiograph acquired at first pulse of corticosteroid (third milestone, 8 days after symptom onset), new involvement of the right upper zone is seen. The other areas of opacification have enlarged and become less well defined. (d) Worst radiograph (fourth milestone, 11 days after symptom onset) shows widespread lung opacification affecting middle and lower zones bilaterally that is worse on the right. (e) Radiograph obtained before hospital discharge (fifth milestone, 24 days after symptom onset) shows that opacification has largely resolved. Reticulations were present in both the middle and lower zones.

View larger version (18K): [in a new window]   Figure 2. Graph shows mean chest radiographic (CXR) scores plotted against mean time for each milestone for patients in whom SARS was fatal and those who survived to discharge. The rate of radiographic progression (slope of each curve) for the two outcome groups is roughly parallel over the first 11 days. After this, radiographic scores in the group in whom SARS was fatal continued to deteriorate, whereas the scores in the patients who were discharged improved. The five data points on each curve refer to the five milestones in sequence. The approximate rate of change in radiographic score between the first and fourth milestones (gradient of slope) was calculated as (17.8 – 4.5)/(20.3 – 3.8 days) = 0.75 per day (where 17.8 is the mean total chest radiographic score and 20.3 is the mean number of days since symptom onset) in the patients in whom SARS was fatal and as (7.6 – 2.6)/(11.4 – 4.5 days) = 0.85 per day in the patients who were discharged.

View larger version (27K): [in a new window]   Figure 3. Graph shows mean chest radiographic (CXR) scores and PaO2/FIO2 ratios plotted for five milestones for patients in whom SARS was fatal and those who survived to discharge. The curves for the radiographic scores were roughly mirror images of the respective ones for PaO2/FIO2 ratios. A divergent point between the outcome groups was present at the third milestone. The five data points on each curve refer to the five milestones in sequence. Error bars indicate 95% confidence intervals.

View larger version (26K): [in a new window]   Figure 4. Graph shows mean chest radiographic (CXR) scores and lymphocyte count plotted for five milestones for patients in whom SARS was fatal and those who survived to discharge. The curves for the radiographic scores were roughly mirror images of the respective ones for lymphocyte count. A divergent point between the outcome groups was present at the third milestone. The five data points on each curve refer to the five milestones in sequence. Error bars indicate 95% confidence intervals.

View larger version (26K): [in a new window]   Figure 5. Graph shows mean chest radiographic (CXR) score and LDH level (as the ratio of LDH to its upper reference limit) plotted for five milestones for patients in whom SARS was fatal and those who survived to discharge. The curves for the radiographic scores showed temporal trends that were similar to the ones shown by the respective curves for LDH level. A divergent point between the outcome groups was present at the third milestone. The five data points on each curve refer to the five milestones in sequence. Error bars indicate 95% confidence intervals.

View larger version (26K): [in a new window]   Figure 6. Graph shows mean chest radiographic (CXR) scores and neutrophil count plotted for five milestones for patients in whom SARS was fatal and those who survived to discharge. The curves for the radiographic scores showed temporal trends that were similar to the ones shown by the respective curves for neutrophil count. A divergent point between the outcome groups was present at the third milestone. The five data points on each curve refer to the five milestones in sequence. Error bars indicate 95% confidence intervals.

View larger version (84K): [in a new window]   Figure 7. Chart shows that an increasing and linear trend for the mortality rate was seen for the radiographic scores. When 10% mortality rate increments are arbitrarily used as cutoffs for mortality rate zones, the "safety margin" is seen to shift with time. More extensive lung opacification indicated a worse prognosis earlier in the disease than later. N = number of patients. Green indicates mortality rates between 0% and 10%; yellow, mortality rates between 10.1% and 20%; pink, mortality rates between 20.1% and 30%; and blue, mortality rates between 30.1% and 100%.