False negative chest X-Rays in patients affected by COVID-19 pneumonia and corresponding chest CT findings

Abstract

Due to the wide availability, rapid execution, low cost, and possibility of being acquired at the patient's bed, chest X-Ray is a fundamental tool in the diagnosis, follow-up and evaluation of the treatment effectiveness of patients with pneumonia, also in the context of COVID-19 infection. However, false negative cases are possible. We report 4 cases of false negative chest X-Rays, in patients who were diagnosed positive for COVID-19 by real-time transverse-transcript-polymerase chain reaction (RT-PCR), and executed chest unenhanced CTs just after the X-Rays, demonstrating signs of COVID-19 pneumonia.

Keywords: COVID-19; Multidetector computed tomography; Pneumonia; Radiography; Severe acute respiratory syndrome coronavirus 2; Viral.

Figure 1

Posteroanterior (Fig. 1A) and lateral (Fig. 1B) projections of the chest X-Ray of a thirty-seven-year-old male colleague, who presented to our Emergency Department with cough and fever up to 39° for 2 days. Chest X-Ray did not demonstrate any lung abnormalities. Chest CT executed just after the X-Ray, showed the presence of a crazy paving area in the right posterior costophrenic recess with mild pleural effusion (Fig. 1C). A small subpleural area of GGO is located anteriorly in the upper right lobe (Fig. 1D).

Figure 2

Posteroanterior (Fig. 2A) and lateral (Fig. 2B) projections of the chest X-Ray of a thirty-seven-year-old female colleague, who presented with cough and fever. Chest X-Ray did not demonstrate any lung abnormalities. Chest CT executed just after the X-Ray, showed an area of crazy paving in the left posterior costophrenic recess (Fig. 2B); patchy GGOs are also bilaterally recognizable (Fig. 2B and C).

Figure 3

Posteroanterior (Fig. 3A) and lateral (Fig. 3B) projections of the chest X-Ray of a thirty-three-year-old nurse, who presented with cough and fever. Chest X-Ray was reported as negative; at a review, a slight thickening of the bronchovascular bundles could be observed at the lower right field. Chest CT executed just after the X-Ray, showed an extensive consolidation, with a peripheral posterior location in the right lower lobe, and some patchy GGOs with lateral peripheral distribution (Fig. 3C).

Figure 4

Posteroanterior (Fig. 4A) and lateral (Fig. 4B) projections of the chest X-Ray of a fifty-six-year-old woman, who presented with chest pain, cough, dyspnoea, and fever. Chest CT demonstrated an area of crazy paving pattern, posteriorly located in the lower left lobe (Fig. 4C).