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| LETTER TO THE EDITOR |
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| Year : 2021 | Volume
: 19
| Issue : 4 | Page : 302-303 |
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Pulmonary nodules on chest imaging - An uncommon finding of pediatric COVID-19 pneumonia
Thirunavukkarasu Arun Babu1, Prudhvinath Annapureddy Reddy2
1 Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Mangalagiri, Andhra Pradesh, India
2 Department of Radiodiagnosis, All India Institute of Medical Sciences (AIIMS), Mangalagiri, Andhra Pradesh, India
| Date of Submission | 26-Apr-2021 |
| Date of Decision | 10-Jul-2021 |
| Date of Acceptance | 15-Jul-2021 |
| Date of Web Publication | 07-Dec-2021 |
Correspondence Address:
Dr. Thirunavukkarasu Arun Babu
Departments of Pediatrics, All India Institute of Medical Sciences (AIIMS), Mangalagiri, Andhra Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/cmi.cmi_43_21
How to cite this article:
Babu TA, Reddy PA. Pulmonary nodules on chest imaging - An uncommon finding of pediatric COVID-19 pneumonia. Curr Med Issues 2021;19:302-3 |
Children account for a small proportion of total COVID-19 cases ranging from 1% to 15%.[1] Around 90% of children with COVID-19 were either asymptomatic or had mild-to-moderate disease and only less than 5% had severe disease.[1] Chest imaging plays a vital role not only in diagnosing COVID-19 pneumonia but also in monitoring disease progression and evaluating therapeutic response. However, radiological findings are milder and less specific in children.[2],[3] We report an 11-year-old male child with COVID-19 pneumonia who presented with atypical findings on chest imaging.
An 11-year-old male child presented with fever, cough, cold, and respiratory distress for 3 days duration. His father was recently diagnosed as coronavirus disease (COVID-19) positive. The child was developmentally normal and had no prior history of any respiratory disease. Examination revealed a febrile, tachypneic child with SpO2 of 94% in room air. His pulse was 106/min and respiratory rate was 34/min. Nasopharyngeal swab test for COVID-19 by reverse transcription polymerase chain reaction came as positive. Chest X-ray showed perihilar bronchial wall thickening, bilateral small parenchymal nodules, and lower zone opacification [Figure 1]. Ultrasound chest revealed left-sided minimal pleural effusion. High-resolution computed tomography (CT) of the chest showed multiple ill-defined, pleural-based isodense nodular areas in the right middle lobe, left upper lobe, and lower lobe and multiple, small, subcentimetric-sized well-defined nodular opacities in bilateral lung parenchyma diffusely [Figure 2]. Level of suspicion was estimated as COVID-19 Reporting and Data System-3. He was diagnosed as a case of COVID-19 pneumonia and was treated with supplemental oxygen, antivirals, antibiotics, and low-dose glucocorticoids. Symptoms improved gradually, and he was discharged after 14 days. He is doing well on follow-up at 4 weeks. | Figure 1: Chest posteroanterior radiograph showing small parenchymal nodules in the bilateral mid zones, ill-defined air space opacities in the bilateral lower zones and bilateral perihilar bronchial wall thickening.
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 | Figure 2: (a) High-resolution computed tomography chest showing multiple ill-defined pleural based isodense nodular areas in the apicoposterior segment of the left upper lobe. (b) High-resolution computed tomography chest showing diffuse, bilateral, multiple, small subcentimetric-sized well-defined nodular opacities.
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Chest radiograph findings in children with COVID-19 infection are nonspecific, which includes common findings such as diffuse interstitial pattern and increase in central peribronchovascular wall thickening.[2],[3] The classic findings of pediatric COVID-19 in noncontrast chest CT imaging includes subpleural lesions, bilateral multifocal ground-glass opacification, patchy consolidation, and halo sign around areas of consolidation.[4],[5] Lesions are frequently wedge shaped, followed by elongated and confluent with ill-defined margins. With increasing severity of lung disease, the consolidations can extend diffusely resulting in “;white-out lung” along with extensive air bronchograms.[4],[5] When compared to adults, children are more likely to demonstrate CT abnormalities but less likely to have bilateral and interstitial involvement.[6] Nodular lesions, though reported in adults, are uncommon in children.[5],[6]
Radiologists should have a sound knowledge of these atypical imaging patterns and a high index of suspicion while dealing with pediatric COVID-19 cases to avoid misdiagnosis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Shankaralingappa A, Arun Babu T. Pathogenesis of COVID-19 and multi-system inflammatory syndrome in children. Int J Contemp Pediatr 2021;8:777-81.  |
| 2. | Annapureddy PR, Arun Babu T. The role of chest imaging in the management of children with COVID-19. Alex J Pediatr 2021;DOI: 10.4103/ajop.ajop_12_21 (Accepted - In Press) |
| 3. | Ilundain López de Munain A, Jimenez Veintemilla C, Herranz Aguirre M, Viguria Sánchez N, Ramos-Lacuey B, Urretavizcaya-Martínez M, et al. Chest radiograph in hospitalized children with COVID-19. A review of findings and indications. Eur J Radiol Open 2021;8:100337. |
| 4. | Foust AM, Winant AJ, Chu WC, Das KM, Phillips GS, Lee EY. Pediatric SARS, H1N1, MERS, EVALI, and now coronavirus disease (COVID-19) pneumonia: What radiologists need to know. AJR Am J Roentgenol 2020;215:736-44. |
| 5. | Shelmerdine SC, Lovrenski J, Caro-Domínguez P, Toso S; Collaborators of the European Society of Paediatric Radiology Cardiothoracic Imaging Taskforce. Coronavirus disease 2019 (COVID-19) in children: A systematic review of imaging findings. Pediatr Radiol 2020;50:1217-30. |
| 6. | Xia W, Shao J, Guo Y, Peng X, Li Z, Hu D. Clinical and CT features in pediatric patients with COVID-19 infection: Different points from adults. Pediatr Pulmonol 2020;55:1169-74. |
[Figure 1], [Figure 2]
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