It is been almost 6 months since the day I got infected with SARS-CoV-2. During my previous night shift, I started with low-grade fever, chills, and myalgia; I did not doubt for a second that I had to have the test for SARS-CoV-2. That same day, I treated many COVID-19 patients, and they had these same cold-like symptoms, remarkably many of them did not have a known epidemiological contact, and therefore the source of the infection could not be traced, that was the sign that the virus was already among us for a while. I performed a quick nasopharyngeal swab on myself, and without time to have any other tests done, laboratory or X-ray, I self-quarantined at home waiting for the result. And finally it came in the midst of the night; I received a call telling me “sorry my friend, your result came back positive”.
In the morning, as my symptoms aggravated, and knew some new started to appear: headache, mild diarrhea, dry cough, loss of smell and taste… I regretted not having more tests done the day before, at least a chest X-ray… but, at that moment, honestly, it was a relief to have my hand-held ultrasound device at home.
There is now growing evidence regarding the imaging findings of COVID-19, but at that time, the only studies were performed via CT scan or X-ray. With my ultrasound probe, I scanned following 12 zones: superior and inferior of anterior, lateral and posterior lobes of both hemithorax. I felt relieved (didn’t last long) to see there was a normal A-line pattern (figure 1). This A-line artifact is the physiologic horizontal reverberation, parallel to the pleura that you would expect in a healthy situation.
What still impresses me most about this disease is its dynamic course, with sudden changes during its evolution until resolution. In this rapid changing situation, we see one of the greatest advantages and main indications of ultrasound, since it is a safe technique that can be performed at the bedside, becomes an attractive tool for monitoring the evolution of any appropriate disease, like COVID-19. In my case, as my symptoms waxed and waned, so did my lung ultrasound. As the disease progressed, I saw all the possible lung findings, from the initial posterior B-lines (figure 2) to small pleural effusions (figure 3), irregular pleural line (figure 4) and finally subpleural or small consolidations (figure 5), especially in posterior and lateral areas. To see the evolution of the disease on figures 1-5 on live lung ultrasound scans, click on the video link.
Figures 2, 3, 4 & 5
In lung ultrasonography you shouldn’t expect to see a high diversity of signs. The B-lines are vertical artifacts that arise from the pleura and extend to the bottom of the screen without fading, the irregular pleural line where you can see an indented or broken pleural line and consolidations, of different sizes. It is the combination and distribution of these different signs in the proper clinical history what will give you the clue of what is happening.
In my case, my impression was that I wasn’t feeling worse when I had more B-lines, but when the subpleural consolidations started to appear and spread. Each time I had a new subpleural consolidations, there was a worsening in my symptoms coming: more myasthenia, cough, and diarrhea. Following the second week, the subpleural consolidations were replaced by B-lines, and the long-awaited improvement of my symptoms. After that, the irregular pleural line persisted much longer.
Surprisingly, during the third week, things started to worsen again, and on ultrasound there was a big consolidation appearing in one lobe, that was my sign for a therapy shift towards antibiotics. From then on, my symptoms slowly started to disappear. However, for my lungs, it took them a little bit longer, since eight weeks from the symptom onset, after recovering and testing negative for SARS-CoV-2, I still had several areas with B-lines, as well as thickening of the pleural line. This is something you could expect also during the resolution phase of any common pneumonia, and longer than that, might be an early sign of fibrosis.
As a firm ‘sono-believer’, I found it extremely useful switch from guessing to SEE my disease, monitor for sonographic progression and or resolution, and quickly detect complications. After this experience and having returned to work, I would have no excuse to irradiate my patients before scanning them, just the same way I went through.
Definitely, this experience was the best lesson I could have before returning to the trenches.
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