Diagnosis of SARS-CoV-2 Infection based on CT scan vs. RT-PCR: Reflecting on Experience from MERS-CoV
Identifieur interne : 000801 ( Pmc/Corpus ); précédent : 000800; suivant : 000802Diagnosis of SARS-CoV-2 Infection based on CT scan vs. RT-PCR: Reflecting on Experience from MERS-CoV
Auteurs : Jaffar A. Al-Tawfiq ; Ziad A. MemishSource :
- The Journal of Hospital Infection [ 0195-6701 ] ; 2020.
Url:
DOI: 10.1016/j.jhin.2020.03.001
PubMed: 32147407
PubMed Central: 7124270
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Diagnosis of SARS-CoV-2 Infection based on CT scan vs. RT-PCR: Reflecting on Experience from MERS-CoV</title><author><name sortKey="Al Tawfiq, Jaffar A" sort="Al Tawfiq, Jaffar A" uniqKey="Al Tawfiq J" first="Jaffar A." last="Al-Tawfiq">Jaffar A. Al-Tawfiq</name><affiliation><nlm:aff id="aff1">Infectious Disease Unit, Specialty Internal Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia</nlm:aff></affiliation><affiliation><nlm:aff id="aff2">Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA;</nlm:aff></affiliation><affiliation><nlm:aff id="aff3">Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA;</nlm:aff></affiliation></author><author><name sortKey="Memish, Ziad A" sort="Memish, Ziad A" uniqKey="Memish Z" first="Ziad A." last="Memish">Ziad A. Memish</name><affiliation><nlm:aff id="aff4">Director Research Center, King Saud Medical City, Ministry of Health</nlm:aff></affiliation><affiliation><nlm:aff id="aff5">Al-Faisal University, Riyadh, Saudi Arabia</nlm:aff></affiliation><affiliation><nlm:aff id="aff6">Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA5</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">32147407</idno><idno type="pmc">7124270</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7124270</idno><idno type="RBID">PMC:7124270</idno><idno type="doi">10.1016/j.jhin.2020.03.001</idno><date when="2020">2020</date><idno type="wicri:Area/Pmc/Corpus">000801</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000801</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Diagnosis of SARS-CoV-2 Infection based on CT scan vs. RT-PCR: Reflecting on Experience from MERS-CoV</title><author><name sortKey="Al Tawfiq, Jaffar A" sort="Al Tawfiq, Jaffar A" uniqKey="Al Tawfiq J" first="Jaffar A." last="Al-Tawfiq">Jaffar A. Al-Tawfiq</name><affiliation><nlm:aff id="aff1">Infectious Disease Unit, Specialty Internal Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia</nlm:aff></affiliation><affiliation><nlm:aff id="aff2">Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA;</nlm:aff></affiliation><affiliation><nlm:aff id="aff3">Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA;</nlm:aff></affiliation></author><author><name sortKey="Memish, Ziad A" sort="Memish, Ziad A" uniqKey="Memish Z" first="Ziad A." last="Memish">Ziad A. Memish</name><affiliation><nlm:aff id="aff4">Director Research Center, King Saud Medical City, Ministry of Health</nlm:aff></affiliation><affiliation><nlm:aff id="aff5">Al-Faisal University, Riyadh, Saudi Arabia</nlm:aff></affiliation><affiliation><nlm:aff id="aff6">Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA5</nlm:aff></affiliation></author></analytic><series><title level="j">The Journal of Hospital Infection</title><idno type="ISSN">0195-6701</idno><idno type="eISSN">1532-2939</idno><imprint><date when="2020">2020</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><back><div1 type="bibliography"><listBibl><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Alfaraj, S H" uniqKey="Alfaraj S">S.H. Alfaraj</name></author><author><name sortKey="Al Tawfiq, J A" uniqKey="Al Tawfiq J">J.A. 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Ying</name></author><author><name sortKey="Pang, P" uniqKey="Pang P">P. Pang</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Corman, V M" uniqKey="Corman V">V.M. Corman</name></author><author><name sortKey="Albarrak, A M" uniqKey="Albarrak A">A.M. Albarrak</name></author><author><name sortKey="Omrani, A S" uniqKey="Omrani A">A.S. Omrani</name></author><author><name sortKey="Albarrak, M M" uniqKey="Albarrak M">M.M. Albarrak</name></author><author><name sortKey="Farah, M E" uniqKey="Farah M">M.E. Farah</name></author><author><name sortKey="Almasri, M" uniqKey="Almasri M">M. Almasri</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Xie, X" uniqKey="Xie X">X. Xie</name></author><author><name sortKey="Zhong, Z" uniqKey="Zhong Z">Z. Zhong</name></author><author><name sortKey="Zhao, W" uniqKey="Zhao W">W. Zhao</name></author><author><name sortKey="Zheng, C" uniqKey="Zheng C">C. Zheng</name></author><author><name sortKey="Wang, F" uniqKey="Wang F">F. Wang</name></author><author><name sortKey="Liu, J" uniqKey="Liu J">J. Liu</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Wei, M" uniqKey="Wei M">M. Wei</name></author><author><name sortKey="Yuan, J" uniqKey="Yuan J">J. Yuan</name></author><author><name sortKey="Liu, Y" uniqKey="Liu Y">Y. Liu</name></author><author><name sortKey="Fu, T" uniqKey="Fu T">T. Fu</name></author><author><name sortKey="Yu, X" uniqKey="Yu X">X. Yu</name></author><author><name sortKey="Zhang, Z J" uniqKey="Zhang Z">Z.-J. Zhang</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Wang, Y" uniqKey="Wang Y">Y. Wang</name></author><author><name sortKey="Kang, H" uniqKey="Kang H">H. Kang</name></author><author><name sortKey="Liu, X" uniqKey="Liu X">X. Liu</name></author><author><name sortKey="Tong, Z" uniqKey="Tong Z">Z. Tong</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Zou, L" uniqKey="Zou L">L. Zou</name></author><author><name sortKey="Ruan, F" uniqKey="Ruan F">F. Ruan</name></author><author><name sortKey="Huang, M" uniqKey="Huang M">M. Huang</name></author><author><name sortKey="Liang, L" uniqKey="Liang L">L. Liang</name></author><author><name sortKey="Huang, H" uniqKey="Huang H">H. Huang</name></author><author><name sortKey="Hong, Z" uniqKey="Hong Z">Z. Hong</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="discussion"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">J Hosp Infect</journal-id><journal-id journal-id-type="iso-abbrev">J. Hosp. Infect</journal-id><journal-title-group><journal-title>The Journal of Hospital Infection</journal-title></journal-title-group><issn pub-type="ppub">0195-6701</issn><issn pub-type="epub">1532-2939</issn><publisher><publisher-name>The Healthcare Infection Society. Published by Elsevier Ltd.</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">32147407</article-id><article-id pub-id-type="pmc">7124270</article-id><article-id pub-id-type="publisher-id">S0195-6701(20)30100-6</article-id><article-id pub-id-type="doi">10.1016/j.jhin.2020.03.001</article-id><article-categories><subj-group subj-group-type="heading"><subject>Article</subject></subj-group></article-categories><title-group><article-title>Diagnosis of SARS-CoV-2 Infection based on CT scan vs. RT-PCR: Reflecting on Experience from MERS-CoV</article-title></title-group><contrib-group><contrib contrib-type="author" id="au1"><name><surname>Al-Tawfiq</surname><given-names>Jaffar A.</given-names></name><email>jaffar.tawfiq@jhah.com</email><email>jaltawfi@yahoo.com</email><xref rid="aff1" ref-type="aff">1</xref><xref rid="aff2" ref-type="aff">2</xref><xref rid="aff3" ref-type="aff">3</xref><xref rid="cor1" ref-type="corresp">∗</xref></contrib><contrib contrib-type="author" id="au2"><name><surname>Memish</surname><given-names>Ziad A.</given-names></name><degrees>MD</degrees><xref rid="aff4" ref-type="aff">4</xref><xref rid="aff5" ref-type="aff">5</xref><xref rid="aff6" ref-type="aff">6</xref></contrib></contrib-group><aff id="aff1"><label>1</label>Infectious Disease Unit, Specialty Internal Medicine, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia</aff><aff id="aff2"><label>2</label>Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA;</aff><aff id="aff3"><label>3</label>Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA;</aff><aff id="aff4"><label>4</label>Director Research Center, King Saud Medical City, Ministry of Health</aff><aff id="aff5"><label>5</label>Al-Faisal University, Riyadh, Saudi Arabia</aff><aff id="aff6"><label>6</label>Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA5</aff><author-notes><corresp id="cor1"><label>∗</label>Corresponding author. P.O. Box 76; Room A-428-2, Building 61, Dhahran Health Center, Johns Hopkins Aramco Healthcare, Dhahran 31311, Saudi Arabia. ; Tel.: +966 13-870-3524; fax: +966 13-870-3790. <email>jaffar.tawfiq@jhah.com</email><email>jaltawfi@yahoo.com</email></corresp></author-notes><pub-date pub-type="pmc-release"><day>6</day><month>3</month><year>2020</year></pub-date><pmc-comment> PMC Release delay is 0 months and 0 days and was based on .</pmc-comment>
<pub-date pub-type="epub"><day>6</day><month>3</month><year>2020</year></pub-date><elocation-id></elocation-id><history><date date-type="received"><day>1</day><month>3</month><year>2020</year></date><date date-type="accepted"><day>2</day><month>3</month><year>2020</year></date></history><permissions><copyright-statement>© 2020 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.</copyright-statement><copyright-year>2020</copyright-year><copyright-holder>The Healthcare Infection Society</copyright-holder><license><license-p>Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.</license-p></license></permissions></article-meta></front><body><p id="p0010">As of 29<sup>th</sup> February 2010 the World Health Organization had reported a total of 83 652 COVID-19 cases in 51 countries in addition of China [<xref rid="bib1" ref-type="bibr">1</xref>]. The diagnosis of respiratory viruses such as Middle East Respiratory Syndrome Coronavirus (MERS-CoV) and SARS-CoV relies on detection of the virus by real-time RT PCR (rRT-PCR) for in vitro qualitative detection. The current recommendations are likewise to use rRT-PCR for the detection of SARS-CoV-2 in respiratory samples. There are many knowledge gaps facing the global health community in dealing with the new emerging SARS-CoV-2. Among the most pertinent is early identification of cases to facilitate application of isolation policies. The currently available RT-PCR kits are variable, offering sensitivities ranging between 45 and 60%; thus, especially early in the course of an infection, repeat testing may be required to make a diagnosis. This is not easy to apply with the global shortage of testing kits. This mirrors experience with MERS-CoV. In a study of 336 MERS patients, 89% had a positive result after 1 swab, 96.5% had a positive result after 2 consecutive swabs, and 97.6% had a positive result after 3 swabs (<xref rid="fig1" ref-type="fig">Figure 1</xref>) [<xref rid="bib2" ref-type="bibr">2</xref>]. China has changed the case definition over the last 2 months to improve the ability to detect new cases. Data have emerged on the value of CTscan of chest in early diagnosis of cases. Multiple reports published to date have revealed higher sensitivity of CT chest in early detection of SARS-CoV-2 cases [<xref rid="bib3" ref-type="bibr">3</xref>]. In a study of 51 patients, the positivity rate for a single respiratory swab was 70%, an additional 24% (94% cumulative) after a second test, and an additional 3.9% (98% cumulative) after a third test (<xref rid="fig1" ref-type="fig">Figure 1</xref>) [<xref rid="bib4" ref-type="bibr">4</xref>]. However, an abnormal CT scan findings compatible with viral pneumonia was seen in 98% of patients [<xref rid="bib4" ref-type="bibr">4</xref>]. This difference had resulted in the recommendations of authors to state that CT scan is more sensitive than PCR. Reasons for low sensitivity of PCR may include insensitive nucleic acid detection methods and variations in the accuracies of different tests, low initial viral load or improper clinical sampling [<xref rid="bib4" ref-type="bibr">4</xref>]. An additional reason may be that lower respiratory samples may be better than upper respiratory samples, as is the cases with MERS-CoV [<xref rid="bib5" ref-type="bibr">5</xref>] [<xref rid="bib6" ref-type="bibr">6</xref>].<fig id="fig1"><label>Figure 1</label><caption><p>Cumulative Positive Rate of Swabs for the diagnosis of SARS-CoV-2 and MERS-CoV based on RT-PCR.</p></caption><alt-text id="alttext0010">Figure 1</alt-text><graphic xlink:href="gr1_lrg"></graphic></fig></p><p id="p0015">In another study of 167 patients, concordant CT scan and PCR test results were observed in 93% of patients, and a discordant results were observed in 4% (positive PCR but negative CT scan) and in 3% (negative initial PCR and positive CT scan) [<xref rid="bib7" ref-type="bibr">7</xref>]. In a larger study of 1014 SARS-CoV-2 patients, 59% had positive RT-PCR and 88% had positive CT scan; using RT-PCR as a reference, the sensitivity of chest CT imaging was 97% [<xref rid="bib8" ref-type="bibr">8</xref>].</p><p id="p0020">Growing evidence of the limitations of rRT-PCR prompts further consideration of the limitations of this diagnostic test. First, there are already over 7 different SARS-CoV-2 nucleic acid PCR tests [<xref rid="bib9" ref-type="bibr">9</xref>]. When considering the viral load in samples, it has shown that upper respiratory tract samples have their peak viral loads 3 days after onset of symptoms, and that nasal, rather than throat samples have the highest viral loads [<xref rid="bib10" ref-type="bibr">10</xref>]. As the current SARS-CoV-2 epidemic evolves globally we need better diagnostic tests that are rapid, reliable, validated and widely available. For hospitalized patients diagnostic algorithms based on a combination of RT-PCR and CT scan of the chest may prove to be necessary in order to ensure accurate detection of cases and to facilitate infection prevention measures. It is also very important to learn from the previous MERS-CoV epidemic and reflect on that experience, especially that a single negative upper respiratory sample is not enough to rule out infection. It may be prudent to keep those patients in isolation while we obtain additional swabs or be able to safely get lower respiratory samples for definite diagnosis.</p><sec sec-type="COI-statement"><title>Declaration of Competing Interest</title><p id="p0025">All authors have no conflicts of interest.</p></sec></body><back><ref-list id="cebib0010"><title>References</title><ref id="bib1"><label>1</label><mixed-citation publication-type="other" id="sref1">World Health Organization. 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