Chest computed tomography and plain radiographs demonstrate vascular distribution and characteristics in COVID-19 lung disease - a pulmonary vasculopathy.

Introduction: Early in the COVID-19 pandemic, CT was demonstrated as a sensitive tool for diagnosing COVID-19. We undertook a detailed study of CT scans in COVID-19 patients to characterise disease distribution within lung parenchyma, respiratory airways, and pulmonary vasculature, aiming to delineate underlying disease processes.

Methods: We characterised acute phase chest CT of 40 participants with COVID-19 from the REACT study, 31 with CT pulmonary angiography (CTPA), 4 with intravenous contrast enhanced CT and 5 with non-intravenous contrast enhanced CT. Participants had neither been vaccinated nor received systemic steroids. We further correlated the distribution of lung parenchymal damage on CT with contemporaneous chest radiographs.

Results: Parenchymal lung damage was found in all subjects. However, airways inflammation was present in only 23% (9) and limited to small areas. Notably, vascular abnormalities were dominant and characterised by dilated peripheral pulmonary vessels supplying areas of lung damage in a gravity-dependent distribution bilaterally in 95% (38), basally in 90% (36), peripherally in 92.5% (37), and posteriorly in 90% (36). Macrothrombosis was demonstrated in 23% (7) of CTPAs. Wedge-shaped peripheral lung damage, resembling areas of pulmonary vascular congestion, were distinct in 53% (21) with or without visible macrothrombosis. Pleural effusions were seen in 28% (11). Notably, lung opacification distribution in 98% of the plain radiographs matched distribution on CT (39).

Conclusion: Our study frames COVID-19 as a pulmonary vasculopathy rather than a more conventional pneumonia which may be important not only for guiding mechanistic study design but also for the development of novel targeted therapeutics.