Important note:

  • >50% of patients with COVID-19 have a normal chest X-ray
  • COVID-19 can coexist with any lung disease and so should not be excluded simply because an another diagnosis is present

COVID-19 negative

All the patients on this page presented with symptoms raising the concern of COVID-19 pneumonia. None of them tested swab positive and the imaging appearances suggests another diagnosis.

Patient 1

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Clinical information

  • 90-year-old male
  • History of heart disease
  • Under investigation for lymphoma
  • Recent stroke resulting in poor swallow (could not tolerate nasogastric tube)
  • Episodes of reduced consciousness and suspected aspiration
  • Poor air entry at lung bases

Patient 1

  • Bilateral effusions have formed with atelectasis of the adjacent lungs
  • A diagnosis of aspiration pneumonia with parapneumonic effusions was made
  • Pleural effusions are uncommon in patients with COVID-19 pneumonia

Patient 2

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Clinical information

  • 70-year-old male
  • Left chest pain
  • Cough and sore throat
  • COVID-19 suspected

Patient 2

  • PA chest
  • The pattern of shadowing raises a high suspicion of COVID-19 - patchy, peripheral, bilateral, basal
  • Features of heart failure are present - the heart is enlarged and there is upper zone vessel prominence
  • A review of previous CT showed calcified pleural plaques which contribute to the increased density peripherally on this chest X-ray (asterisks)
  • The chest X-ray appearances were completely unchanged since mid 2019

Patient 3

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Clinical information

  • 30-year-old female
  • Cough and raised temperature
  • COVID-19 swab negative
  • Sputum positive for Haemophilus influenzae and Streptococcus pneumoniae

Patient 3

  • PA chest
  • Shadowing is unilateral, mid zone and is not peripherally located
  • Air bronchogram indicates consolidation rather than a lung mass
  • The features are not typical of COVID-19 pneumonia but are more in keeping with a lobar pneumonia - probably of the upper segments of the right lower lobe

Patient 4

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Clinical information

  • 30-year-old male
  • Presented with cough, fever and right-sided chest pain
  • Stony dullness to percussion at right lung base
  • Swab negative for COVID-19
  • Blood culture positive for Streptococcus pneumoniae

Patient 4

  • Unilateral right lower zone consolidation had developed over several days in this patient despite antibiotics
  • The left lung is clear
  • Imaging features are of a pleural effusion secondary to a lobar pneumonia
  • Pleural effusions are uncommon in COVID-19 pneumonia

Patient 5

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Clinical information

  • 70-year-old male life-long smoker
  • New cough
  • In the context of the pandemic this patient was considered likely to have COVID-19 pneumonia

Patient 5

  • PA chest
  • Increased size and density of the right hilum and minor blunting of the left costophrenic angle
  • The features are typical of a bronchogenic primary lung cancer (later biopsy proven) at the hilum and a small effusion
  • COVID-19 could not account for these appearances

Page author: Salisbury NHS Foundation Trust UK (Read bio)

Last reviewed: May 2020