key: cord-1000182-pkrt8hkz
authors: Faqeeh, Samah; Madkhali, Raad
title: Kidney Imaging Findings in a Patient with COVID-19
date: 2020-08-25
journal: Radiol Case Rep
DOI: 10.1016/j.radcr.2020.08.049
sha: 0124cfa8ddbfbd043a4f73db1a36bcee642a1b89
doc_id: 1000182
cord_uid: pkrt8hkz

COVID-19 infection is associated with increased risk of acute kidney injury, but the imaging changes of the kidneys are not fully investigated yet. We report the CT findings in a 17-year-old male who developed severe reversible renal impairment. Those findings are similar to the changes observed in patients with vasculitis and can be contributed to the thromboembolic manifestations associated with corona virus infection.

and pleuritic chest pain. The patient was referred from a private hospital with acute respiratory distress and oxygen desaturation reaching 55% in room air associated with tachypnea (respiratory rate, 50 breaths/min) and tachycardia (pulse rate, 135 beats/min). His temperature was 38.5°C and blood pressure was 138/87 mmHg. The physical examination was unremarkable.

Laboratory findings revealed leukocytosis (WBC count of 21.9 × 10 9 /L), hemoglobin of 151 g/L, sodium 129 mmol/L, blood urea nitrogen 4.2 mmol/L, creatinine 65 µmol/L, serum LDH 453 U/L, creatine kinase > 42670 U/L, lactic acid 4.41 mmol/L and D-dimer 5.19 mg/L. The liver function tests were also significantly elevated, ALT of 407 U/L and AST of 430 U/L

A chest x-ray showed diffuse bilateral coarse reticular infiltrates.

The patient was placed on BiPAP and was admitted to the ICU. A nasopharyngeal swab was performed and COVID-19 infection was confirmed. On the following day, his clinical condition worsened and he was intubated. He also developed acute kidney injury that required the initiation of hemodialysis. The serum creatinine level raised significantly from 65 to 134 µmol/L.

A CT scan of the chest, abdomen and pelvis was obtained. The chest CT showed bilateral peripheral lower-lobe predominant ground glass opacities, classical for COVID-19 infection but no pulmonary embolism ( fig. 1 ). The abdominal CT revealed bulky kidneys with bilateral peripheral focal areas of decreased attenuation ( fig. 2) . A trans-esophageal echocardiography was normal without signs of infective endocarditis.

After 7 weeks of fluctuating hospital course with supportive treatment, the patient's clinical status gradually improved. He was extubated with maintained oxygen saturations on room air. The renal impairment was resolved with cessation of hemodialysis. Renal and liver function tests as well as the inflammatory markers were normalized and the repeated throat swabs were negative. The last chest X-ray was almost normal. A repeated CT scan of the abdomen and pelvis was carried out and revealed significant improvement of the bilateral kidney changes (fig. 3 ). The patient was discharged home and continued to do well.

With the emergence of coronavirus disease 2019 pandemic, several studies were carried out to explore the imaging findings in patients with COVID-19. The chest imaging findings were thoroughly evaluated in the recent reports; however, few studies were published regarding the abdominal findings. Of those, the most reported abdominal imaging findings were related to the gastrointestinal tract. Only 3 case reports described the kidney changes associated with COVID-19 infection (1, 2, 4, 6) .

The kidney changes in our patient were similar to the previously reported findings in the form of multiple bilateral low attenuation defects and infarctions. Those changes are similar to the findings observed in patients with vasculitis and are likely related to vasculopathy as proposed in the recent literature.

All the reported cases in addition to our patient developed reversible acute renal impairment that gradually improved after treatment. Our patient and only one of the previously reported patients required temporary hemodialysis.

There are multiple proposed mechanisms for the development of vasculopathy, hypercoagulability and acute kidney injury in patients with COVID-19 infection.

They may include direct cytopathic effects of the virus on endothelial cells and kidneys, cytokine storm, hypotension leading to renal hypoperfusion or renal medullary hypoxia (3, 5, 7) .

COVID-19 infection affecting the kidneys can manifest radiologically as bilateral peripheral low perfusion changes similar to the findings observed in patients with vasculitis and can be contributed to vasculopathy and thromboembolic manifestations associated with corona virus infection. 

Renal infarct in a COVID-19-positive kidney-pancreas transplant recipient

Kidney Infarction in Patients With COVID-19

Extrapulmonary manifestations of COVID-19: Radiologic and clinical overview

Pulmonary, Cerebral, and Renal Thromboembolic Disease Associated with COVID-19 Infection

COVID-19: Are we dealing with a multisystem vasculopathy in disguise of a viral infection

Abdominal Imaging Findings in COVID-19: Preliminary Observations

RadioGraphics Update: Venous Thrombosis and Hypercoagulability in the Abdomen and Pelvis-Findings in COVID-19