537Copyright © 2020 The Korean Society of Radiology
After the outbreak of the novel coronavirus in December
of last year in China, the virus has spread widely in
countries such as South Korea, Italy, and Iran. Increasing
numbers of researchers fear that the virus will become a
worldwide pandemic, which will cause fatal consequences.
The most common signs and symptoms of the 2019 novel
coronavirus (COVID-19; temporarily termed as 2019-
nCoV) at onset are fever, a dry cough, shortness of breath,
myalgia or fatigue, and dyspnea. Owing to the complexity
of COVID-19, some patients may present with atypical
2019 Novel Coronavirus (COVID-19) Pneumonia with
Hemoptysis as the Initial Symptom: CT and Clinical
Fengxia Shi, MD1, Quanbo Yu, MD2, Wei Huang, MD3, Chaochao Tan, MD4
Departments of 1Radiology and 4Clinical Laboratory, Hunan Provincial People’s Hospital, The First Affiliated Hospital of Hunan Normal University,
Hunan Normal University, Changsha, China; 2Department of Radiology, Yueyang Second People’s Hospital, Yueyang, China; 3Department of
Radiology, Changsha First Hospital, Changsha, Hunan, China
Recently, some global cases of 2019 novel coronavirus (COVID-19) pneumonia have been caused by second- or third-generation
transmission of the viral infection, resulting in no traceable epidemiological history. Owing to the complications of COVID-19
pneumonia, the first symptom and imaging features of patients can be very atypical and early diagnosis of COVID-19 infections
remains a challenge. It would aid radiologists and clinicians to be aware of the early atypical symptom and imaging features
of the disease and contribute to the prevention of infected patients being missed.
Keywords: COVID-19; Hemoptysis; Atypical symptoms; Atypical imaging features; 2019 novel coronavirus
Received February 26, 2020; accepted after revision March 2,
This study was funded by the Novel Coronavirus Pneumonia
Emergency Project of Hunan Provincial Science and Technology
Corresponding author: Chaochao Tan, MD, Department of Clinical
Laboratory, Hunan Provincial People’s Hospital, The First Affiliated
Hospital of Hunan Normal University, Hunan Normal University, 61
JieFangXi Rd, Furong District, Changsha 410000, China.
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manifestations such as hemoptysis or atypical CT findings,
and this presents a substantial challenge for the control of
the epidemic situation.
A 57-year-old man, without history of respiratory disease,
presented to the emergency department with a 3-hour
history of hemoptysis in Hunan, China. He denied recent
travel to Wuhan City, Hubei Province, or any exposure to
2019-nCoV. No supportive results were found in laboratory
tests upon admission. A unenhanced CT scan of the chest
showed a localized area of ground-glass opacity (GGO) in
the apicoposterior segment of the left upper lobe (Fig. 1).
This patient was admitted to the hospital with a suspicion
of pulmonary infection or tuberculosis. Three days after
admission, a small amount of pleural effusion was seen.
No affirmative results were found in the drainage of pleural
effusion. Hemoptysis was unable to be controlled after
symptomatic treatments including hemostasis and anti-
infection therapy. Eight days later, a follow-up chest CT
scan showed that the GGO in the left upper lobe had
evolved into consolidation (Fig. 2). The GGO appeared
on the superior segment of the left lower lobe. Bleeding
was confirmed in the apicoposterior segment of the left
Korean J Radiol 2020;21(5):537-540
Case Report | Thoracic Imaging
Shi et al.
upper lobe by using a fiber bronchoscope on the 10th day
after admission. Fever occurred on the 11th day and the
patient reached their highest body temperature of 39°C.
Dyspnea was present on 14th day and gradually increased.
On day 18 post admission, the GGOs and consolidation in
the medial aspect of the left upper lobe decreased, while
diffuse GGO and consolidation increased in the remaining
areas of the lungs. The patient showed diffuse haziness in
both lungs, batwing appearance, crazy-paving appearance,
and the air-bronchogram sign. GGO was also distributed
along the peripheral or subpleural regions (Fig. 3). The
COVID-19 infection was eventually confirmed by a real
time reverse-transcription-polymerase chain-reaction assay.
The hemoptysis gradually decreased and the dyspnea was
relieved with symptomatic treatment and antiviral therapy
according to the Guidelines and Management for COVID-19.
A chest CT scan showed that the consolidation in both
lungs were obviously absorbed; the GGO region enlarged but
Fig. 1. CT findings on day of admission.
A. Unenhanced chest CT showed area of localized GGO in apicoposterior segment of left upper lobe (yellow arrow). Distribution of lesions was
mainly located in medial lung. B. No lesions were observed in other regions of lungs. GGO = ground-glass opacity
Fig. 2. CT findings on 8th day after admission.
A. Chest CT showed that GGO in left upper lobe had evolved into consolidation (yellow arrow). B. Newly presented GGO in superior lingual
segment of left upper lobe and superior segment of left lower lobe were distributed along subpleural regions (yellow arrows).
A B C
Fig. 3. CT findings on 18th day after admission.
A-C. Initial GGOs and consolidation in medial aspect of left upper lobe zone decreased on 18th day, while diffuse GGO and consolidation
increased in remaining areas of lungs with appearance of diffuse haziness in both lungs and batwing sign (red arrows). Crazy-paving and air-
bronchogram sign (yellow arrow) were visible. Some GGO was also distributed along peripheral or subpleural regions.
Atypical Symptom and Imaging Features of COVID-19
the GGO density decreased on day 24 (Fig. 4A, B). On day
29 post admission, GGO and a small patch of consolidation
continued to be absorbed. Initial GGO on the first CT scan
and the initial GGO and consolidation on the second CT scan
in the apicoposterior segment of the left upper lobe were
obviously absorbed (Fig. 4C, D). This study was approved
by the ethics board of Hunan province Hospital, and the
informed consent for present study was waived.
Early diagnosis of COVID-19 infections remains an
enormous challenge (1, 2). The most common signs and
symptoms of COVID-19 infection at onset of illness have
been reported to include fever, a dry cough, shortness of
breath, myalgia or fatigue, and dyspnea (3-5). However,
hemoptysis was the only clinical symptom in this patient
during the first ten days of the disease course, combined
with the slow progression of lung lesions. Hemoptysis has
been rarely reported in patients with COVID-19 infections
to date (3, 6), and thus, it has not been included in the
Guidelines and Management of COVID-19, constituted by
the National Health Commission of China. Hence, it is
difficult to diagnose COVID-19 infections especially without
obvious epidemiological exposure. After the onset of
fever and dyspnea, combined with typical CT findings, the
patient was rapidly diagnosed with COVID-19 pneumonia
by physicians. This case indicates the complexity of the
pathogenesis of pneumonia caused by COVID-19 infection.
Typical CT findings include GGO, mixed GGO, or crazy-paving
patterns and consolidation of the peripheral or subpleural
regions with bilateral lower lung involvements (7-9). An
area of localized GGO in the apicoposterior segment of the
left upper lobe of this patient was not a typical CT finding
of COVID-19 pneumonia. It is a challenge to diagnose
COVID-19 infections from GGO with a unilateral, isolated,
or non-peripheral distribution with the only symptom
of hemoptysis, but without epidemiological exposure.
The first consideration was blood in the alveoli or an
atypical manifestation of tuberculosis upon admission.
The typical manifestations of the COVID-2019 pneumonia
appeared on the 18th day after admission. The two final
CT findings corresponded to the absorption stage, in which
the clinical symptoms improved after adequate treatment
Fig. 4. CT findings on 24th and 29th day post-admission.
A, B. On day 24, consolidation was clearly absorbed. GGO regions were enlarged but GGO density had decreased. Some GGO was mixed with small
patch consolidation. C, D. On day 29, GGO and small patch consolidation continued to absorb. Initial GGO on first CT scan and initial GGO and
consolidation on second CT scan in apicoposterior segment of left upper lobe were clearly absorbed.
Shi et al.
according to the Guidelines and Management of COVID-19.
Moreover, initial GGO on the first and second CT scans
in the apicoposterior segment of the left upper lobe was
clearly absorbed, which was consistent with the gradual
improvement of hemoptysis.
In summary, the present case of COVID-19 pneum