114 JURNAL RESPIRASI, SEPTEMBER 2021, VOL 07 (03); 114-121

ORIGINAL ARTICLE

The Relationship of Chest X-Ray in COVID-19 Patients

and Disease Severity in Arifin Achmad General Hospital
Riau
Aulia Rahman1* , Sri Melati Munir1 , Indra Yovi1 , Andreas Makmur2
1
Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, University of Riau/Arifin Achmad
General Hospital, Riau, Indonesia.
2
Department of Radiology, Faculty of Medicine, University of Riau/Arifin Achmad General Hospital, Riau,
Indonesia.

ARTICLE INFO ABSTRACT

Article history: Introduction: Coronavirus Disease 2019 (COVID-19) pandemic is caused by SARS-
Received 12 May 2021 CoV-2 which spreads rapidly throughout the world and causes clinical manifestations in
Received in revised form 26 various organs, especially in the lungs. Clinical symptoms arise from asymptomatic,
September 2021 mild, moderate, severe, and critical symptoms in patients with or without the comorbid
Accepted 28 September 2021 disease. Chest X-ray examination is one of the modalities in the diagnostic of COVID-
Available online 30 September 2021 19 which is cheap and easy to do.
Methods: This study was performed by analyzing medical record data of confirmed
Keywords: COVID-19 patients from March to December 2020. This study aimed to examine the
COVID-19, relationship between chest X-ray and the degree of disease severity.
Chest X-Ray, Results: The results showed that from the examined 542 total samples, the highest
Comorbidities, number was found in the age group of 40-49 years old (23.6%), women (53%), mild
Severity, degree of COVID-19 (67.9%), normal chest X-ray (54.6%), predominance on the lower
Infection disease. zone of the lung, peripheral and bilateral on abnormal chest X-ray, no comorbid
(56.3%), hypertensive in comorbid disease (26.6%). There was a significant relationship
between chest X-ray and comorbidity towards COVID-19 severity (p = 0.000).
Conclusion: Chest X-ray can determine disease severity, therefore it can be used as the
first modality for triage and treatment evaluation in COVID-19 patients.

INTRODUCTION
could be without clinical symptoms, then worsen to a
Coronavirus Disease 2019 (COVID-19) is caused critical condition and become ARDS, respiratory failure,
by Severe Acute Respiratory Syndrome Coronavirus-2 and death.3–5 Imaging plays an important role in the
(SARS-CoV-2) infection and was first reported in diagnosis and management of COVID-19. Chest X-ray
Wuhan, China at the end of December 2019. World is considered to be the first-line imaging modality for
Health Organization (WHO) declared COVID-19 as a the initial triage of suspected COVID-19 cases.
pandemic on 11 March 2020.1,2 The manifestations of Although chest X-ray is considered insensitive for
COVID-19 are similar to SARS-CoV and MERS-CoV detecting pulmonary involvement in early-stage disease,
which affect lung organs and also have a wide impact on they can be useful diagnostic tools for monitoring rapid
other organs, such as cardiovascular, gastrointestinal progress in critically ill patients who are admitted to the
tract, liver, kidneys, eyes, and skin. The most common intensive care unit (ICU). Chest X-ray can reflect
clinical manifestations are cough, shortness of breath, disease severity, thus it is useful for monitoring the
fever, and sore throat. The clinical course of the patient changes in chest X-ray during treatment.6–9

*Corresponding author: [email protected]

Jurnal Respirasi, p-ISSN: 2407-0831; e-ISSN: 2621-8372.

Accredited No. 200/M/KPT/2020; Available at https://e-journal.unair.ac.id/JR. DOI: 10.20473/jr.v7-I.3.2021.114-121
This work is licensed under a Creative Commons Attribution-Share Alike 4.0 International License.
 115 JURNAL RESPIRASI, SEPTEMBER 2021, VOL 07 (03); 114-121

METHODS statistically significant. This study had been approved

ethically by the Medical Research Ethics Unit Faculty of
This was an analytical study with a cross- Medicine, the University of Riau with the number
sectional design. This study aimed to examine the B/013/UN19.5.1.1.8/UEPKK/2021.
correlation between chest X-ray and COVID-19 severity
using secondary data, namely medical records of RESULTS
inpatients of PINERE Room Arifin Achmad General
Hospital Riau. This study was conducted in March 2021 The number of research subjects included was
by taking medical record data from March to December 542 patients. The age range was 18 - 91 years old and
2020. The sample was taken by total sampling. The the median was 43 years old. Group of 40-49 years old
inclusion criteria were medical record data from adult (128, 23.6%) and female (287, 53%) were the largest
numbers. The characteristics of the subjects are
COVID-19 patients aged ≥18 years old who were treated
presented in Figure 1 and Figure 2.
in PINERE Room Arifin Achmad General Hospital Riau Disease severity was determined by the
and had complete data with criteria degree severity: mild pulmonologist when the COVID-19 patient was
illness if patients with symptoms without evidence of hospitalized early and was recorded in the medical
viral pneumonia or hypoxia; moderate illness if clinical record. In this study, the highest number was found in
signs of pneumonia (fever, cough, shortness of breath, the mild COVID-19 group (368, 67.9%). The second
rapid breathing) but no signs of severe pneumonia was the moderate degree group (114, 21.03%) and the
third was the severe degree group (43, 7.93%). COVID-
including SpO2 > 93% with room air; severe illness if
19 group with a critical severity had the lowest number
clinical signs of pneumonia plus one of respiratory rate among other groups (17, 3.14%) as shown in Figure 3.
> 30 breaths/minute, severe respiratory distress, or SpO2 Chest X-ray of the research subjects was assessed
< 93% in room air; and critical illness if patients with by a radiologist using the Brixia Score method taken
Acute Respiratory Distress Syndrome (ARDS), sepsis from chest X-ray of COVID-19 patient in early
and septic shock.10 Incomplete medical record, chest X- hospitalization. This study divided the research subjects
rays not worth reading, history of pulmonary into 4 groups: normal chest X-ray (score of 0), mild
tuberculosis, bronchiectasis, lung cancers and tumor pneumonia (1-6), moderate degree (7-12), and severe
metastases in the lungs, pleural effusions, degree (13-18). Normal chest X-ray image was found
pneumothorax, and hydropneumothorax were excluded (296, 54.6%) more than those which were abnormal
from the sample. (246, 45.4%). The group of subjects with mild
Chest X-rays are assessed with the Brixia Score pneumonia degree (160, 29.5%) had the largest number
method. The lungs are divided into six zones on frontal among the group of research subjects with chest X-ray
chest projection: upper zones (right and left), middle abnormalities, followed by moderate (71, 13.1%) and
zones (right and left) and lower zones (right and left) severe group (15, 2.8%). Abnormal chest X-ray feature
which are assessed based on the lung abnormalities of COVID-19 patients in this study was mostly bilateral
detected with a score of 0 if no lung abnormalities, a pneumonia in (204, 37.6%), peripheral (177, 32.7%),
score of 1 with interstitial infiltrates, a score of 2 with and lower zone of the lung (220, 40.6%) as seen in
interstitial and alveolar infiltrates (interstitial Table 1.
predominance) and a score of 3 with interstitial and
140 128
alveolar infiltrates (alveolar predominance). The scores 119
120 102 102
of the six lung zones are then added to obtain an overall
Total (n)

100
CXR score ranging from 0 to 18. In this study, we divide 72
80
the research subjects into 4 groups: normal chest X-ray 60
40
(score of 0), mild pneumonia (1-6), moderate degree (7- 14
20 4 1
12), and severe degree (13-18).7 0
The data obtained were analyzed with a statistical
package for social science (SPSS) software 2.4 version.
The relationship between chest X-ray and COVID-19
Age Group
severity was analyzed using the Chi-Square test. The
results with p values < 0.05 were considered to be Figure 1. Characteristics of the research subjects based on age
116 JURNAL RESPIRASI, SEPTEMBER 2021, VOL 07 (03); 114-121

Figure 2. Characteristic of the research subjects Figure 3. Disease severity of the research subjects
based on gender

Table 1. Chest X-ray results of the research subjects

Chest X-ray n %
Pneumonia severity (N=542)
Normal (score 0) 296 54.6
Pneumonia 246 45.4
Mild (score 1-6) 160 29.5
Moderate (score 7-12) 71 13.1
Severe (score 13-18) 15 2.8
Laterality (N=246)
Right Unilateral 24 4.4
Left Unilateral 18 3.3
Bilateral 204 37.6
Distribution (N=246)
Peripheral 177 32.7
Central 3 0.6
Diffuse 66 12.2
Zonal Predominance (N=246)
Upper 14 2.6
Middle 12 2.2
Lower 220 40.6

Table 2. The relationship between pneumonia severity on chest X-ray and COVID-19 severity
Severity of disease p-Value PR 95% CI
Chest X-ray Mild - Moderate Severe - Critical
n (%) n (%)
Pneumonia Severity
0 - 6 (Normal – Mild 436 (95.6) 20 (4.4)
18.957
Pneumonia)
0.000* (10.230-35.126)
7 - 18 (Moderate-
Severe Pneumonia) 46 (53.5) 40 (46.5)
Laterality
Unilateral 42 (17.07) 0 0.000*
Bilateral 154 (62.60) 50 (20.33)
Distribution
Peripheral 162 (65.85) 15 (6.010)
Central 2 (0.81) 1 (0.41) 0.000**
Difuse 32 (13.01) 34 (13.82)
Zonal Predominance
Upper 11 (4.47) 3 (1.22)
Middle 8 (3.25) 4 (1.63) 0.251**
Lower 177 (71.95) 43 (17.48)
* Chi-Square Test
**Mann-Whitney U test
 117 JURNAL RESPIRASI, SEPTEMBER 2021, VOL 07 (03); 114-121

Chest X-ray results were grouped into normal- Table 3. Comorbidities of the research subjects
mild pneumonia and moderate-severe pneumonia Comorbidity n %
groups. Furthermore, bivariate analysis was performed No 305 56.3
with COVID-19 severity which was grouped into mild- Yes 237 43.7
moderate and severe-critical groups. The bivariate Hypertension 144 26.6
analysis used Chi-Square statistical test, which Diabetes mellitus 76 14
Kidney failure 32 5.9
statistically gave a significant value if p <0.05. The Cardiovascular disease 26 4.8
result found that there was a significant relationship Malignancy 24 4.4
between the severity of pneumonia on chest X-ray and Hepatobiliary disease 10 1.8
Cerebrovascular disease 9 1.7
COVID-19 severity (PR 18.957; 95% CI 10.230-
Asthma 7 1.3
35.126; p = 0.000) from the total of 542 research COPD 5 0.9
subjects analyzed as shown in Table 2. The statistical Gastrointestinal disease 3 0.6
analysis results of 246 research subjects who had chest HIV-AIDS 3 0.6
Hyperthyroidism 2 0.4
X-ray abnormalities showed a relationship between Autoimmune disease 1 0.2
pneumonia laterality and disease severity (p = 0.000).
Significant results were also obtained between the

Table 4. The relationship between comorbidity and COVID-19 severity

Comorbidity n (%) Severity Disease P Value PR 95%CI
Mild-Moderate Severe-
Critical
No 305 (56.27) 297 (54.79) 8 (1.48) 0.000* 10.435 (4.848-22.462)
Yes 237 (43.72) 185 (34.13) 52 (9.59)
Hypertension 144 (26.6) 114 30 0.000* 3.228 (1.866-5.584)
Diabetes mellitus 76 (14) 52 24 0.000* 5.513 (3.052-9.957)
Kidney failure 32 (5.9) 18 14 0.000** 7.845 (3.664-16.798)
Cardiovascular disease 26 (4.8) 18 8 0.004** 3.966 (1.644-9.569)
Malignancy 24 (4.4) 21 3 0.741
Hepatobiler disease 10 (1.8) 6 4 0.017** 5.667 (1.552-20.691)
Cerebrovascular disease 9 (1.7) 6 3 0.067
Asthma 7 (1.3) 6 1 0.562
COPD 5 (0.9) 3 2 0.097
Gastrointestinal dsiease 3 (0.6) 3 0 1.000
HIV-AIDS 3 (0.6) 2 1 0.297
Hyperthyroidism 2 (0.4) 2 0 1.000
Autoimmune disease 1 (0.2) 1 0 1.000
*Chi-Square Test
**Fisher Exact Test

distribution of pneumonia to disease severity (p = cardiovascular disease (26, 4.8%), and malignancy (24,
0.000). There was no significant relationship between 4.4%) as seen in Table 3.
pneumonia zone and disease severity (p = 0.251). Based on the results of statistical analysis of the
Comorbidities were concluded by the research subjects, it was found that there was a
pulmonologist or other specialists in Arifin Achmad significant relationship between comorbidities and
General Hospital Riau based on anamnesis, physical COVID-19 severity (PR 10.435; 95% CI 4.848-22.462;
examination, laboratory examination, or other p = 0.000). Comorbidities which had a significant
relationship to COVID-19 severity in this study include
supporting examinations. Most of the research subjects
hypertension (PR 3.228; 95% CI 1.866-5.584; p=0.000),
did not have comorbidities (305, 56.3%) but they were
diabetes mellitus (PR 5.513; 95% CI 3.052-9.957; p =
not much different from the group that had
0.000), kidney failure (PR 7.845; 95% CI 3.664-16.798;
comorbidities (237, 43.7%). The most common p = 0.000), cardiovascular disease (PR 3.966; 95% CI
comorbidities found were hypertension (144, 26.6%), 1.644-9.569; p = 0.004), and hepatobilier disease (PR
diabetes mellitus (76, 14%), kidney failure (32, 5.9%), 5.667; 95% CI 1.552-20.691; p = 0.017).
 118 JURNAL RESPIRASI, SEPTEMBER 2021, VOL 07 (03); 114-121

DISCUSSION This study found the mild group (67.95%) was

the largest group. The results of this study are similar to
The characteristics of the research subjects found the Chinese Center for Disease Control (CDC) report
that the 40-49 years old age group had the largest with 80.9% mild or moderate cases, 13.8% severe cases,
number (128, 23.6%). The results of this study are not and 4.7% critical cases of 44,672 cases ofCOVID-19
much different from the study conducted by Huang, et outbreak.20 Yue, et al. also found the mild group was the
al., which found that the 25-49 years old group (49%) largest (75.6%), but this group was combined with the
was the most group infected with COVID-19.3 Guan, et moderate group.16 Lian, et al. found a much higher
al. also had the 15-49 years old age group (55.1%) as number (90.08%) for the mild degree group.21
most group infected with COVID-19.10 Data from It can be seen that 296 chest radiographs were
Indonesian COVID-19 Task Force stated that the 31-45 found normal (54.6%) in this study. This was similar to
years old age group had the highest number (29.3%).11 the results of a study conducted by Weinstock, et al.,
However, Chen, et al. found that 50-59 years old age which found 371 patients (58.3%) had normal images.
group was slightly more infected (30%).4 Zhang, et al. The subjects with mild symptoms had the largest
also found that the slightly older group was more number of subjects with images of chest X-ray
abnormalities (160, 29.5%). This result is not much
infected, namely the 50-69 years old age group
different from the results of a study conducted by
(49.3%).12 Borghesi, et al. found the 70-79 years old age
Weinstock, et al., which found 195 patients (30.7%) had
group (26.8%).13 The difference in the number of
mild symptoms.22
infections in each age group was probably influenced by
Pneumonia on chest X-ray of COVID-19
the ratio of age groups and different levels of mobility in
patients in this study was mostly bilateral (204, 37.6%),
each region. Tay argued that older people and people
at the peripheral (177, 32.7%), and dominance in the
with comorbidities have a greater likelihood of impaired lower lung zone (220, 40.6%). This result is not much
immune response leading to abnormalities and failure to different from the results of a study conducted by
eradicate pathogens. This condition is caused by aging Weinstock, et al. which also found that the most were
lung tissue, which causes changes in dendritic cell bilateral (133, 20.9%), at peripheral (225, 35.4%) and
maturation and migration to lymphoid organs, which dominance in the lower lung zone (215, 33,8%).22
then disrupts T-cell activation. The contradictory results Kaleemi, et al. also obtained similar results of chest X-
were found in children who tended to have no severe ray COVID-19 patients with bilateral, peripheral, and
disease despite experiencing high viral titers.14 dominant distribution in the lower lobe.23
Female was found (53%) more than male (47%) This study found a significant relationship
in this study. Data from the Indonesian COVID-19 Task between chest X-rays in COVID-19 patients and disease
Force also found females (51.1%) were more infected severity based on Chi-Square test results (PR 10.605;
than males (48.9%).11 Shang, et al. obtained similar 95% CI 6.531-17.220; p = 0.000). Guan, et al. stated
results in which females (52.6%) were more infected that patients with severe disease had a higher incidence
compared to males (47.4%).15 Yue, et al. also obtained of pneumonia than patients with mild disease.10
the same results (55.8%).16 However, Zhang, et al. According to Toussie, et al., the severity of opacity in
found different results, with the male group was more the initial chest X-ray was associated with the need for
infected (50.7%) compared to the female group hospitalization and intubation. Patients with at least two
(49.3%).12 Hu, et al. also found that male were slightly lung zone opacities were more likely to require
higher than female (51.4%).17 There was no significant hospitalization and those with opacity in at least three
gender difference as the number of COVID-19 cases lung zones were more likely to require intubation. 24 A
continued to increase. It is important to note that study conducted by Borghesi, et al. concluded that chest
COVID-19 figures show a difference in mortality rates X-ray severity scores were associated with mortality.25
between male and female. This difference is due to Wong, et al. reported that findings on chest X-ray
Angiotensin-Converting Enzyme 2 (ACE2) which is changed over time and reached their peak at 10-12 days
located on the X chromosome. Different from the onset of symptoms. Patients who are in the
immunoregulatory functions of sex hormones estrogen "early stages" of disease are characterized by the
and testosterone, physiological factors, and different presence of ground-glass density, which may be very
lifestyles are also thought to play a role.14,18,19 difficult to detect on chest X-ray.26
119 JURNAL RESPIRASI, SEPTEMBER 2021, VOL 07 (03); 114-121

Blain, et al. obtained more pictures of bilateral angiotensin system (RAS), resulting in increased cardiac
pneumonia than unilateral (69%), but in this study, he load, cardiomyocyte hypertrophy, and high blood
did not associate whether there was a relationship with pressure.30,31 Diabetics are more susceptible to infection
the disease severity. This study also found that the lower because their immune system is compromised. Immune
lung field area was more dominant than other areas, but dysfunction in diabetics can be affected by
he also did not mention whether there was any hyperglycemia, altered cytokine production, impaired T
relationship with the degree of disease severity.27 Wong, cell-mediated immune response, inhibition of neutrophil
et al. mentioned in their study that pneumonia chemotaxis, ineffective microbial clearance, and
abnormalities on chest X-rays were more bilateral phagocytic cell dysfunction. Another hypothesis
(50%). Peripheral abnormalities were more compared to suggests that ACE2 may play an important role in
other areas (41%). The lower zone was found more than COVID-19 severity infection in diabetic individuals
other zones (50%). Wong's study also did not mention because the virus uses ACE2 to attack the host
whether there was a relationship between the image of pneumocytes and it is also expressed in pancreatic
chest X-ray pneumonia in bilateral lungs, distributed in tissue. In addition, diabetics have been shown to have
the periphery, and lower lung field zones to the degree elevated levels of proinflammatory cytokines, especially
of COVID-19 severity.26 Cozzi, et al. also found the IL-1, IL-6, and TNF-α as well as other markers, such as
same thing that there were more pictures of chest X-ray C-reactive protein, D-dimer, and fibrinogen. This in turn
abnormalities in the group which affected bilateral can prolong the cytokine storm and cause severe illness
(69.2%) compared to unilateral ones. Pneumonia in diabetics with COVID-19 infection. The role of
abnormalities were more distributed in the periphery markers in COVID-19 is to induce diabetes.31–33
(57.7%) compared to central or diffuse areas. This study This study also examined whether there was a
also found dominance in the lower lung (58.5%) relationship between COVID-19 severity and
compared to the upper or middle zone. This study did comorbidities in the research subjects. After combining
not explain whether there was a significant relationship mild to moderate degree in a group and severe to critical
between laterality, distribution, and zone domination of in a group for Chi-Square statistical tests, the results of
chest X-ray abnormalities on the degree of disease the statistical test showed that there was a significant
severity.28 relationship between the degree of disease severity and
The result of this study showed that the numbers comorbidities (PR 2.258; 95% CI 1.943-2.625; p =
of the non-comorbidities patient (305, 56.3%) were 0.000). This study also obtained the results of several
larger than the patients who had comorbidities. The five comorbidities that had a significant relationship with the
most common comorbidities in this study were degree of disease severity, including hypertension (PR
hypertension (144, 26.6%), diabetes mellitus (76, 14%), 3.228; 95% CI 1.943-2.625; p = 0.000), diabetes
kidney failure (32, 5.9%), cardiovascular disease (26, mellitus (OR 5.513), kidney failure (OR 7.845),
4.8%), and malignancy (24, 4.4%). The results of this cardiovascular disease (OR 3.966), and hepatobiliary
study are similar to the results of a study conducted by disease (OR 5.667).
Li, et al., who got hypertension (35, 47.3%) in the first This study is similar to the study of Surendra, et
order of comorbidities found in COVID-19 patients, al. in Jakarta which obtained significant results on
followed by diabetes (14, 18.9%) and coronary heart comorbidities, such as hypertension (p-value <0.0001),
disease (6, 8.1%).29 Zhang, et al. also found similar diabetes (p-value <0.0001), cardiovascular disease (p-
results with hypertension in the first place as much as 42 value <0.0001), failure kidney (p-value <0.0001), and
people (30%), followed by diabetes mellitus as much as liver disease (p-value <0.032). The difference is in the
17 people (12.1%), liver disease as many as 8 people study, Surendra, et al studied the relation of
(5.7%), and coronary heart disease as many as 7 people comorbidities and the outcome of treatment (returning
(5%).12 home with recovery or death).34 Hu, et al.'s study in
Hypertension has been identified as the chronic Wuhan found only diabetes (p-value <0.001) and
disease that most COVID-19 patients suffer from. ACE2 cardiovascular disease (p-value <0.001) which were
receptor which mediates SARS-CoV-2 invasion via the related to the degree of disease severity.17
glycoprotein spikes binding pathway - widely expressed According to Zhang, et al., patients with severe
in the lungs and heart. The balance between ACE1 and COVID-19 were associated with a higher frequency
ACE2 is very important to control levels of Angiotensin of comorbidities. His research found that patients with
II. The binding of SARS-CoV-2 with ACE2 causes comorbidities showed a higher severity than those
excessive release of angiotensin II through the renin- without comorbidities.12 Wang, et al. found in their
120 JURNAL RESPIRASI, SEPTEMBER 2021, VOL 07 (03); 114-121

study that COVID-19 patients treated in the ICU were Novel Coronavirus in Wuhan, China. Lancet.
older and had a higher number of comorbidities more 2020;395(10223):497-506.
than patients who were treated in a regular ward. This 4. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et
al. Epidemiological and clinical Characteristics of 99
suggests that age and comorbidities may be risk factors
Cases of 2019 Novel Coronavirus Pneumonia in
for poor outcomes. Comorbidities such as hypertension, Wuhan, China: A Descriptive Study. Lancet.
diabetes, and coronary heart disease can affect COVID- 2020;395(10223):507-13.
19 severity.35 This, according to Chen, et al., is related 5. Rodriguez-MoralesAJ,Cardona-OspinaJA,Gutiérrez-
to an imbalance of ACE2 and cytokine storms caused by OcampoE,Villamizar-Pena R, Holguin-Rivera Y,
disorders of Glucolipid metabolism (GLMD).36 Escallera-Antezana JP, et al. Clinical, Laboratory
and Imaging Features of COVID-19: A Systematic
Review and Meta-Analysis. Travel Med Infect Dis.
CONCLUSION
2020;(3)34.
6. Tsakok M, Shaw R, Murchison A, Ather S, Xie C,
The proportion of 40-49 year age group was the
Watson R, et al. Diagnostic Accuracy of Initial Chest
most common and women are more found than men in Radiograph Compared to SARS-CoV-2 PCR in
this study. The severity of COVID-19 is highest in the Patients with Suspected COVID-19. BJR|Open.
mild grade group and the number decreases with 2020;2(1):20200034.
increasing severity. The normal group in the CXR 7. Borghesi A, Maroldi R. COVID-19 Outbreak in Italy
assessed with the Brixia Score method found more than : Experimental Chest X-Ray Scoring System for
the abnormal CXR images. The higher the degree of Quantifying and Monitoring Disease Progression.
Radiol Med. 2020;125(5):509-13.
pneumonia, the lower the proportion found. The
8. Manna S, Wruble J, Maron SZ, et al. COVID-19: A
majority of CXRs found were bilateral, peripheral, and Multimodality Review of Radiologic Techniques,
predominantly in the lower lung fields. Research Clinical Utility, and Imaging Features. Radiol
subjects who do not have comorbidities are found more Cardiothorac Imaging. 2020;2(3):e200210.
than those who have comorbidities. The five most 9. Zu ZY, Jiang Mdi, Xu PP, Chen W, Ni QQ, Lu GM,
common comorbidities are hypertension, diabetes et al.Coronavirus Disease 2019 (COVID-19): A
mellitus, kidney failure, cardiovascular disease, and Perspective from China. Radiology.
2020;296(2):E15-E25.
hepatobiliary disease. There is a significant relationship 10. Burhan E, Dwi Susanto A, Isbaniah F, Aman
between CXR images and the severity of COVID-19 Nasution A, Ginanjar E, Pitoyo CW, et al. Pedoman
also between comorbidities and the severity of COVID- Tatalaksana COVID-19 Edisi 3 Tim Editor
19. The CXR can determine the severity of the disease Perhimpunan Dokter Paru Indonesia (PDPI)
so that it can be used as the first modality for triage Perhimpunan Dokter Spesialis Kardiovaskular
COVID-19 patients. Indonesia (PERKI) Perhimpunan Dokter Spesialis
Penyakit Dalam Indonesia (PAPDI) Perhimpunan
Dokter Anestesiologi Dan Terapi; 2020.6-7
Acknowledgement 11. Guan W, Ni Z, Hu Y, W Liang, C Ou, J He, et al.
The authors gratefully acknowledge the Director Clinical Characteristics of Coronavirus Disease 2019
of Arifin Achmad General Hospital, Department of in China. 2020. N Engl J Med. 2020;382:1708-20.
Pulmonology and Respiratory Medicine, Department of 12. COVID-19 STP. Peta Sebaran. Satgas Penanganan
Radiology, staff of Medical Record, staff of PINERE COVID-19 [Internet]. 2021 [cited 2021 April 03].
ward for their great support in this study. Available form: https://covid19.go.id/peta-sebaran
13. Zhang JJ, Dong X, Cao YY, Yuan YD, Yang YB,
Yan YQ, et al. Clinical Characteristics of 140
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