A 58-year-old woman with diabetes and morbid obesity (body mass index 44.3 kg/m2) presented to an outpatient facility for routine staging for Hodgkins lymphoma using positron emission tomography–computed tomography (PET/CT) staging. The patient was prescreened outside the clinic doors, and she denied having any symptoms of coronavirus disease 2019 (COVID-19), was afebrile and had no history of travel or contact with anyone with COVID-19. She was injected with fluorodeoxyglucose F 18 (18F-FDG) radiotracer, after which she rested in the supine position in the injection room to allow radiotracer biodistribution, during which the patient was first overheard to have occasional coughing spells.
The PET/CT imaging confirmed the biopsy-proven, stage 2 right pelvic adenopathy (Figure 1A, white arrow), with only mild 18F-FDG activity (SUVmax 2.9). Imaging also showed that the patient had multifocal bilateral peripheral lung opacities (Figures 1C and 1D), with moderate 18F-FDG activity (SUVmax 4.5) in the left lower lobe (Figure 1C, white arrow). We did not find any pleural effusions or 18F-FDG-avid mediastinal adenopathy. One week before presentation, staging diagnostic CT of her chest was clear (Figure 1B).
We immediately notified the referring clinician, and the patient was sent for same-day testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with instructions to self-isolate. Two days later, a positive result for reverse transcriptase–polymerase chain reaction (RT–PCR) for SARS-CoV-2 was reported; concurrently, the patient had acquired a runny nose, more frequent coughing and fever (38°C).
Many outpatients have presented for diagnostic imaging after passing prescreening for COVID-19 and have unexpected findings on subsequent chest radiography and CT,1 typically multifocal ground-glass opacities or more dense infiltrates.2 On PET/CT, pneumonia associated with COVID-19 is 18F-FDG avid.3–5 Although some researchers have suggested that this modality may be a prognostic indicator, evidence is limited to case reports.3
Our patient was admitted to hospital for observation. Her symptoms abated over the course of a week, and she was discharged. Her planned course of pelvic radiation was delayed because of restrictions implemented during the COVID-19 pandemic.
Acknowledgement
The authors thank Dr. Marc Freeman (MyHealth Centre, Toronto) for assistance with interpretation of positron emission tomography–computed tomography images.
Footnotes
Competing interests: Leonard Grinblat and Mansoor Husain are minority shareholders in the privately owned facility (MyHealth Centre, Toronto) where this case originated. No other competing interests were declared.
This article has been peer reviewed.
The authors have obtained patient consent.