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 Table of Contents     
LETTER TO THE EDITOR
Year : 2020  |  Volume : 35  |  Issue : 3  |  Page : 274-275  

Imaging spectrum in coronavirus disease-2019: What every nuclear medicine physician must know?


Division of PET Imaging, Institute of Nuclear Medicine and Allied Sciences, Delhi, India

Date of Submission06-May-2020
Date of Acceptance18-May-2020
Date of Web Publication01-Jul-2020

Correspondence Address:
Dr. Maria Mathew DSouza
Institute of Nuclear Medicine and Allied Sciences, Brig. SK Majumdar Marg, Delhi - 110 054
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnm.IJNM_96_20

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How to cite this article:
DSouza MM, Sharma R, Jaimini A. Imaging spectrum in coronavirus disease-2019: What every nuclear medicine physician must know?. Indian J Nucl Med 2020;35:274-5

How to cite this URL:
DSouza MM, Sharma R, Jaimini A. Imaging spectrum in coronavirus disease-2019: What every nuclear medicine physician must know?. Indian J Nucl Med [serial online] 2020 [cited 2020 Nov 29];35:274-5. Available from: https://www.ijnm.in/text.asp?2020/35/3/274/288475



Sir,

The coronavirus disease-2019 (COVID-19) pandemic is spreading at an inexorable pace and infecting more and more people worldwide. Many infected individuals are asymptomatic, at least in the initial stages. A recent study has shown that 50%–75% of individuals infected with COVID-19 were asymptomatic.[1] Although nuclear medicine imaging is unlikely to be part of the armamentarium for initial diagnosis, there have been cases described in the recent past of incidental detection of COVID-19 in asymptomatic cases undergoing scans for other indications. In all probability, this occurrence is bound to increase in frequency. While nuclear medicine services need to stringently follow the standard guidelines mandatory for healthcare personnel, it is equally important to be conversant with the imaging hallmarks, atypical features, and pattern of evolution of changes induced by the disease.

The respiratory system is the site of primary involvement. All pulmonary lesions reported in the literature were FDG avid.[2],[3],[4],[5],[6] The first report on FDG positron emission tomography (PET)/computed tomography (CT) findings came from Wuhan at a time when the COVID-19 outbreak was still unrecognized.[2] The four patients described in this report had FDG avid peripheral ground-glass opacities (GGOs) and/or consolidations in the multiple pulmonary lobes, along with FDG avid mediastinal, hilar, or subclavian lymphadenopathy. They had typical clinical symptomatology of COVID-19, and the diagnosis was made on retrospective review of the clinical, laboratory, and imaging data.

FDG avid pulmonary lesions have been incidentally detected in asymptomatic cases as well. In fact, a recent report from another high prevalence region describes similar findings on a group of six patients who underwent PET/CT for various malignancies.[3] They were asymptomatic not only at the time of imaging but also for a period of at least 2 weeks before the study and were carefully screened by a triage before entering the scanning unit. Nevertheless, the patients had FDG-positive GGOs and consolidation in both the lungs; most pronounced in the inferior lobes. The study also describes incidental detection of GGOs in a patient who underwent 131 I-single-photon emission computed tomography/CT – the lesions predictably did not demonstrate radioiodine uptake. The patients went on to develop respiratory symptoms and tested positive for COVID-19. Similar findings were subsequently published by another group on a series of five patients.[4]

The classic CT appearance of COVID-19 lesions is now well described in the literature. Initial stages show the presence of multilobar GGOs, predominantly in the periphery of the lung, mainly in the lower lobes. With time, the lesions increase in size and number and spread to the center. Disease progression is marked by consolidation, septal thickening, crazy paving, CT halo sign, lymphadenopathy, pleural effusion, and pneumothorax.[7],[8]

An unusual presentation of COVID-19 is the development of acute necrotizing encephalopathy (ANE): a rare complication of influenza and other viral infections. COVID-related ANE has presented as areas of symmetric hypoattenuation within medial thalami on CT and as hemorrhagic rim enhancing lesions within bilateral thalami, medial temporal lobes, and subinsular regions on magnetic resonance imaging (MRI).[9] Although PET/CT findings have not yet been described, the disease per se arises due to intracranial cytokine storms, and hence, in all probability, it is likely to be FDG avid depending on the disease stage at the time of scanning. Cardiac involvement presenting as myocarditis and myopericarditis is also a well-recognized complication, which has been described on MRI as increased wall thickness with biventricular hypokinesia, interstitial edema, and left ventricular dysfunction with circumferential pericardial effusion.[10] Nuclear medicine scan findings of cardiac involvement in COVID are yet to be published.

A thorough preparedness to meet the challenges of handling a COVID patient (known or incidentally diagnosed) is imperative for every nuclear medicine facility.[11] Designation of an isolation room with negative air pressure is necessary. Use of standard (Personal protective equipment) PPE (with proper donning and doffing) for personnel and mask and gown for the patient is mandatory. Disinfection of scanner (as per the manufacturer's recommendations) and deep disinfection of scanner room are essential. The names of all personnel dealing with the patient should be recorded for contact tracing (if required). The principles of “time, distance, and shielding” in the appropriate context should be followed at all times.[11]

Sooner or later, COVID cases are bound to find their way into nuclear medicine imaging departments. Knowledge of the imaging spectrum and the standard operating procedures would enable a prompt and effective management of patients and personnel.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Day M. COVID-19: Identifying and isolating asymptomatic people helped eliminate virus in Italian village. BMJ 2020;368:m1165.  Back to cited text no. 1
    
2.
Qin C, Liu F, Yen TC, Lan X. 18F-FDG PET/CT findings of COVID-19: A series of four highly suspected cases. Eur J Nucl Med Mol Imaging 2020;47:1281-6.  Back to cited text no. 2
    
3.
Albano D, Bertagna F, Bertoli M, Bosio G, Lucchini S, Motta F, et al. Incidental findings suggestive of COVID-19 in asymptomatic patients undergoing nuclear medicine procedures in a high-prevalence region. J Nucl Med 2020;61:632-6.  Back to cited text no. 3
    
4.
Setti L, Kirienko M, Dalto SC, Bonacina M, Bombardieri E. FDG-PET/CT findings highly suspicious for COVID-19 in an Italian case series of asymptomatic patients. Eur J Nucl Med Mol Imaging 2020;47:1649-56.  Back to cited text no. 4
    
5.
Zou S, Zhu X. FDG PET/CT of COVID19. Radiology 2020. doi: 10.1148/radiol.2020200770. Online ahead of print.  Back to cited text no. 5
    
6.
Kirienko M, Padovano B, Serafini G, Marchianò A, Gronchi A, Seregni E, et al. CT, [18F] FDG- PET/CT and clinical findings before and during early Covid-19 onset in a patient affected by vascular tumour Eur J Nucl Med Mol Imaging 47:1769-70.  Back to cited text no. 6
    
7.
Salehi S, Abedi A, Balakrishnan S, Gholamrezanezhad A. Coronavirus disease 2019 (COVID19): A systematic review of imaging findings in 919 patients. AJR Am J Roentgenol 2020. PMID: 32174129.  Back to cited text no. 7
    
8.
Bernheim A, Mei X, Huang M, Yang Y, Fayad ZA, Zhang N, et al. Chest CT findings in coronavirus disease19 (COVID19): Relationship to duration of infection. Radiology 2020;295(3):200463. doi: 10.1148/radiol.2020200463. Epub 2020 Feb 20.  Back to cited text no. 8
    
9.
Poyiadji N, Shahin G, Noujaim D, Stone M, Patel S, Griffith B. COVID19associated acute hemorrhagic necrotizing encephalopathy: CT and MRI features. Radiology 2020. doi: 10.1148/radiol.2020201187. Online ahead of print.  Back to cited text no. 9
    
10.
Inciardi RM, Lupi L, Zaccone G, Italia L, Raffo M, Tomasoni D, et al. Cardiac involvement in a patient with coronavirus disease 2019 (COVID19). Cardiol 2020. doi: 10.1001/jamacardio.2020.1096. Online ahead of print.  Back to cited text no. 10
    
11.
Singh H. Preparedness of nuclear medicine departments during the severe acute respiratory syndromecoronavirus2 (COVID19) pandemic. Indian J Nucl Me DOI: 10.4103/ijnm.IJNM_62_20 [Epub ahead of print].  Back to cited text no. 11
    




 

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