key: cord-0999975-x9iazkqt
authors: Rathod, Shrinivas; Ahmed, Shahida; Vanstone, Robin; Fatoye, Tunji; Desautels, Danielle; Koul, Rashmi
title: Working in the dark: Interaction with a sub clinical COVID-19 subject and lessons learned
date: 2020-06-02
journal: Eur J Cancer
DOI: 10.1016/j.ejca.2020.05.008
sha: 4dc1c0bb93f9523a6a6641e32be279f8ac900590
doc_id: 999975
cord_uid: x9iazkqt

• Presentation of a subclinical COVID-19 case in Oncology. • Importance of clinical vigilance. • Role of imaging in the identification of subclinical COVID-19. • Risk to healthcare team.

difficulty in breathing, chest pain, sore throat, myalgia, diarrhea, runny nose or any other concerning symptoms. She also did not have any history of recent travel within the last 2 weeks and did not have any contact with proven COVID-19 subjects. She was deemed safe at the COVID-19 screening and subsequently was seen by a breast radiation oncologist. The option of adjuvant radiation was discussed with her and she agreed to proceed. As per standard breast radiation protocol, CT of the thorax was performed for patient set-up and tumour localization and radiation planning for her breast radiation on 31 st March 2020. Surprisingly the CT showed ground-glass opacities that the caught eye a vigilant radiation therapist.

These concerning findings were discussed with the involved radiation oncologist and further COVID-19 assessment including a diagnostic CT thorax (image 1) was initiated after a discussion with the local Infection Prevention and Control team. She had a nasopharyngeal swab performed on 31 st March 2020 and did test positive for COVID-19. Contact tracing protocol was initiated. Subsequently, the patient A, radiation oncologist, radiation therapist, nursing team and close contacts were advised 2 weeks of self-isolation. Fortunately, the involved health care team did not contract the infection and safely returned to work after 2 weeks as per provincial COVID-19 policy. Despite the changes seen on CT Chest, Patient A remained entirely well and asymptomatic, and on day 16 following the positive test patient had a repeat test, which was negative This case involved a very close clinical interaction with a subclinical COVID-19 subject that met the "standard screening criteria" is unique in several ways. She had appropriately self-isolated for 14 days following travel from the US. Thus, she did not meet the 14 days travel criteria. Fortunately, as she was a breast cancer patient, radiation-planning CT involved thorax and the vigilance of involved radiation team members made this detection possible at early stages. Hypothetically, had she suffering from brain, abdomen or pelvic malignancy we would not have caught this.

Patient A remained entirely well and asymptomatic throughout the quarantine and never developed symptoms. With several other immunocompromised patients in the oncological facility, there was a risk of spread and consequences. The risk of therapists, nurses and physicians contracting infection, and spreading it is paramount. The implications of the risk of a decrease in specialized radiation oncology workforce could hamper and even halt operations of radiation oncology.

The fact that 1 in 10 COVID-19 subjects is healthcare personnel is alarming and highlights the need for better policy measures for the healthcare team. 4, 5 Ironically, at this point, although PPE guidelines were in place for interaction with suspected or positive COVID-19 subjects, it did not apply to other routine clinical interactions.

Learning from these and other such experiences, updated PPE guidelines were enforced that recommended the use of surgical mask, hand and eye protection during all clinical interactions. 6

This case highlights the importance of clinical vigilance and role of imaging in the identification of subclinical COVID-19. Learning from our experience, we suggest close attention should be paid to any unexpected findings such as ground-glass opacity on CT as it could help early identification of subclinical COVID-19 infection.

Indeed subclinical COVID-19 subjects pose a unique challenge amid the ongoing crisis and yet very little attention is offered to it. Collective effort and research are needed to design or modify policies to protect our healthcare personnel against the current and any future infections are urgently needed.

Protecting health-care workers from subclinical coronavirus infection

What Hospitals and Health Care Workers Need to Fight Coronavirus

Health-care workers make up 1 in 10 known cases of COVID-19 in

workers-make-up-1-in-10-known-cases-of-covid-19-in-ontario-1.5518456 6. Provincial Requirements for COVID-19 Personal Protective Equipment (PPE)

Role of imaging in the identification of subclinical COVID-19

of all authors, I confirm we do not have any conflict of interest to declare

Shrinivas Rathod Radiation Oncologist, Radiation Oncology Program, CancerCare Manitoba Assistant Professor, University of Manitoba ON3256 -675 McDermot Avenue Winnipeg MB R3E 0V9 Telephone