key: cord-1040064-yxs15png authors: Kidane, Biniam; Levin, Daniel P. title: Identification and Resolution of Asymptomatic Coronavirus Disease 2019 Pneumonitis and Colitis: Serial Assessment of Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography for Evaluation of Lung Cancer date: 2020-10-05 journal: J Thorac Oncol DOI: 10.1016/j.jtho.2020.09.004 sha: f731e2bc2256e2d837b4df4846fa45fa568ca5cf doc_id: 1040064 cord_uid: yxs15png nan with no smoking history had a chest radiograph for dyspnea, which identified a right lung nodule. The patient subsequently had a computed tomography (CT) chest which confirmed a spiculated lung nodule suggestive of lung cancer and nothing else. This initiated a diagnostic and staging workup for lung cancer; the time between first CT and positron emission tomography (PET)/CT was 4 weeks. He traveled to Egypt and Jordan after the first CT and 3 weeks before the fluorodeoxyglucose PET/CT. He had no fever or respiratory symptoms. He reported mild gastrointestinal symptoms while traveling, attributed to traveler's diarrhea Q6 . The diarrhea resolved rapidly, 3 weeks before the PET/CT. His initial PET/CT (Figs. 1A, 2, and 3A) revealed mildto-moderate uptake in the pulmonary nodule (maximum standardized uptake value: 4.1; blood glucose 4.5 mmol/ liter). There was bilateral parenchymal fluorodeoxyglucose activity corresponding to ground-glass opacities (GGOs), with hypermetabolic hilar and mediastinal lymphadenopathy. There was also intense colonic hypermetabolism. He was neither diabetic nor on metformin. As he was asymptomatic, he did not meet the criteria for coronavirus testing. When the patient had CT-guided biopsy of the lung mass a week after, he still had GGOs. The biopsy was performed on the day coronavirus disease 2019 (COVID-19) was declared a pandemic. Because of the pulmonary opacities, he was tested for the coronavirus and was found positive. Owing to his asymptomatic status, he did not receive any COVID-19 treatment other than selfisolation. His biopsy confirmed lung adenocarcinoma. The patient returned for repeat PET/CT staging 32 days after the initial study (Figs. 1B and 3). The nodule now had a maximum standardized uptake value of 6.1 (blood glucose 4.8 mmol/liter). Although some GGOs persisted, none had abnormal activity. The hypermetabolic lymphadenopathy had resolved, as had bowel activity. Because of the cancellation of elective surgeries, the patient underwent stereotactic body radiation therapy (48 Gy in four fractions). This report highlights several important issues. The appearance of COVID-19-related pan-colitis on PET/CT has not been previously reported. The primary symptoms of COVID-19 are that of a respiratory flu-like illness. 1 COVID-19 may induce a persistent, intense inflammatory reaction in the respiratory system despite an asymptomatic respiratory state. PET/CT has revealed metabolically active GGOs and hilar and mediastinal lymph nodes in patients with COVID-19, even when asymptomatic. 2, 3 Our patient was considered asymptomatic, although diarrhea is not uncommon with COVID-19. A total of 10% to 15% of patients have gastrointestinal symptoms. 4 Thus, diarrhea should be considered a significant Q7 symptom of coronavirus infection. COVID-19 infection, even in those with minimal symptoms, induces an intense inflammatory state locally; the PET result of this patient revealed colitis several weeks after resolution of mild diarrhea and resolved before the subsequent study. This report highlights the interplay between lung cancer workup and COVID-19 infection. We must now be cognizant of the impact of asymptomatic COVID-19 infection on the routine workup of lung cancer. The pulmonary inflammatory reaction in this patient was so intense that it created a relative metabolic steal phenomenon: the known cancer appeared to have relatively low activity in the presence of the inflammatory changes, but after the resolution of the inflammation as revealed by repeat PET/CT, the metabolic activity was higher. The initial activity in the hilar and mediastinal nodes prohibited staging of his lung adenocarcinoma. All metabolically active GGOs and hilar and mediastinal lymph nodes subsequently resolved. This is the first report of resolution of COVID-19related abnormalities as revealed on PET/CT, in both lung and bowel. Repeat PET/CT may be necessary in patients with COVID-19 for accurate evaluation and staging of lung cancer, even if the patient is asymptomatic and many weeks past the presumed exposure. 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 Clinical characteristics of 3062 COVID-19 patients: a meta-analysis 18 F-Fluorodeoxyglucose uptake in patient with asymptomatic severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019) referred to positron emission tomography/computed tomography for NSCLC restaging Incidental findings suggestive of COVID-19 in asymptomatic patients undergoing nuclear medicine procedures in a high prevalence region COVID-19 and the digestive system Drs. Kidane and Levin contributed to conceptualization, data curation, resources, investigation, writing-original draft preparation, and reviewing and editing of the manuscript.