key: cord-1044710-o4kedm0u
authors: Otero, Rafael; Cintron, Jeann Maldonado; de la Garza, Oziel Garza; Mejia, Earl; Jin, Luyang; Khaddam, Ayman; Apolinario, Ralph; Zarate, Nayeli; Montalvo, Alberto; Hanley, James; Lopez, Henderson
title: CATCHING COVID-19 HIDDEN IN THE CANCER
date: 2020-10-31
journal: Chest
DOI: 10.1016/j.chest.2020.08.1397
sha: cb6e8287a836f0001d341d8e51d4e65b7bfff3d6
doc_id: 1044710
cord_uid: o4kedm0u

nan

The COVID-19 pandemic has set a precedent for medicine, especially vulnerable immunocompromised patients. Cancer patients are facing a dilemma, uncertain of their treatment course, and the serious risk of contracting the viral illness, all while there is no current research showing mortality rates in this group. We present a rapidly evolving undiagnosed COVID-19 patient after chemotherapy initiation for a recent lung cancer diagnosis.

A 64-year-old Caucasian male with a history of COPD, tobacco use and a recent diagnosis of lung cancer presented to the emergency department after experiencing palpitations and 10 days of malaise and dyspnea on exertion. Prior to this, he underwent lung cancer screening with a CT chest scan on April 19, 2020 (baseline CT chest, Figure 1 ). The results showed a left lower lobe mass without infiltrates, subsequently biopsied and confirmed small cell lung carcinoma. Upon presentation to our hospital on May 1, 2020, our patient's labs were significant forabsolute lymphocyte count (745), D-dimer (4.33), NT-proBNP (2149), troponin (0.05), ALT (97), AST (87), creatinine (1.39). There was no evidence of an elevated total WBC, abnormal thyroid studies or any labs suggestive of paraneoplastic syndrome. His initial ECG showed atrial flutter with a rapid ventricular rate. CT chest showed honeycombing lesions in the central right lobe and around the left lobe near the lung mass ( Figure 2) . Given the patient's hemodynamic instability, the patient was admitted to the ICU and successfully cardioverted following a negative TEE. A respiratory PCR panel returned negative on May 4 (did not include COVID-19). Chemotherapy was initiated with carboplatin, etoposide and dexamethasone. A follow-up CT chest revealed evolution of the honeycombing lesions, now spread diffusely, raising concern for COVID-19 (Figure 3) . A COVID-19 NAAT returned positive on May 6.

DISCUSSION: This case illustrates the increased susceptibility of cancer patients to COVID-19. Given this, we recommend preemptive COVID-19 testing for all patients prior to starting any chemotherapy. Secondly, this serves as an example of the rapid evolution of COVID-19, and the benefits of repeated imaging.

CONCLUSIONS: Prior reports from Chinese patients showed bilateral infiltrates upon admission 79% of the time and median 5 days of symptom onset to admission (Zhao1). CT chest scans typically showed ground glass opacities and bilateral patchy shadowing (Guan2, Shi3). If testing is not readily available or turn-around time is prolonged, repeat CT chest scans can help guide treatment. Having a baseline CT chest helped initiate testing for COVID-19 after his symptoms worsened once he received chemotherapy. The evolution is rapid, requiring a high index of suspicion for diagnosis and extensive testing to monitor the course in these patients. This case hopes to set a standard for similar patients.

Reference #1: Zhao D, Yao F, Wang L, et al. A comparative study on the clinical features of COVID-19 pneumonia to other pneumonias. Clinical Infectious Diseases, ciaa247, March 12, 2020. DOI: https://academic.oup.com/cid/advance-article/doi/ 10.1093/cid/ciaa247/5803302external icon.

Clinical Characteristics of Coronavirus Disease 2019 in Chinaexternal icon