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Atypical Presentation of COVID-19 Incidentally Detected at 18F-FDG PET/CT in an Asymptomatic Oncological Patient

Mattoli, Maria Vittoria MD; Taralli, Silvia MD; Pennese, Elsa MD; D’Angelo, Carla MD§; Angrilli, Francesco MD; Villano, Carlo MD

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doi: 10.1097/RLU.0000000000003175
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A 59-year-old man with diffuse large B-cell lymphoma on whom an 18F-FDG PET/CT was performed for immunochemotherapy response evaluation on March 18, 2020, 27 days after COVID-19 outbreak in Italy. Along with partial metabolic response, PET maximum intensity projection image (A) revealed a focal uptake area in the middle field of the right lung, corresponding on axial images (B, low-dose free-breathing coregistered CT; C, fused PET/CT; D, PET only) to a metabolically active (SUVmax 3.3) isolated centrilobular consolidation in the middle lung lobe surrounded by a faint ground-glass opacity (GGO) (maximum diameter 28 mm), without any other parenchymal alterations detectable bilaterally at coregistered CT (E). At that time, the patient was considered at low risk of SARS-CoV-2,1 being completely asymptomatic and denying suspected expositions to infected people. Based on clinical and morphofunctional characteristics, the PET/CT finding was interpreted as a nonspecific pneumonia at an early phase, as frequently occurring during chemotherapy. A subsequent clinical/radiological evaluation was suggested. On March 30, still asymptomatic without specific medication, the patient underwent a chest x-ray for revaluation, showing bilateral parenchymal consolidations, highly suggestive of viral pneumonia. He suddenly was tested for SARS-CoV-2 through nasopharyngeal swab, resulting as positive, and he was quarantined at home.
Soon after, the patient developed fever, cough, and intense dyspnea. On April 4, he went to a local accident and emergency department, where a chest CT was performed: axial images showed widespread multiple bilateral GGOs and consolidations with air bronchogram in both upper and lower lung fields with predominant peripheral distribution, concordant with typical bilateral COVID-19 pneumonia.2,3 After several days of assisted ventilation with continuative positive airway pressure and multidrug treatment (including steroids, hydroxychloroquine, tocilizumab, levofloxacin, azithromycin, low-molecular-weight heparin, antiplatelet, lopinavir/ritonavir), patient’s disease status improved. To the best of our knowledge, this is the first reported case of an atypical presentation of a confirmed COVID-19 pneumonia as unilateral isolated and relatively small 18F-FDG–avid consolidation in an asymptomatic oncological patient incidentally detected at PET/CT. Growing literature reports on symptomatic and asymptomatic4–18 oncological patients with incidental 18F-FDG–avid pulmonary findings highly suggestive of COVID-19, although presenting with more common multiple bilateral GGOs and consolidations. Our case highlighted that atypical PET/CT presentation of COVID-19 in asymptomatic oncological patients, appearing as in our case, is the most challenging issue for nuclear medicine physicians. Indeed, oncological patients undergoing PET/CT may present with pulmonary malignancies (eg, lung cancer, lymphoma), but often copresenting pulmonary treatment-related inflammatory/infective processes (eg, nonspecific pneumonia). At PET/CT, these conditions could show similar morphofunctional appearance, but considered atypical for COVID-19. Therefore, in such unexpected COVID-19 case, to suspect the most likely diagnosis, although incorrect, is highly probable. Now more than ever, it is of paramount importance to avoid delay in COVID-19 diagnosis. Consequently, we should consider any new-onset pulmonary lesion as a possible COVID-19 manifestation, until proven otherwise. Therefore, a SARS-CoV-2 test may be considered even for an asymptomatic patient at low risk of SARS-CoV-2 infection and presenting with an apparently “far-from-COVID-19” finding at 18F-FDG PET/CT, aiming to promptly reach a definitive diagnosis, reduce the viral spread, and early indicate appropriate therapeutic management.


1. Coronaviridae Study Group of the International Committee on Taxonomy of Viruses. The species severe acute respiratory syndrome-related coronavirus: classifying 2019-nCoV and naming it SARS-CoV-2. Nat Microbiol. 2020;5:536–544.
2. Naming the coronavirus disease (COVID-19) and the virus that causes it. Available at: Accessed April 16, 2020.
    3. Ye Z, Zhang Y, Wang Y, et al. Chest CT manifestations of new coronavirus disease 2019 (COVID-19): a pictorial review. Eur Radiol. 2020.
      4. Zou S, Zhu X. FDG PET/CT of COVID-19. Radiology. 2020;200770.
        5. Czernin J, Fanti S, Meyer PT, et al. Nuclear medicine operations in the times of COVID-19: strategies, precautions, and experiences. J Nucl Med. 2020;61:626–629.
          6. Polverari G, Arena V, Ceci F, et al. 18F-FDG uptake in asymptomatic SARS-CoV-2 (COVID-19) patient, referred to PET/CT for non–small cells lung cancer restaging [published online March 31, 2020]. J Thorac Oncol. 2020:
            7. Albano D, Bertagna F, Bertoli M, et al. Incidental findings suggestive of COVID-19 in asymptomatic patients undergoing nuclear medicine procedures in a high-prevalence region. J Nucl Med. 2020;61:632–636.
              8. Kirienko M, Padovano B, Serafini G, 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. 2020.
                9. Tulchinsky M, Fotos JS, Slonimsky E. Incidental CT findings suspicious for COVID-19 associated pneumonia on nuclear medicine exams: recognition and management plan [published online April 9, 2020]. Clin Nucl Med. 2020.
                  10. Lu Y, Zhu X, Yan SX, et al. Emerging attack and management strategies for nuclear medicine in responding to COVID-19-ACNM member experience and advice. Clin Nucl Med. 2020.
                    11. Qin C, Liu F, Yen TC, et al. 18F-FDG PET/CT findings of COVID-19: a series of four highly suspected cases. Eur J Nucl Med Mol Imaging. 2020;47:1281–1286.
                    12. Doroudinia A, Tavakoli M. A case of coronavirus infection incidentally found on FDG PET/CT Scan. Clin Nucl Med. 2020.
                      13. Liu C, Zhou J, Xia L, et al. 18F-FDG PET/CT and serial chest CT findings in a COVID-19 patient with dynamic clinical characteristics in different period. Clin Nucl Med. 2020;45:495–496.
                        14. Playe M, Siavellis J, Braun T, et al. FDG PET/CT in a patient with mantle cell lymphoma and COVID-19: typical findings. Clin Nucl Med. 2020;00:00–00.
                          15. Xu X, Yu C, Qu J, et al. Imaging and clinical features of patients with 2019 novel coronavirus SARS-CoV-2. Eur J Nucl Med Mol Imaging. 2020;47:1275–1280.
                          16. Huang HL, Allie R, Gnanasegaran G, et al. COVID19 -nuclear medicine departments, be prepared! Nucl Med Commun. 2020;41:297–299.
                          17. Paez D, Gnanasegaran G, Fanti S, et al. COVID-19 pandemic: guidance for nuclear medicine departments. Eur J Nucl Med Mol Imaging. 2020.
                            18. Buscombe JR, Notghi A, Croasdale J, et al; Council and Officers of British Nuclear Medicine Society. COVID-19: guidance for infection prevention and control in nuclear medicine. Nucl Med Commun. 2020;41:499–504.

                              18F-FDG; consolidation; COVID-19; PET/CT; pneumonia; SARS-CoV-2

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