Added value of 18F-FDG PET/CT in a SARS-CoV-2-infected complex case with persistent fever

Abstract

A 75-year-old diabetic man with a cardiac history of pacemaker implantation and mechanical prosthetic valve (PV) replacement, also known for chronic osteitis of the first left metatarsophalangeal joint (MTP I), was treated with oral antibiotic on an outpatient basis with poor compliance when he developed intermittent fever (39.8°C) and left foot pain. Laboratory testing revealed a slight elevation of the white blood cell count (10.7 G/L) and a significant elevation of the C-reactive protein (235 mg/L). Hemocultures turned positive for multi-sensitive Staphylococcus aureus and Proteus mirabilis. A left foot CT showed MTP I osteoarthritis without collection. Transoesophageal echocardiography (TOE) showed no evidence of endocarditis. A double antibiotic regimen was started, but the patient developed persistent fever. Repeated TOE raised endocarditis suspicion. Because of a newly developed cough, a search for respiratory pathogens was performed and turned positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. An 18 F-FDG PET/CT was requested for investigating the suspicion of PV infection with a 72-h low-carbohydrate diet preparation.The 18 F-FDG PET maximum-intensity projection image shows (a) bilateral metabolic lung lesions, the foot infection (*), and one metabolically active draining sentinel lymph node (arrowhead). (b) Free-breathing lung CT and 18 F-FDG with hypermetabolic (SUV max 7.6 g/mL) focal ground-glass opacities with partial consolidation and mild bronchial dilatation with a peripheral distribution in the subpleural and periscissural regions of the apical and posterior segments of both upper lobes and right middle lobe, as previously described on CT [1]. (c) Hypermetabolic lymphadenopathies in the right lower paratracheal, subcarinal, and bilateral hilar stations (SUV max 6.

Coronavirus Disease 2019 (COVID-19) in Molecular Imaging: A Systematic Review of Incidental Detection of SARS-CoV-2 Pneumonia on PET Studies

“…Furthermore, these patients are more prone to developing complications related to SARS-CoV-2 infection, with increased rates of hospital admissions and mortality, stressing the need for early detection and management of SARS-CoV-2 pneumonia in this high-risk population. The detection of incidental COVID-19 pneumonia in FDG PET/CT findings has been common in recent studies 16 , 17 , 23 . Yet, the reports are so limited and sparse, and a comprehensive review of these manifestations is still lacking.…”

“…Lower lobe interlobular thickening P2/M/57 Li 38 China NR 18 F-FDG Normal-sized LN in the mediastinum but with increased metabolic activity Focal GGOs and bands in both lungs without increased metabolic activity P3/F/58 Amin 12 Canada Hodgkin's lymphoma 18 F-FDG NR Multifocal and bilateral peripheral GGOs, moderate 18 F-FDG activity (SUVmax:4.5) in Lt. lower lobe P4/F/56 Doroudinia 13 Iran NR 18 F-FDG NR Bilateral and diffuse GGOs with associated metabolic activity, few bilateral hypermetabolic nodules P5/M/60 Mo 39 USA SCC of tonsil 18 F-FDG Mediastinal hilar foci Irregular bilateral GGOs P6/M/55 Loforte 40 Italy NR 18 F-FDG NR Multilobular and subpleural GGOs and consolidation in Rt. and Lt. inferior lobes (SUVmax:10.3-10.6) P7/M/75 Kamani 23 Switzerland NR 18 F-FDG Hypermetabolic lymphadenopathies in the Rt. lower paratracheal, subcarinal, and bilateral hilar stations (SUVmax:6.1) Bilateral metabolic lung lesions, hypermetabolic (SUVmax:7.6) focal GGOs with partial consolidation P8/M/37 Liu 41 China NR 18 F-FDG NR Multiple bilateral 18 F-FDG uptake, GGOs lesions: at apical segment of left and right upper lobes; at posterior segment of Lt. upper lobe P9/M/57 Qin 42 China NR 18 F-FDG NR Peripheral GGOs with increased 18 F-FDG uptake (SUVmax range:2.2-4.6) in Rt.…”

Role of 2-[18F]FDG as a Radiopharmaceutical for PET/CT in Patients with COVID-19: A Systematic Review

“…Therefore, as for other organs [ 21 ], PET/CT reading physicians should consider and recognize pulmonary incidental findings, and in particular potential COVID-19 related features, at 2-[ 18 F]FDG PET/CT. These findings should be reported to the referring physicians immediately for appropriate action, as the incidental detection of COVID-19 pneumonia in early stages may help to prevent further spread of the virus [ 7 , 8 , 9 , 10 , 12 , 13 , 14 , 15 , 16 , 17 , 22 , 23 , 24 , 25 ].…”

“…Even if one article included in our systematic review has reported the possible utility of 2-[ 18 F]FDG PET/CT to monitor the inflammatory status in patients with known COVID-19, and even if 2-[ 18 F]FDG PET/CT may be feasible in patients with confirmed SARS-CoV-2 infection when taking adequate protective measures [ 10 , 25 ], the current available evidence are scarce and not sufficient to justify the use of 2-[ 18 F]FDG PET/CT in patients with suspicious or known COVID-19 in the clinical practice and further research is needed before this can be eventually considered [ 3 ]. It should be noted that, in comparison to CT, 2-[ 18 F]FDG PET/CT is a complex procedure requiring more human resources and a long stay in the investigation unit, bearing a certain risk of infectious disease spreading for the health personnel.…”

Asymptomatic COVID–19 cancer patients incidentally discovered during F18-FDG PET/CT monitoring

“…The UK Coronavirus Cancer Monitoring Project published in Lancet Oncology [5] that patients with specific types of cancer might be at an increased risk of COVID-19, with reports highlighting the high proportion of patients with lung cancer who are at a higher risk of developing severe complications following their infection by SARS-CoV-2 [6][7][8]. The role of F18-fluorodeoxyglucose positron emission tomography/computed tomography (F18-FDG PET/CT) is not yet well established in COVID-19 disease [9][10][11][12][13][14][15][16], but its fundamental role in the initial diagnosis, staging, prognosis, response evaluation and follow-up in cancer disease is well known and well established. Recent studies have found a potential role of F18-FDG PET/CT in the evaluation of positive patients during recovery [17].…”