Need for Caution in the Diagnosis of Radiation Pneumonitis During the COVID-19 Pandemic

Abstract

Purpose: Patients with cancer are at high risk for mortality from coronavirus disease 2019 (COVID-19). Radiation pneumonitis (RP) is a common toxicity of thoracic radiation therapy with clinical and imaging features that overlap with those of COVID-19; however, RP is treated with high-dose corticosteroids, which may exacerbate COVID-19-associated lung injury. We reviewed patients who presented with symptoms of RP during the intensification of a regional COVID-19 epidemic to report on their clinical course and COVID-19 testing results.

Methods and materials: The clinical course and chest computed tomography (CT) imaging findings of consecutive patients who presented with symptoms of RP in March 2020 were reviewed. The first regional COVID-19 case was diagnosed on March 1, 2020. All patients underwent COVID-19 qualitative RNA testing.

Results: Four patients with clinical suspicion for RP were assessed. Three out of 4 patients tested positive for COVID-19. All patients presented with symptoms of cough and dyspnea. Two patients had a fever, of whom only 1 tested positive for COVID-19. Two patients started on an empirical high-dose corticosteroid taper for presumed RP, but both had clinical deterioration and ultimately tested positive for COVID-19 and required hospitalization. Chest CT findings in patients suspected of RP but ultimately diagnosed with COVID-19 showed ground-glass opacities mostly pronounced outside the radiation field.

Conclusions: As this pandemic continues, patients with symptoms of RP require diagnostic attention. We recommend that patients suspected of RP be tested for COVID-19 before starting empirical corticosteroids and for careful attention to be paid to chest CT imaging to prevent potential exacerbation of COVID-19 in these high-risk patients.

© 2020 The Author(s).

Figures

Figure 1

Chest computed tomography (CT) imaging of case 1. Top row: Radiation treatment planning scan from November 6, 2019, with the radiation dose distribution set at the 50% isodose line. Middle row: CT imaging at the initial presentation of pulmonary symptoms demonstrating minimal inflammatory changes. Bottom row: CT imaging upon the diagnosis of coronavirus disease 2019 (COVID-19) with ground-glass changes most pronounced outside the radiation field (circled in red).

Figure 2

Flow chart illustrating a recommended approach to cases with concern for radiation pneumonitis during the coronavirus disease 2019 (COVID-19) pandemic. ∗An abnormal chest computed tomography (CT) is not specific for COVID-19 diagnosis. Patients with clinical and radiographic features consistent with COVID-19 should be tested when possible.