Hilar Lymphadenopathy, a Novel Finding in the Setting of Coronavirus Disease (COVID-19)

A Case Report

Mohsin Sheraz Mughal; Rameez Rehman; Ramy Osman; Nathan Kan; Hasan Mirza; Margaret H. Eng

Disclosures

J Med Case Reports. 2020;14(124) 

In This Article

Abstract and Introduction

Abstract

Background: As the outbreak of coronavirus disease 2019 (COVID-19) has progressed, computed tomography has emerged as an integral part of the diagnosis alongside reverse transcriptase–polymerase chain reaction assays. Frequently encountered imaging findings include peripheral airspace consolidations; bilateral ground-glass opacities; and, less commonly, cavitation. Hilar lymphadenopathy is a rarely reported finding in the setting of COVID-19.

Case Presentation: A 73-year-old Caucasian woman presented to our hospital with fever and fatigue. She had a maximum body temperature of 102.3 °F with lymphopenia and thrombocytopenia. She was diagnosed with severe acute respiratory syndrome coronavirus 2 infection on the basis of a positive result from a reverse transcriptase–polymerase chain reaction of a nasopharyngeal swab sample. Contrast-enhanced chest computed tomography revealed multifocal, subpleural ground-glass opacities with nodular consolidations bilaterally. Computed tomography also demonstrated atypical bilateral hilar lymphadenopathy, a rarely reported imaging feature of COVID-19. Chest computed tomography 1 month before the presentation did not show focal consolidations or lymphadenopathy. This indicated that the findings were due to the patient's severe acute respiratory syndrome coronavirus 2 infection. She received 5 days of oral hydroxychloroquine and experienced resolution of her symptoms.

Conclusion: Chest computed tomography has been used extensively to diagnose and characterize the distinguishing radiological findings associated with viral pneumonia. It has emerged as an integral part of the diagnosis of COVID-19 alongside reverse transcriptase–polymerase chain reaction assays. Clinicians must be aware of uncommon clinical and radiological findings in order to diagnose this entity. Hilar lymphadenopathy is commonly seen with fungal infections, mycobacterial infections, and sarcoidosis. An extensive literature review found that bilateral hilar lymphadenopathy has not been reported in the setting of COVID-19. More data are needed to establish the clinical impact of this novel finding.

Introduction

The World Health Organization declared coronavirus disease 2019 (COVID-19) a pandemic in March 2020. Though the incidence of the disease has drastically dropped in China, it is rising worldwide.[1] Coronavirus is an encapsulated ribonucleic acid (RNA) virus, a novel coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which was identified as the culprit of a cluster of lower respiratory tract illnesses in Wuhan, China. A study suggested that it has two strains: type S and type L.[2] The understanding of the disease, its transmission, and its treatment are still evolving. COVID-19 can range from being asymptomatic to a wide variety of severe symptoms.[3] Several observational studies suggested that fever, malaise, dry cough, and dyspnea are the most common presenting symptoms.[4] As the outbreak of COVID-19 has progressed, so have the methodologies used in its diagnostic workup. A chest computed tomographic (CT) scan has quickly emerged as an integral part of the diagnosis alongside reverse transcriptase–polymerase chain reaction (RT-PCR) assays.[5] The most commonly reported CT findings in patients with COVID-19 are bilateral ground-glass opacities.[6] In another study, CT manifestations were peripheral airspace consolidations in one-third of the cases. Less common findings include pleural effusion, pericardial effusion, cavitation, air bronchograms, and pneumothorax.[7] These data are helpful for clinicians to gain an understanding of a wide spectrum of imaging findings in patients with COVID-19. Hilar lymphadenopathy is a common radiological finding associated with fungal infections, mycobacterial infections, and sarcoidosis. However, it is rarely seen in viral pneumonia. Because the COVID-19 pandemic is affecting healthcare and economic systems worldwide, it is imperative to detect the disease earlier in the course before complications involving acute hypoxic respiratory failure warranting invasive mechanical ventilation arise. Characteristic CT scan findings, alongside RT-PCR and antibody testing, help clinicians diagnose COVID-19. None of these modalities can be used as a single tool to diagnose SARS-CoV-2 infection. An extensive literature review found that acute bilateral hilar lymphadenopathy has not been reported in the setting of COVID-19.[6,8] It is important to report atypical imaging findings to establish their frequency and association with disease severity and outcomes.

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