September 3, 2020 — A 68-year-old English lady was treated for a possible case of COVID-19 after a radiologist noticed unusual pulmonary findings on an MRI scan for breast cancer staging. The staff behind the case revealed a report within the September print issue of Radiology Case Reports.
The woman was asymptomatic for COVID-19 on the time of the MRI, and she only reported feeling mild upper respiratory symptoms two weeks previous to the scan. However, the radiologist deciphering her contrast-enhanced MR images discovered signs of subpleural consolations and an excessive T2 signal, suggesting she was contaminated with the novel coronavirus.
“Given the predilection of COVID-19 for affecting the respiratory system, any imaging which encompasses all or a part of the lungs may show incidental modifications of an infection,” wrote the authors, led by Dr. Adam Brown from Royal Free Hospital in London (Radiology Case Reports, September 2020, Vol. 15:9, pp. 1629-1632).
The woman was diagnosed with an invasive lobular breast carcinoma after an abnormal mammography result. She had been referred to the Royal Free Hospital radiology department for the local stage, which confirmed unifocal carcinoma within the patient’s upper, outer quadrant of her left breast.
However, breast cancer wasn’t the only notable finding in the patient’s MRI. The reading radiologist additionally noticed incidental findings within the pulmonary space on the patient’s MRI, together with abnormal subpleural high T2 signal intensity within the lung periphery and enhancement in subpleural areas on postcontrast, fat-saturated T1-weighted images.
“Given the excessive prevalence of COVID-19 infection in the local people on the time, concern was raised that the incidental lung findings could also be secondary to optimistic COVID-19 status,” the authors wrote.
The radiology department contacted the patient, urging her to hunt follow-up care in the hospital. She underwent chest radiography, which confirmed peripheral patchy airspace consolidation — a finding frequent with COVID-19. At the time, the patient was asymptomatic, and she and her family members had been instructed to self-isolate in accordance with federal guidelines.
After one day, the patient experienced increased breathlessness and get back to the emergency department. A CT scan revealed bilateral subpleural ground-glass opacities with consolidation and a number of right lower lobe segmental acute pulmonary emboli, serving to strengthen the probability of COVID-19 infection.
The hospital workers treated the patient for COVID-19, based on senior examine author Dr. Anmol Malhotra, consultant radiologist, and breast imaging lead on the Royal Free Hospital. Malhotra famous that the patient additionally developed an incidental pulmonary embolism secondary to COVID-19, however she recovered and was discharged.
“This represents the 1st case of COVID-19 recognized on breast MR imaging that the authors have seen and highlights the importance of immediate identification and flagging of incidental pulmonary findings to reduce additional transmission of the virus in asymptomatic carriers,” the group wrote.
T2-weighted MRI depicting subpleural high T2 signal intensity (red arrows). All images courtesy of Dr. Anmol Malhotra.
T1-weighted postcontrast fat-saturated MRI depicting subpleural consolidation enhancement (red arrows).
Whereas COVID-19 findings are well-documented for CT and chest radiography, the disease’s presentation will not be as properly understood on MRI. Different studies have mentioned COVID-19 can present equally to other forms of pneumonia, together with nonspecific high T2 signal intensity with enhancement on post-contrast T1 imaging.
This case also highlights the significance of looking for incidental findings on images that at least partially visualize the lungs. This not only contains breast MRI but in addition shoulder trauma imaging and a few abdominal CT and MRI, the authors noted.
“Identification of those findings in asymptomatic patients allows applicable isolation measures of patient and family contacts to be commenced to reduce further spread of the virus and also permits safety net advice to be given to make the patient conscious of any possible future deterioration,” Anmol and colleagues concluded. “Training of radiographers to establish suspicious lung modifications on the time of image acquisition can allow for appropriate cleansing of equipment and environment to attenuate the risk of infection to subsequent patients.”