COVID-19 and pancreatic cancer: what we didn't see

date : 04.06.2020

* **Orlin Zlatarski
*Kaloyana Kaleva
Prof. Galina Kirova-Nedyalkova

*Department of Radiology, Acibadem City Clinic Tokuda Hospital **Department of Emergency Medicine, Acibadem City Clinic Tokuda Hospital

e-mail: o.zlatarski@hotmail.com

Keywords: COVID-19, chest CT, oncology

Clinical history: A 68-year-old man diagnosed with pancreatic cancer and known metastatic liver lesions was admitted to the Department of Medical Oncology for a course of chemotherapy and CT of the chest, abdomen and pelvis for initial staging of the disease. The patient had complaints of fatigue upon exertion and loss of appetite, which had been developing for several months. Until the scan, there was no change in these complaints - the patient was afebrile with Sat. O2 95%.

Imaging findings:

The following findings were established on the chest CT: Figure 1: Chest CT (AD; cranial to caudal) Diffuse zones of ground glass with small areas of peripheral consolidation. Thickening of interlobular septa. Left-side pleural effusion. Uneven nodular thickening of the pleural sheets with fibrous changes mainly at the bases as in pulmonary fibrosis and carcinomatosis. From the laboratory tests: CRP - 220, 88 mg / l; rapid IgG / IgM antibody test was positive for both; sample for RT-PCR test taken from nasopharyngeal secretion - positive result; Leukocytes - 12.31 10 ^ 9 / l; Lymphocytes% - 9.4%; LDH - 560 U / l; Ferritin - 3580.4 ng / ml, D-dimer 19.54 mcg / ml and Sat. O2 98%. On the same day, the patient progressed to tachydyspnoea and Sat. O2 87% with 3 l / min oxygen therapy. The next day this value rose to 97% and the next yet to 94% in ambient conditions, without O2 therapy. Due to the initiation of antibiotics, CRP levels decreased to 52 mg / l and the patient remained stable until discharge on day 15. Figure 2. Control X-ray examination after 4 days shows multiple reticular changes and superimposed areas of ground glass with a peripheral arrangement on both sides. All lung fields are involved. Figure 3. Control radiography on day 8. No significant dynamics. Figure 4. Control radiography on day 14. The study showed persistent infiltrative shadowing, without significant changes.

Final diagnosis: Viral pneumonia caused by coronavirus (SARS-CoV-2) - COVID 19

Discussion:

Unfortunately, studies on the severity of the course, the need for screening and treatment recommendations in patients with concomitant disease are scarce and still unconvincing. A retrospective study of the cases of 28 cancer patients infected with coronavirus in Wuhan, China, showed a high mortality rate and severe clinical course. However, the data are insufficient to discuss a standardized behavioral algorithm. Our case demonstrates several aspects of the comorbidity between COVID-19 and cancer. First, it is extremely difficult to differentiate chronic / chronically progressive underlying disease complaints from those associated with COVID-19, especially when "typical" organ systems are affected. It is for this reason that we were not been able to identify the infection clinically. Second, the question arose whether there should be standardized screening for cancer patients and what it should be. Third, if we assume that there are virtually asymptomatic patients, then should such screening be applied more widely? Fourth, how are patients with diseases mimicking COVID-19 infection (pulmonary and gastrointestinal symptoms) clinically triaged before performing laboratory tests? All these questions are relevant to our everyday practice and do not currently have definitive answers. In our case, the patient was discharged after a double negative RT-PCR and restoration of baseline pulmonary status. However, the consequences of his contact with unprotected hospital personnel still cannot be objectified.

Differential diagnosis:

Non-SARS-CoV2 viral pneumonia; other diseases presenting with diffuse ground-glass opacity on chest CT.

Take home messages:

Patients with positive serological and immunological tests for COVID-19 may be asymptomatic. 2. In our case, the outcome of a COVID-19 patient with cancer was favorable, despite the cited international statistics. 3. Should a screening algorithm be standardized for patients regardless of their clinical status, and, which patient groups should be screened?

Bibliography:

Zhang L, Zhu F, Xie L, et al. Clinical characteristics of COVID-19-infected cancer patients: a retrospective case study in three hospitals within Wuhan, China. Ann Oncol. 2020;31. https://doi.org/10.1016/j.annonc.2020.03.296. Miyashita H, Mikami T, Chopra N, Yamada T, Chernyavsky S, Rizk D, Cruz C., Do patients with cancer have a poorer prognosis of COVID-19? An experience in New York City. Ann Oncol. 2020 Apr 21; doi: 10.1016/j.annonc.2020.04.006. Oh WK. COVID-19 infection in cancer patients: early observations and unanswered questions. Ann Oncol. 2020;31. https://doi.org/10.1016/j. annonc.2020.03.297. Xu Z, Shi L, Wang Y, et al. Pathological findings of COVID-19 associated with acute respiratory distress syndrome. Lancet Respir Med. 2020;8: 420e422. Xia Y, Jin R, Zhao J, Li W, Shen H. Risk of COVID-19 for patients with cancer. Lancet Oncol. 2020;21:e180.

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