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

Shaverdian, Narek; Shepherd, Annemarie; Rimner, Andreas; Wu, Abraham J.; Simone, Charles B.; Gelblum, Daphna Y.; Gomez, Daniel R.

INTRODUCTION: Patients with cancer are at high-risk for mortality from coronavirus-disease 2019 (COVID-19). Radiation pneumonitis (RP) is a common toxicity of thoracic radiotherapy with overlapping clinical and imaging features with 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: 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 3/1/2020. All patients underwent COVID-19 qualitative RNA testing. RESULTS: Four patients with clinical suspicion for RP were assessed. Three out of four patients tested positive for COVID-19. All patients presented with symptoms of cough and dyspnea. Two patients had a fever, of whom only one tested positive for COVID-19. Two patients started on an empiric 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 empiric corticosteroids and for careful attention be paid to chest CT imaging in order to prevent potential exacerbation of COVID-19 in these high-risk patients.