Diagnostic and treatment dilemma during the coronavirus disease 2019 pandemic: a primary pulmonary lymphoma presenting as a cavitary mass in a patient with coronavirus disease 2019: a case report.
Fatima Wong, Megan Doyle-McClam, Spencer Pugh, Tina Dudney, Michael McCormack, Jared Kravitz
Author Information
Fatima Wong: Division of Pulmonary and Critical Care Medicine, Department of Medicine, Graduate School of Medicine, University of Tennessee Health Sciences Center Knoxville, Knoxville, TN, USA. fjwong2181@gmail.com.
Megan Doyle-McClam: Division of Pulmonary and Critical Care Medicine, Department of Medicine, Graduate School of Medicine, University of Tennessee Health Sciences Center Knoxville, Knoxville, TN, USA.
Spencer Pugh: Division of Pulmonary and Critical Care Medicine, Department of Medicine, Graduate School of Medicine, University of Tennessee Health Sciences Center Knoxville, Knoxville, TN, USA.
Tina Dudney: Division of Pulmonary and Critical Care Medicine, Department of Medicine, Graduate School of Medicine, University of Tennessee Health Sciences Center Knoxville, Knoxville, TN, USA.
Michael McCormack: Division of Pulmonary and Critical Care Medicine, Department of Medicine, Graduate School of Medicine, University of Tennessee Health Sciences Center Knoxville, Knoxville, TN, USA.
Jared Kravitz: Division of Pulmonary and Critical Care Medicine, Department of Medicine, Graduate School of Medicine, University of Tennessee Health Sciences Center Knoxville, Knoxville, TN, USA.
BACKGROUND: A radiological finding of a cavitary pulmonary lesion in a patient acutely infected with severe acute respiratory syndrome coronavirus-2 early during the coronavirus disease 2019 pandemic created a diagnostic and treatment dilemma, as invasive procedures with bronchoscopy and percutaneous needle lung biopsy posed an infection hazard to healthcare workers due to the associated risk of viral aerosolization. Available guidelines recommended delay of non-emergent procedures, but timely proceeding with those deemed urgent provided appropriate personal protective equipment and negative pressure isolation were available and exposure risk was not excessive. Thoughtful consideration by clinicians was required to avoid delay in diagnosis of a potential new malignancy and prevent unnecessary healthcare worker exposure to the virus. Additionally, acute severe acute respiratory syndrome coronavirus-2 infection in patients with malignancy complicated timing of oncologic treatment. CASE PRESENTATION: A 26-year-old otherwise healthy Caucasian male initially presented with an enlarging right upper lobe cavitary pulmonary lesion despite antimicrobial therapy. During his hospitalization and evaluation, the patient was found to be acutely infected with severe acute respiratory syndrome coronavirus-2 without hypoxia or viral pneumonia. Bronchoscopy was deemed too high risk for viral aerosolization and healthcare worker infection. He underwent computed-tomography-guided percutaneous needle biopsy of the lesion by interventional radiology while on mechanical ventilation after elective intubation by anesthesiology. Biopsy revealed classic Hodgkin lymphoma consistent with primary pulmonary Hodgkin lymphoma. After collaboration with oncology, his treatment with combined chemotherapy and immunotherapy was delayed for 3 weeks following diagnosis to allow for viral clearance. CONCLUSION: A careful multidisciplinary strategy is required to expeditiously diagnose and treat aggressive cancers of the respiratory tract in patients acutely infected with severe acute respiratory syndrome coronavirus-2 while observing practices to prevent healthcare worker infection during the ongoing coronavirus disease 2019 pandemic.
