Lobar expression of SARS-CoV-2 pneumonia.

Description

A 59-year-old man with a personal history of gastritis and pulmonary tuberculosis of the left lung without sequelae 40 years earlier was admitted to the emergency department reporting of high fever (maximum 40°C), dry cough and haemoptysis for the past 5 days. He had been subjected to a SARS-CoV-2 PCR screening test 2 days earlier, with an inconclusive result. Laboratory tests revealed lymphopenia and a mild elevation of hepatic transaminases, lactate dehydrogenase and C reactive protein. The chest X-ray was unremarkable; however, the CT scan revealed a wide area of ground-glass opacity in the right upper lobe (figure 1). The microscopic screening of the sputum was negative for tuberculosis. The patient was diagnosed with COVID-19 after a now-positive PCR result. He had a favourable evolution, with mild disease and neither respiratory distress nor hypoxemia. He was asymptomatic 5 days later and presented a normal chest X-ray and positive SARS-CoV-2 serology after 1 month of follow-up.

Figure 1

CT scan showing upper lobe COVID-19, bound by its fissures, in the transverse plane (A), coronal plane (B) and sagittal plane (C).

CT imaging has become an important tool in the evaluation of patients with COVID-19. Typical hallmarks of this infection include bilateral, multifocal, lower lobe and posterior-dominant ground-glass opacities and crazy-paving appearance.1 Lower lobe involvement can be seen in 90% of patients, while 86% present bilateral lesions.2 Amorphous patchy, nodular, patchy-nodular and rounded lesions are also commonly found.3 Additionally, more extensive lung involvement with opacification is associated with dyspnoea and a more severe course of COVID-19.4 Isolated upper lobe involvement is infrequent and is more frequently found in early stages of the disease.1 Moreover, haemoptysis is a rare symptom, reported in less than 5%5 of cases, usually associated with a more severe clinical course.6

We present a case of isolated right upper lobe involvement that is well limited by its fissure.

Several patients can present with atypical imagiological findings.

Isolated upper lobe involvement is a possible, although infrequent, presentation of COVID-19.

Haemoptysis is a rare presentation of COVID-19.