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Review
. 2021 Sep-Oct;40(5):299-309.
doi: 10.1016/j.remnie.2021.07.005. Epub 2021 Jul 28.

18F-FDG-PET/CT in SARS-CoV-2 infection and its sequelae

B Rodríguez-Alfonso  1 , S Ruiz Solís  2 , L Silva-Hernández  3 , I Pintos Pascual  4 , S Aguado Ibáñez  5 , C Salas Antón  6
Affiliations
Review

18F-FDG-PET/CT in SARS-CoV-2 infection and its sequelae

B Rodríguez-Alfonso et al. Rev Esp Med Nucl Imagen Mol (Engl Ed). 2021 Sep-Oct.

Abstract
in English, Spanish

In recent months, much of the scientific efforts have focused on research on SARSCoV-2 infection and its consequences in humans. Still, many aspects remain unknown. It is known that the damage caused by SARS-CoV-2 is multifactorial and that its extension goes beyond lung inflammation and the acute phase, with the appearance of numerous complications and sequelae. To date, knowledge about the usefulness of 18F-FDG-PET/CT in the acute phase has been limited to the incidental detection of SARS-CoV-2 unsuspected pneumonia. Recent studies have been appearing collecting the findings of 18F-FDG-PET/CT in long COVID-19 or persistent COVID-19 state as well as the alterations caused after mass vaccination of the population in the metabolic studies. This work aims to review the existing literature focusing on these three issues and to briefly present our own preliminary experience.

Durante los últimos meses gran parte de los esfuerzos científicos se han centrado en la investigación sobre el SARS-CoV-2 y las consecuencias de su infección en humanos. Aun así, muchos aspectos siguen siendo desconocidos. Se sabe que la afectación por SARS-CoV-2 es multifactorial y que su extensión va más allá del daño pulmonar y del momento agudo, con aparición de numerosas de complicaciones y secuelas. El conocimiento de la utilidad de la 18F-FDG-PET/TC en el momento agudo se ha limitado, hasta la fecha, a la detección incidental de afectación pulmonar por SARS-CoV-2. En los últimos meses han ido apareciendo trabajos que recogen los hallazgos de la 18F-FDG-PET/TC en el estado post-COVID, asícomo las alteraciones provocadas en la imagen metabólica tras la vacunación masiva de la población. Este trabajo pretende revisar la literatura existente sobre estas tres cuestiones y exponer de manera breve la experiencia preliminar propia.

Keywords: (18)F-FDG-PET/CT; (18)F-FDG-PET/TC; COVID-19 persistente; Inflamación; Inflammation; Long COVID-19; SARS-CoV-2; Vaccine; Vacuna.

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Figures

Figure 1
Figure 1
Acute infection by SARS-CoV-2 detected during an 18F-FDG-PET/CT study in 2 asymptomatic patients from a respiratory and infectious point of view, later confirmed by RT-PCR. Case 1. MIP (A) of a patient with diffuse large cell B lymphoma in complete metabolic response showing multiple pulmonary uptakes also visible in the axial PET slice (B) and corresponding to ground glass opacities in the axial CT (C) and PET/CT slices (D). Case 2. MIP (A) of patient followed for melanoma showing intense pulmonary and hilar mediastinal uptake corresponding to bilateral ground glass opacities of peripheral predominance and mediastinal and hilar adenopathies visible in the PET (B), CT (C) and PET/CT tomographic slices (D).
Figure 2
Figure 2
Case 1. MIP (A) of patient with fever of unknown origin and Sjögren syndrome receiving treatment with rituximab. Clinical picture compatible with COVID-19 (fever and CT with bilateral parenchymatous involvement) since March 25, 2020 with 3 PCR-negative nasopharyngeal exudates. PET/CT 1 month later showing intense bilateral pulmonary uptake coinciding with radiological alterations visible in the axial CT (B) and PET/CT slices (C) and probable medullary reactivation. A posterior bronchoaspirate was performed confirming persistent infection by SARS-CoV-2 in the PCR. Case 2. MIP (A) of patient with multiple sclerosis receiving treatment with rituximab and post-COVID fever of 2 months of evolution. Pathological uptake of elevated intensity is observed in both pulmonary parenchymas coinciding with areas of opacification in the CT and PET/CT (B,C). A transbronchial biopsy was later performed showing T lymphocyte pneumonitis (D), and immunohistochemical staining showed the persistence of SARS-CoV-2 in lung tissue. (E). Case 3. MIP (A) of young patient with no history of interest with post-COVID dsypnea of 8 months of evolution. Multiple nodular uptakes are shown in both lungs and bilateral hilar mediastinal uptake, coinciding with areas of opacification of the parenchyma and adenopathies which were not increased in size (B, C). The histological lymph node study obtained by echobronchoscopy (D) showed non necrotizing sarcoid type granulomatous inflammation. The posterior transbronchial biopsy showed the same type of granulomatous inflammation without the presence of virus in the immunostaining.
Figure 3
Figure 3
Patient with autoimmune profile (history of sacroileitis, uveítis, sensitivity to gluten) and mild SARS-CoV-2 infection with progressive loss of short-term memory, attention deficit and important asthenia. The statistical brain surface maps obtained by automated analysis are shown (Syngo.via Neurology; Siemens). CT images showing normalization of the whole brain (A) and comparative analysis with the database adjusted for the age of the patient (B) showing frontal hypometabolism (fronto-orbital, rectal and inferior gyri) bilateral temporal bilateral (amygdalas and hippocampos), in both thalamuses and brain stem relative to both cerebellar hemispheres.
Figure 4
Figure 4
Patient with general malaise and weight loss and elevation in C-reactive protein following mild COVID-19. The patient was followed for a polymyalgic picture as the presentation of HLAB27+ enthesopathy. MIP (A) showing a diffuse increase of intestinal uptake attributed to oral antidiabetic treatment and slight bilateral hilar uptake and of the thoracic aorta. Axial (B) and sagittal slices (C) of CT and PET showing an increase of uptake in the aorta wall, not visible in a previous study performed for a rhematological picture (D, E).
Figure 5
Figure 5
(A) 18F-FDG PET/CT study in a patient who had received the first dose of Vaxzevria 5 days previously. The MIP image shows focal uptake in the area of the injection site in the left arm and ipsilateral axillary adenopathies localized at levels I and II in the axial CT and PET/CT slices. (B) 68Ga-edotreotide (Somakit-TOC) PET/CT study in a patient who had received the second dose of Vaxzevria 15 days previously. The MIP image shows uptake in the left axilla corresponding to adenopathies at the left axillary level I, visible in the axialCT and PET/CT slices.
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