Clinical course of coronavirus disease 2019 in 11 patients after thoracic surgery and challenges in diagnosis

Abstract

Objectives: To illustrate the clinical course and difficulties in early diagnosis of coronavirus disease 2019 (COVID-19) in patients after thoracic surgery.

Methods: We retrospectively analyzed the clinical course of the first 11 patients diagnosed with COVID-19 after thoracic surgery in early January 2020. Postoperative clinical, laboratory, and radiologic records and the time line of clinical course were summarized. Potential prognostic factors were evaluated.

Results: In the 11 confirmed cases (3 female, 8 male), median days from symptom onset to case detection was 8. Insidious symptom onset and misinterpreted postoperative changes on chest computed tomography (CT) resulted in delay in diagnosis. There were 3 fatalities due to respiratory failure, whereas 4 severe and 4 mild cases recovered and were discharged. All patients had once experienced leukocytosis and eosinopenia. Remittent fever and resected lung segments ≥5 were associated with fatality.

Conclusions: The case fatality rate of postsurgical patients subsequently diagnosed with COVID-19 was 27.3%. Insidious symptom onset, postoperative leukocytosis with lymphopenia, and postsurgical CT changes overshadowed the early signs of viral pneumonia. Dynamic symptom monitoring, serial chest CTs, and tests for viral RNA and serum antibody improve the chance for prompt detection of COVID-19. Consideration should be given to preadmission and preoperative screening and strict contact isolation during the postoperative period.

Keywords: COVID-19; Sars-Cov-2; esophageal cancer; lung cancer; postoperative; surgery.

Timeline of events in coronavirus disease 2019 for 11 patients after thoracic surgery.

Figure 1

Timeline of events in the clinical course of coronavirus disease 2019 in 11 patients after thoracic surgery. IDs 1, 2, and 3 represent 3 critical patients dead from respiratory failure. Severe cases (IDs 4, 5, 6, 7) and nonsevere cases (IDs 8, 9, 10, 11) were discharged upon recovery. Median of days from surgery to death was 35 (range 5-42, n = 3), and from surgery to discharge upon recovery was 50 (range 38-72, n = 8). (Date of first exposure for case ID 1 and case ID 9 were uncertain.) Sars-Cov-2, Severe acute respiratory syndrome coronavirus 2; COVID-19, coronavirus disease 2019; CT, computed tomography.

Figure 2

CT of the chest of a 63-year-old male patient (case ID 1) with progression of COVID-19 before and after operation. Biopsy of solid tumor in the right lower lobe indicated adenocarcinoma. The subpleural ill-defined ground-glass opacification had increased extent and intensity from 23 days (A) to 14 (B) days preoperatively. He was asymptomatic and had abrupt onset of fever (39°C) within 12 hours after right lower lobectomy. C, Postoperative CT at day 2 shows postoperative changes and sign of consolidation. D, On day 4, he had extended bilateral reticular consolidation and sign of bronchogram. He died from respiratory failure 5 days after surgery.

Figure 3

CT findings of COVID-19, overshadowed by postoperative changes at the onset, shows progression on repeated CT of the chest and typical signs of progressive viral pneumonia. A, A 61-year-old male patient (case ID 5) 6 days after left lower lobectomy. He had intermittent fever for 3 days with CT findings of emphysema, reticular areas of increased opacity, and irregular patchy consolidation. His repeat CT scan after 5 days shows increased extent and intensity of lesions, suspicious for viral pneumonia (E). B, Chest CT of a 56-year-old female patient (case ID 3) 11 days after left lower lobectomy shows irregular subsolid patchy opacity in left upper lobe. After 5 days (F), the lesion has increased in size and number, with consolidation, pleural effusion and interlobular septal thickening. C, CT of the chest of a 66-year-old female patient (case ID 10) 10 days after left lung wedge resection of upper lobe with basal segmentectomy. CT scan shows small irregular GGO in the right upper lobe and subpleural cord-like consolidation (C), which were not rare as postoperative reactive change. After 8 days, CT shows typical signs of viral pneumonia (G): diffuse ground glass opacifications with “paving stone” signs and, irregular subpleural cord-like consolidation. D, A 68-year-old male patient (case ID 2) 12 days after right lower lobectomy. Chest CT (D) shows pneumothorax, subcutaneous emphysema, postoperative changes, and inflammation around chest drain. After 18 days, he had sudden onset of fever and CT scan revealed (H) multiple diffuse GGOs in the lung peripheries with reticular consolidation.