First Detection of SARS-CoV-2 by Real-Time Reverse Transcriptase-Polymerase Chain Reaction Assay in Pleural Fluid

Abstract

Coronavirus disease 2019 (COVID-19) is a pandemic infection due to the spread of a novel coronavirus (severe acute respiratory syndrome coronavirus 2), resulting in a wide range of clinical features, from asymptomatic carriers to ARDS. The gold standard for diagnosis is nucleic acid detection by real-time reverse transcriptase-polymerase chain reaction in nasopharyngeal swabs. However, due to limitations in this technique's sensitivity, thoracic imaging plays a crucial, complementary role in diagnostic evaluation and also allows for detection of atypical findings and potential alternative targets for sampling (eg, pleural effusion). Although less common, pleural involvement has been described in a minority of patients. This report describes the first case of reverse transcriptase-polymerase chain reaction detection of severe acute respiratory syndrome coronavirus 2 in pleural fluid obtained by means of ultrasound-guided thoracentesis, and its main characteristics are detailed. Pleural effusion is not a common finding in COVID-19 infection, but a prompt recognition of this potential localization may be useful to optimize diagnostic evaluation as well as the management of these patients.

Keywords: CT-guided biopsy; diagnostic yield; meta-analysis; pleural lesions; safety; ultrasound-guided biopsy.

Figure 1

A-C, Thoracic imaging at baseline. A, High-resolution CT imaging showed multiple bilateral consolidations with inner air bronchogram sign (red arrows) with predominant right-side distribution. B, Contrast-enhanced CT scan ruled out pulmonary embolism, revealing small bilateral pleural effusion (yellow arrows). C, Thoracic ultrasound by convex probe array in right mid-axillary line confirmed demarcated consolidation (green circle) with inner air bronchogram sign (arrowhead).

Figure 2

A-C, Thoracic imaging at day 6. A, Six days, later high-resolution CT imaging showed persistent multiple bilateral consolidations with predominant right-side distribution and increasing of bilateral pleural effusion (red arrows). B, Contrast-enhanced CT scan confirmed a large amount of right-sided pleural effusion with a slight enhancement on parietal pleura (yellow arrows). C, Thoracic ultrasound in the right mid-axillary line revealed moderate pleural effusion with atelectasis of the lower lobe.