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Alert to Potential Contagiousness: A Case of Lung Cancer With Asymptomatic Severe Acute Respiratory Syndrome Coronavirus 2 Infection

  • Wen Ouyang
    Affiliations
    Department of Radiation and Medical Oncology, Zhongnan Hospital, Wuhan University, Wuhan, People’s Republic of China
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  • Jing Yu
    Affiliations
    Department of Radiation and Medical Oncology, Zhongnan Hospital, Wuhan University, Wuhan, People’s Republic of China
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  • Junhong Zhang
    Affiliations
    Department of Radiation and Medical Oncology, Zhongnan Hospital, Wuhan University, Wuhan, People’s Republic of China
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  • Conghua Xie
    Correspondence
    Address for correspondence to: Conghua Xie, MD, Department of Radiation and Medical Oncology, Zhongnan Hospital, Wuhan University, 169 Donghu Road, Wuchang District, Wuhan, Hubei 430071, People’s Republic of China.
    Affiliations
    Department of Radiation and Medical Oncology, Zhongnan Hospital, Wuhan University, Wuhan, People’s Republic of China
    Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital, Wuhan University, Wuhan, People’s Republic of China
    Hubei Clinical Cancer Study Center, Zhongnan Hospital, Wuhan University, Wuhan, People’s Republic of China
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Open ArchivePublished:April 16, 2020DOI:https://doi.org/10.1016/j.jtho.2020.04.005
      To the Editor:
      The novel coronavirus disease 2019 (COVID-19) has become a global pandemic and affected more than 1 million people all over the world.
      • Huang C.
      • Wang Y.
      • Li X.
      • et al.
      Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.
      This disease is notably linked to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Nowadays, asymptomatic SARS-CoV-2 carriers are causing concern.

      Hu Z, Song C, Xu C, et al. Clinical characteristics of 24 asymptomatic infections with COVID-19 screened among close contacts in Nanjing, China [e-pub ahead of print]. Sci China Life Sci. https://doi.org/10.1007/s11427-020-1661-4, accessed April 7, 2020.

      We previously reported that patients who had cancer were at an increased risk of COVID-19.

      Yu J, Ouyang W, Chua MLK, Xie C. SARS-CoV-2 transmission in patients with cancer of a tertiary care hospital in Wuhan, China [e-pub ahead of print]. JAMA Oncol. https://doi.org/10.1001/jamaoncol.2020.0980, accessed April 7, 2020.

      Here, we report a case of an asymptomatic SARS-CoV-2 carrier with lung cancer who might be contagious.
      A 56-year-old Chinese man diagnosed as having advanced lung adenocarcinoma with EGFR 19-Del mutation, after gefitinib and subsequent osimertinib treatments, was receiving a third-line maintenance chemotherapy of pemetrexed coupled with bevacizumab before the onset of the COVID-19 outbreak in Wuhan, People’s Republic of China. Given that the city is within the epidemic epicenter, and owing to the overload of infected, most hospitals suspended their regular health care services. As a result, almost all patients with cancer had to be isolated at home. After a 3-week delay in chemotherapy, the patient reported pain of the lumbar spine on February 9, 2020, followed by a slight dry cough after 3 days. The patient denied fever, myalgia, diarrhea, and other symptoms. During online consultation with an oncologist, the patient reported that his current symptoms were quite similar to those seen in the past for progression of lung cancer. On February 14, 2020, the patient chose to rechallenge osimertinib as an alternative treatment. After 1 day of rechallenge, his symptoms were greatly relieved; however, on February 25, 2020, the patient complained of new bone pain at inconsistent sites.
      As the outbreak passed, medical institutions in Wuhan gradually recovered. The patient returned to our hospital on March 30, 2020. Screening tests for COVID-19 were done including chest computed tomography and throat swab reverse transcriptase-polymerase chain reaction, which revealed negative results. Testing for serologic IgM and IgG antibodies for SARS-CoV-2 were also performed and were found to be positive, which suggested that the patient was an asymptomatic SARS-CoV-2 carrier (Fig. 1). On consideration that the positive IgM antibody might represent potential infectivity, the patient was placed in an isolation ward to prevent possible in-hospital transmission. Subsequent throat swabs tests performed on March 31, April 2, and April 3, 2020 were all negative. Further serologic IgM antibody results turned negative on April 3, 2020, confirming the patient had recovered from COVID-19. Meanwhile, as a close contact, his wife was required to undergo screening tests; she tested positive for serologic IgG antibody alone but was negative on throat swab assay and chest computed tomography. His wife denied any clinical symptoms and contact history. This familial transmission highlights that asymptomatic carriers are indeed contagious.
      Figure thumbnail gr1
      Figure 1Timeline of clinical history for a patient having lung cancer with asymptomatic severe acute respiratory syndrome coronavirus 2 infection.
      On April 7, 2020, after consulting COVID-19 specialists, the patient resumed his chemotherapy regimen to which he was confirmed to be responsive before the COVID-19 outbreak. Subsequently, a postchemotherapy diagnostic test was performed, which revealed that only serologic antibody IgG was positive.
      In conclusion, this case suggests that we should be alert to suspicious symptoms in patients with lung cancer, which might overlap with those of asymptomatic COVID-19. To our knowledge, we are the first to report that chemotherapy might be safe for asymptomatic carriers after the serologic IgM antibody turns negative. However, further studies are urgently required.

      References

        • Huang C.
        • Wang Y.
        • Li X.
        • et al.
        Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.
        Lancet. 2020; 395: 497-506
      1. Hu Z, Song C, Xu C, et al. Clinical characteristics of 24 asymptomatic infections with COVID-19 screened among close contacts in Nanjing, China [e-pub ahead of print]. Sci China Life Sci. https://doi.org/10.1007/s11427-020-1661-4, accessed April 7, 2020.

      2. Yu J, Ouyang W, Chua MLK, Xie C. SARS-CoV-2 transmission in patients with cancer of a tertiary care hospital in Wuhan, China [e-pub ahead of print]. JAMA Oncol. https://doi.org/10.1001/jamaoncol.2020.0980, accessed April 7, 2020.

      Linked Article

      • Coronavirus Disease 2019 or Lung Cancer: A Differential Diagnostic Experience and Management Model From Wuhan
        Journal of Thoracic OncologyVol. 15Issue 8
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          In the Journal of Thoracic Oncology, Tian et al.1 reported one patient who died of coronavirus disease-2019 (COVID-19) after undergoing lung lobectomy for adenocarcinoma. Bonomi et al.2 presented a patient with metastatic lung cancer who died rapidly after contracting COVID-19. Russano et al.3 believed that patients with tumors had a higher risk of lethal COVID-19 complications. This news seems foreboding for patients with cancer who also acquire COVID-19. Therefore, because of the dramatic COVID-19 outbreak, extreme caution is required to ensure COVID-19 is not misdiagnosed as lung cancer and to consider that COVID-19 can coexist in patients with lung cancer.
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