Hilar Lymphadenopathy, a Novel Finding in the Setting of Coronavirus Disease (COVID-19)

A Case Report

Mohsin Sheraz Mughal; Rameez Rehman; Ramy Osman; Nathan Kan; Hasan Mirza; Margaret H. Eng


J Med Case Reports. 2020;14(124) 

In This Article

Case Presentation

A 73-year-old Caucasian woman with a past medical history of hypertension, hyperlipidemia, pulmonary embolism, and rheumatoid arthritis came to our emergency department with complaints of fever, chills, generalized weakness, and decreased appetite of 1 day's duration. Her home medication list included amlodipine 10 mg, pantoprazole 40 mg, rivaroxaban 20 mg, and omega-3 polyunsaturated fatty acid 1000 mg. The patient had a remote history of rheumatoid arthritis, for which she was not taking any medication. She had quit smoking almost 30 years ago and admitted to one or two glasses of alcohol consumption occasionally. In the emergency department, she was febrile with a maximum body temperature of 102.3 °F. Her blood pressure was 157/73 mmHg, heart rate was 81 beats/minute, respiratory rate was 16 breaths/minute, and pulse oxygen saturation was 96% on room air. At admission, she was alert and oriented and did not seem to be in any distress. Her pulse was regular; her heart sounds (S1, S2) were audible without any murmur or additional heart sounds; and no lower extremity edema was observed during her physical examination. Her lungs were grossly clear with equal air entry without any wheeze or rhonchi. Her abdomen was soft, and bowel sounds were present. Her hematological workup showed leukopenia (white blood cell count, 3400/mm3), anemia (hemoglobin, 10.5 g/dl), thrombocytopenia (platelets, 163,000/mm3), and elevated inflammatory markers including C-reactive protein (66.8 mg/L) and erythrocyte sedimentation rate (74 mm/hour). The result of multiplex respiratory viral polymerase chain reaction (PCR) was negative for respiratory tract viral infections. Liver function tests, including aspartate aminotransferase (26 U/L) and alanine aminotransferase (ALT 8 U/L), and a basic metabolic panel, including blood urea nitrogen (16 mg/dl) and creatinine (1.03 mg/dl), were within the normal ranges. The result of a nasopharyngeal (NP) swab sample for SARS-CoV-2 was positive by RT-PCR, and a diagnosis of COVID-19 was established. Blood cultures and sputum culture did not show any bacterial or fungal growth. The patient started developing a dry cough and respiratory distress requiring supplemental oxygen via a nasal cannula (up to 6 L/minute) on the second day of admission with sporadic rhonchi detected by physical examination. Contrast-enhanced chest CT revealed multifocal, subpleural ground-glass opacities with nodular consolidations bilaterally (Figure 1a, b). A CT scan also demonstrated atypical bilateral hilar lymphadenopathy, a rarely reported CT finding in COVID-19 (Figure 2a). Chest CT one month before the current presentation demonstrated no focal consolidations or lymphadenopathy (Figure 2b). The patient received hydroxychloroquine (HCQ) 200 mg and azithromycin 500 mg orally for 5 days alongside supportive treatment with acetaminophen and supplemental oxygenation via nasal cannula. Her fever resolved, and her respiratory status improved. At discharge, she was breathing without any distress on room air.

Figure 1.

Contrast-enhanced chest computed tomography reveals multifocal, subpleural ground-glass attenuation opacities (arrow) (a) with nodular consolidations bilaterally (arrow) (b)

Figure 2.

a Atypical bilateral hilar lymphadenopathy (arrow), a novel finding of coronavirus disease 2019. b Chest computed tomography 1 month before presentation demonstrates no focal consolidations and no lymphadenopathy