A case–control evaluation of pulmonary and extrapulmonary findings of incidental asymptomatic COVID-19 infection on FDG PET-CT

OBJECTIVES: To describe the findings of incidental asymptomatic COVID-19 infection on FDG PET-CT using a case–control design. METHODS: Incidental pulmonary findings suspicious of asymptomatic COVID-19 infection on FDG PET-CT were classified as a confirmed (positive RT-PCR test) or suspected case (no/negative RT-PCR test). Control cases were identified using a 4:1 control:case ratio. Pulmonary findings were re-categorised by two reporters using the BSTI classification. SUV metrics in ground glass opacification (GGO)/consolidation (where present), background lung, intrathoracic nodes, liver, spleen and bone marrow were measured. RESULTS: 7/9 confirmed and 11/15 suspected cases (COVID-19 group) were re-categorised as BSTI 1 (classic/probable COVID-19) or BSTI 2 (indeterminate COVID-19); 0/96 control cases were categorised as BSTI 1. Agreement between two reporters using the BSTI classification was almost perfect (weighted κ = 0.94). SUV(max) GGO/consolidation (5.1 vs 2.2; p < 0.0001) and target-to-background ratio, normalised to liver SUV(mean) (2.4 vs 1.0; p < 0.0001) were higher in the BSTI 1 & 2 group vs BSTI 3 (non-COVID-19) cases. SUV(max) GGO/consolidation discriminated between the BSTI 1 & 2 group vs BSTI 3 (non-COVID-19) cases with high accuracy (AUC = 0.93). SUV metrics were higher (p < 0.05) in the COVID-19 group vs control cases in the lungs, intrathoracic nodes and spleen. CONCLUSION: Asymptomatic COVID-19 infection on FDG PET-CT is characterised by bilateral areas of FDG avid (intensity > x2 liver SUV(mean)) GGO/consolidation and can be identified with high interobserver agreement using the BSTI classification. There is generalised background inflammation within the lungs, intrathoracic nodes and spleen. ADVANCES IN KNOWLEDGE: Incidental asymptomatic COVID-19 infection on FDG PET-CT, characterised by bilateral areas of ground glass opacification and consolidation, can be identified with high reproducibility using the BSTI classification. The intensity of associated FDG uptake (>x2 liver SUV(mean)) provides high discriminative ability in differentiating such cases from pulmonary findings in a non-COVID-19 pattern. Asymptomatic COVID-19 infection causes a generalised background inflammation within the mid-lower zones of the lungs, hilar and central mediastinal nodal stations, and spleen on FDG PET-CT.