MRI of Patients Infected With COVID-19 Revealed Cervical Lymphadenopathy
Ear, nose, and throat (ENT) symptoms are common in the coronavirus disease 2019 (COVID-19). The most commons ENT symptoms are loss of smell and taste, nasal obstruction, rhinorrhea, and sore throat.1,2 Recently, some otolaryngologists described acute parotitis3,4 and facial nerve palsy5 associated with COVID-19 disease. In the pediatric population, cases of Kawasaki-like disease have occurred in children who tested positive for COVID-19, supporting the occurrence of COVID-19-related vasculitis in children.6 In this article, we report the findings of 3 COVID-19 patients presenting cervical lymphadenopathies.
From March 22 to May 15, 2020, 3 patients presented to Foch Hospital for symptoms related to COVID-19 disease. All the patients had a mild form of the disease with no medical history. The diagnosis of COVID-19 was confirmed by reverse transcription polymerase chain reaction. A magnetic resonance imaging was performed without injecting contrast to precisely assess the head and neck involvement. In the 3 cases, 2 experienced radiologists observed cervical lymph nodes in the following neck regions: I, II, and III (jugular group). They were considered pathological (cervical lymphadenopathy [CLA]) if their short-axis diameter in axial plane of level I or II nodes exceeds 11 mm, retropharyngeal nodes exceed 5 mm, and other cervical nodes exceed 10 mm.7
The case 1 was a 26-year-old man. He had general symptoms: fever, asthenia, cough, and headache, and ENT symptoms: loss of smell and taste, nasal obstruction, and rhinorrhea. Magnetic resonance imaging was performed 8 days after the onset of symptoms. It revealed multiple bilateral cervical lymph nodes. The largest CLA measured 15 mm and was located in group II (upper jugular group). The radiologists observed an enlargement of the parotid with intraparotid lymph nodes (Figure 1). There was also an enlargement of the palatine tonsils.
The case 2 was a 23-year-old woman. She had asthenia, headache, loss of smell and taste, nasal obstruction, rhinorrhea, and sore throat. She also reported cervical swelling. Magnetic resonance imaging was performed 14 days after the onset of symptoms. It revealed multiple bilateral cervical and intraparotid lymph nodes without glandular enlargement. The largest CLA measured 12 mm and was located in group II. The radiologists also observed a complete enlargement of the Waldeyer’s ring (Figure 1).
The case 3 was a 57-year-old woman. Initially, she had fever and asthenia and then a loss of smell and taste with sore throat. Magnetic resonance imaging was performed 22 days after the onset of symptoms. It revealed multiple cervical lymph nodes, and the largest CLA measured 13 mm. This CLA was located in group II. It also revealed intraparotid lymph nodes without glandular enlargement and enlargement of the lingual tonsils (Figure 1).
These 3 patients all had a mild form of the disease with multiple ENT symptoms. Indeed, the symptoms such as sore throat, rhinorrhea, nasal obstruction, and loss of smell and taste are the most common in this disease.8
Mediastinal lymphadenopathy has already been described in COVID-19 disease on chest computed tomography, but not CLA.9 Nonspecific reactive hyperplastic lymph nodes are frequent in head and neck region. The most common CLA causes are infections and malignant tumors.10 CLA may develop in the following infectious diseases: mycobacterial infections,11 Epstein-Barr virus-related mononucleosis,12 cat scratch disease, toxoplasmosis, and HIV.13
Interestingly, the most important CLA were located in group II (upper jugular group). Group II lymph nodes drain pharyngeal structure, which includes tonsils and adenoids. We believe that the COVID-19 virus would cause inflammation of the nasopharynx and oropharynx, clinically causing sore throat and nasal symptoms (nasal obstruction, rhinorrhea), as in tonsillitis or nasopharyngitis. This inflammation would cause a local immune reaction leading to an enlargement of the Waldeyer’s ring and cervical and intraparotid lymphadenopathies. Moreover, since the outbreak of the pandemic, otolaryngologists reported an increasing number of acute parotitis.3,4 The presence of intraparotid lymphadenopathies could be associated with the development of parotitis-like symptoms in COVID-19 patients. These features support the diagnosis of adenitis-related parotitis, which differs from primary diffuse parotitis.
ORCID iDs
Amine Ammar https://orcid.org/0000-0003-4211-8050
Jerome R. Lechien https://orcid.org/0000-0002-0845-0845
Sven Saussez https://orcid.org/0000-0002-3655-1854
References
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2. Lechien JR, Chiesa Estomba CM, Place S, et al. Clinical and epidemiological characteristics of 1,420 European patients with mild-to-moderate coronavirus disease 2019 [published online ahead of print April 20, 2020]. J Intern Med. doi:10.1111/joim.13089
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12. Ebell MH, Call M, Shinholser J, Gardner J. Does this patient have infectious mononucleosis?: the rational clinical examination systematic review. JAMA. 2016;315(14):1502–1509. doi:10.1001/jama.2016.2111
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Article first published online: July 23, 2020
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