Metastatic pulmonary dissemination as differential diagnosis
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In the current context of COVID-19 pandemic, it is necessary to identify pathologies with a similar clinical–analytical presentation in order to define the differential diagnoses, especially in patients presenting at atypical ages or with repeatedly negative diagnostic tests. This is a case of metastatic pulmonary dissemination of Ewing’s sarcoma with clinical presentation similar to COVID-19 disease.

A 13-year-old boy presented to hospital with 3-day self-limited fever, followed by dry cough, persistent asthenia and impaired general condition of 2 weeks’ duration. Blood analyses showed a severe inflammatory status and chest X-ray images were consistent with bilateral COVID-19 pneumonia. He developed an acute respiratory failure that required pediatric intensive care admission and non-invasive ventilation.

A targeted COVID-19 treatment was initiated with hydroxychloroquine, corticosteroids, enoxaparine and a single dose of tocilizumab. Repeated serological tests and real-time reverse transcription PCR for SARS-CoV-2 were negative. Other infectious pathogens were also ruled out. Thoracic high resolution CT showed an intense bilateral pulmonary dissemination with lytic vertebral bone lesions. After diagnostic investigations, Ewing’s sarcoma with metastatic pulmonary dissemination was diagnosed.

Nowadays, in the context of SARS-CoV-2 community pandemic, one cannot forget that COVID-19 clinical presentation is not specific and other entities can mimic its clinical features.