A Unique Triad of Invasive Sinusitis, Brain Abscess with Focal Cerebritis, and COVID-19

Abstract

Patient: Male, 49-year-old Final Diagnosis: Rhinosinusitis Symptoms: Cough • fatigue • headache • seizure Medication: — Clinical Procedure: — Specialty: Infectious Diseases Objective: Rare coexistence of disease or pathology Background: We present a case of invasive sinusitis with rhinocerebral infection in a patient who had mild symptoms of COVID-19 infection and did not receive any immunosuppressive therapies. Case Report: A 49-year-old man with a history of uncontrolled diabetes presented to the hospital with multiple generalized tonic clonic seizures. He had recently been diagnosed with mild COVID-19 and was treated at home with supportive care only. He was found to have cerebritis in the right frontal lobe along with right fronto-ethmoid sinusitis. He underwent extensive testing with nasal endoscopy with gram stain and culture, cryptococcal studies, 1–3-Beta-D glucan, blood cultures, fungal CSF studies, Lyme disease, HIV, Fungitell assay, and galactomannan studies, which were all negative. He was started on i.v. antibacterial therapy with cefepime, vancomycin, and metronidazole along with amphotericin B. After 2 weeks, his repeat imaging revealed progression of cerebritis along with new early abscess. Given these findings, his antibiotics were changed to meropenem and the amphotericin B dose was increased. He was recommended debridement and sinus surgery but refused. During the course of treatment, he developed acute kidney injury and was switched to Posaconazole. Unfortunately, the patient decided to leave against medical advice 6 weeks into admission. He was advised to continue Posaconazole and levofloxacin but he could only afford levofloxacin. He was then recommended long-term levofloxacin. He has since recovered, with resolution of cerebritis noted in follow-up imaging 1 year later. Conclusions: Our patient had mild COVID-19 infection and presented with secondary infective complications, which are usually associated with an immunocompromised state, despite receiving no immunosuppressives. It is imperative that all clinicians treating COVID-19 be watchful for fungal or bacterial co-infections in patients with active SARS-CoV-2 infection, even if the presenting symptoms are mild, particularly if other risk factors are present.

Sinusitis complicated by intracranial abscess in 3 patients with coronavirus disease 2019: illustrative cases

“…The Delta variant has been associated with higher viral loads and increased rates of hospitalization in adolescents and young adults. 13,14 With the exception of 2 previous cases and our third case with preexisting risk factors, 6,7 all other reported cases occurred in young, previously healthy patients. Most cases were treated with craniotomy for abscess evacuation followed by parenteral antibiotics.…”

“…To our knowledge, there are only 7 other reported cases of sinusitis and associated intracranial abscess in the setting of COVID-19 (Table 1). [5][6][7][8] Of the known cases, only 1 occurred in a patient with a history of chronic sinusitis. Although intracranial abscesses are known to occur because of contiguous spread in the setting of chronic sinusitis, the absence of chronic sinusitis in the remaining cases suggests that SARS-CoV-2 could have contributed to the pathogenesis.…”

An enigmatic case of central nervous system infection and superior sagittal sinus thrombosis in an adolescent with COVID-19

“…The patient was treated with broad-spectrum antibiotic therapy; after two weeks, however, progression of purulent lesions was observed. This case also suggests an opportunistic infection following COVID-19 in a man who was previously immunocompetent [3].…”

Sinonasal complications of severe acute respiratory syndrome coronavirus‐2: A single center case series

“…[23][24][25] There have been isolated reports of these sinonasal complications in the setting of SARS-CoV-2 described in the medical literature. 8,10,11,13 The nasal cavity and nasopharynx are known reservoirs of SARS-CoV-2 viral load and replication. With this high viral activity, the virus is hypothesized to cascade a cytokine driven inflammatory response, which exacerbates endothelial damage and potentiates these severe sinonasal complications.…”

“… 1 , 3 , 4 In the otolaryngologic literature, there are isolated reports of atypical, severe presentations in context of SARS‐CoV‐2 infection, however, there are no larger comprehensive series. 7 , 8 , 9 , 10 , 11 , 12 , 13 We present our single center series of nine cases of patients with severe complications from sinonasal disease in the setting of acute SARS‐CoV‐2 infection. Institutional Review Board approval at the University of North Carolina was obtained prior to completing the study.…”