ABSTRACT
Introduction: There have been multiple reports of acute invasive fungal rhinosinusitis (AIFRS) in patients with COVID-19 infection. Most cases were associated with high dose steroid therapy in diabetic patients. We report a case of a patient with COVID-19 infection and AIFRS. We will discuss management with the unique risks to the care team. Case: A 61-year-old diabetic woman was admitted to another facility with COVID-19 pneumonia and treated with oral dexamethasone. Three days later, she developed sharp stabbing pain in the right eye with ptosis and blurry vision. She was treated with analgesics and discharged. She returned with persistent pain and increasing right-sided hypesthesia. A CT scan did not show an acute orbital or sinus infection. She was discharged with outpatient ophthalmology follow-up. She presented to our emergency department 3 days later with 48 hours of right vision loss. Physical exam also showed disconjugate gaze and right V1/V2 hypesthesia. Nasal endoscopy showed necrotic tissue within the right nasal cavity. She was immediately started on IV amphotericin and taken to the operating room for biopsy and debridement. Pathology results were consistent with necrosis and invasive fungal hyphae. She was treated with liposomal amphotericin and was eventually discharged with permanent loss of right vision. Discussion: Management of COVID-19-associated acute invasive fungal sinusitis (CA-AIFRS) presents challenges for safety of the health care team. Diabetic COVID-19 patients' new sinonasal complaints or cranial nerve deficits must be immediately evaluated for AIFRS. The CT scan changes associated with AIFRS are nonspecific early in the disease process, therefore nasal endoscopy and biopsy are critical. This requires appropriate PPEnasal endoscopy should be performed with N95 respirator, eye protection, gloves, and a disposable gown. In patients with suspicious nasal endoscopy, immediate initiation of IV antifungals is critical. The next step is biopsy and surgical debridement. This should not be delayed in COVID-19 patients. At our institution, several steps are taken to protect the healthcare team. During intubation, only necessary anesthesia staff are in the roomwith properly worn powered air purifying respirator (PAPR). A viral filter is placed on the ET tube and the room doors are closed for 20 minutes after intubation to allow for air exchange. After 20 minutes, surgical staff may enter the room. The surgical team is outfitted with PAPRs. Powered instruments associated with aerosol generation such as high-speed drills are avoided. The surgical specimens are considered contaminated with COVID19. Therefore, frozen analysis is not used. Margins are sent for permanent analysis. Cultures are sent with appropriate labeling for laboratory precautions. The tissue is debrided to healthy tissue or natural barriers such as the skull base. Conclusion: Management of COVID-19 must include an awareness of CA-AIFRS. Diabetic patients on steroids appear to be more susceptible to CA-AIFRS. Nasal endoscopy is important for evaluation. Avoiding delays in starting antifungals and operative biopsy and debridement is critical. Safety considerations need to be prepared in advance for safe surgical debridement of these patients.
ABSTRACT
Global infection and mortality rates from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are disproportionately high in certain populations, including the elderly. Care home residents are frequently exposed to infection due to contact with staff and other residents, and are highly susceptible to infection due to their age and co-morbidity. In England, official statistics suggest that at least 25% of all deaths in care home residents since the start of pandemic are linked to coronavirus disease 2019 (COVID-19), but limited testing for SARS-CoV-2 early in the pandemic means estimates of the true burden of disease are lacking. Additionally, little is known about patterns of transmission between care homes, the community and hospitals, or the relationship between infection and immunity in care home staff and residents. The VIVALDI study plans to address these questions. VIVALDI is a prospective cohort study aiming to recruit 6,500 staff and 5000 residents from 105 care homes across England. Successive rounds of testing for infection will be performed over a period of 12 months. Nasopharyngeal swabs will detect evidence of viral RNA and therefore active infection (accompanied by collection of data on symptoms), whereas blood tests will detect antibodies and evidence of cellular immunity to SARS-CoV-2. Whole genome sequencing of viral isolates to investigate pathways of transmission of infection is planned in collaboration with the COVID-19 Genomics UK Consortium. Qualitative interviews with care home staff will investigate the impact of the pandemic on ways of working and how test results influence infection control practices and behaviours. Data from residents and staff will be linked to national datasets on hospital admissions, antibody and PCR test results, mortality and care home characteristics. Data generated will support national public health efforts to prevent transmission of COVID-19 and protect care home staff and residents from infection © 2020. Krutikov M et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited
ABSTRACT
Global infection and mortality rates from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are disproportionately high in certain populations, including the elderly. Care home residents are frequently exposed to infection due to contact with staff and other residents, and are highly susceptible to infection due to their age and co-morbidity. In England, official statistics suggest that at least 25% of all deaths in care home residents since the start of pandemic are linked to coronavirus disease 2019 (COVID-19), but limited testing for SARS-CoV-2 early in the pandemic means estimates of the true burden of disease are lacking. Additionally, little is known about patterns of transmission between care homes, the community and hospitals, or the relationship between infection and immunity in care home staff and residents. The VIVALDI study plans to address these questions. VIVALDI is a prospective cohort study aiming to recruit 6,500 staff and 5000 residents from 105 care homes across England. Successive rounds of testing for infection will be performed over a period of 12 months. Nasopharyngeal swabs will detect evidence of viral RNA and therefore active infection (accompanied by collection of data on symptoms), whereas blood tests will detect antibodies and evidence of cellular immunity to SARS-CoV-2. Whole genome sequencing of viral isolates to investigate pathways of transmission of infection is planned in collaboration with the COVID-19 Genomics UK Consortium. Qualitative interviews with care home staff will investigate the impact of the pandemic on ways of working and how test results influence infection control practices and behaviours. Data from residents and staff will be linked to national datasets on hospital admissions, antibody and PCR test results, mortality and care home characteristics. Data generated will support national public health efforts to prevent transmission of COVID-19 and protect care home staff and residents from infection. Protocol registration: ISRCTN14447421 05/06/2020.