ABSTRACT
TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Acute airway obstruction is a life-threatening event requiring emergent identification and management. Limited reports of acute airway compromise in patients with recent novel coronavirus infection (COVID-19) suggest this may be a rare and late complication in COVID-19 patients. CASE PRESENTATION: A 19-year-old Guatemalan male with no known past medical history, unclear vaccination status, no smoking or alcohol history presented to the emergency department with complaints of worsening sore throat, muffled voice, difficulty swallowing, bloody vomitus, and subjective fever for two hours prior to arrival. He was diagnosed with mild COVID-19 3 weeks prior. History was limited by severe respiratory distress. On physical exam, the patient was afebrile. He had muffled voice, stridor, and a normal uvula. Labs were significant for leukocytosis, and respiratory panel positive for SARS-CoV-2. X-ray of chest and neck were unremarkable. Patient was given dexamethasone and antibiotics. Given concern for airway compromise and possible epiglottitis, the patient was urgently intubated. First attempt with video laryngoscopy was unsuccessful due to extensive edema and erythema of the hypopharyngeal tissues, then re-attempted successfully with a smaller endotracheal tube. The epiglottis could not be visualized. CT neck showed diffuse inflammation with enlargement of the adenoids and tonsils;epiglottis was obscured given presence of the endotracheal tube;no abscess seen. Differential included bacterial or viral epiglottitis, idiopathic angioedema reaction, and post-COVID reaction. The patient was admitted to the ICU for management of presumed epiglottitis and continued on dexamethasone for 40 hours and empiric antibiotics. He had rapid resolution of airway edema, was successfully extubated on day 4 of admission, and discharged home on day 6 with a 10-day course of cephalexin. DISCUSSION: Most mild, symptomatic cases of COVID-19 typically resolve within 2-3 weeks. This late presentation raises concern for epiglottitis as a rare but serious complication of COVID-19. The time course additionally suggests possible post-viral superinfection of the epiglottis and upper airway from other causes. Confirmation via direct visualization or imaging was not possible in this patient but he was treated presumptively for epiglottitis given his concerning physical exam findings. In cases of acute respiratory distress, airway management should supersede diagnostic evaluation due to the risk of rapid respiratory compromise. CONCLUSIONS: There are many known etiologies of acute airway obstruction, including epiglottitis, but it is important to consider COVID-19 as another possible etiology. While direct visualization is the gold standard for confirmation, diagnosis should not precede emergent intubation in cases of severe respiratory distress. REFERENCE #1: Çaytemel B, Kılıç H, Çomoğlu Ş. Approach to otolaryngology emergency in COVID-19 pandemic. Tr-ENT. 2020;30(50):24-36. DISCLOSURES: No relevant relationships by Gerardo Carino, source=Web Response No relevant relationships by Sugi Min, source=Web Response No relevant relationships by Claudia Sorin, source=Web Response