Invasive fungal rhinosinusitis associated with SARS-CoV-2 infection

ABSTRACT

Introduction: We describe the atypical clinical course of 3 cases of invasive fungal rhinosinusitis (IFRS) in the setting of COVID-19. Method: In case 1, a 59-year-old man with no remarkable medical history presented with right ocular impairment after 4 weeks since the resolution of COVID-19. Biopsies of nasal mucosa reported the presence of angioinvasive zygomycetes. Endoscopic sinus surgery (ESS) debridement with eyeball preservation was undertaken, obtaining clinical satisfactory results. In case 2, a 64-year-old female patient with no remarkable medical history presented with a 2-month history of left visual impairment. A positive polymerase chain reaction test for SARS-CoV-2 was obtained. Imaging studies reported findings consistent with fungus ball of the left frontal sinus. ESS and surgical debridement was performed. Pathologic evaluation revealed consistent findings with invasive granulomatous aspergillosis. In case 3, a 61-year-old man with a history of type 2 diabetes presented with a 1-month history of headache, left ocular pain, proptosis, and vision loss. Upon arrival to the emergency department, the patient was intubated and diagnosed with severe ketoacidosis. During endotracheal intubation, necrotic oropharyngeal and palatine plaques were noticed. A positive result for COVID-19 was obtained during the initial diagnostic approach. Biopsy of the left middle and inferior turbinates and palate was performed, and the presence of angioinvaisive zygomycetes was reported. The patient presented a rapidly progressive deterioration leading to a fatal outcome. Results: IFRS can be occasionally seen in immunocompetent patients. SARS-CoV-2 infection can impair the cellular immune response by altering the function of lymphocytes and natural killer cells, leading to higher proinflammatory and anti-inflammatory cytokine levels. This immune function dysregulation might explain a higher predisposition for fungal coinfection in the setting of COVID-19. Conclusion: Due to the constantly increasing number of cases of COVID-19, otolaryngologists should expect a rise in the cases of IFRS with an atypical clinical presentation.