COVID-19-Associated Acute Invasive Fungal Rhinosinusitis

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.