A COVID-19 Patient Who Underwent Endonasal Endoscopic Pituitary Adenoma Resection: A Case Report

Abstract

Background and importance: A pituitary adenoma patient who underwent surgery in our department was diagnosed with COVID-19 and 14 medical staff were confirmed infected later. This case has been cited several times but without accuracy or entirety, we feel obligated to report it and share our thoughts on the epidemic among medical staff and performing endonasal endoscopic surgery during COVID-19 pandemic.

Clinical presentation: The patient developed a fever 3 d post endonasal endoscopic surgery during which cerebrospinal leak occurred, and was confirmed with SARS-CoV-2 infection later. Several medical staff outside the operating room were diagnosed with COVID-19, while the ones who participated in the surgery were not.

Conclusion: The deceptive nature of COVID-19 results from its most frequent onset symptom, fever, a cliché in neurosurgery, which makes it hard for surgeons to differentiate. The COVID-19 epidemic among medical staff in our department was deemed as postoperative rather than intraoperative transmission, and attributed to not applying sufficient personal airway protection. Proper personal protective equipment and social distancing between medical staff contributed to limiting epidemic since the initial outbreak. Emergency endonasal endoscopic surgeries are feasible since COVID-19 is still supposed to be containable when the surgeries are performed in negative pressure operating rooms with personal protective equipment and the patients are kept under quarantine postoperatively. However, we do not encourage elective surgeries during this pandemic, which might put patients in conditions vulnerable to COVID-19.

Keywords: Adenoma; COVID-19; Case report; Endonasal; Endoscopic.

FIGURE 1.

Preoperative imaging studies. A, Preoperative X-ray indicated no obvious abnormalities. ©2020 Xiaobing Jiang. Used with permission. B, Axial preoperative head CT indicated well-defined mass lesion in sellar region, measuring 3.8, 3.5, 4.5 cm in size and compressing the optic chiasm, black arrows indicates the boundary. C, Coronal reconstruction of head CT scan, black arrows indicates the boundary. D, Sagittal reconstruction of head CT scan, black arrows indicates the boundary. Note that the patient had metallic prosthetic teeth which made it impossible to obtain magnetic resonance imaging.

FIGURE 2.

Postoperative pathology, imaging and peak axillary temperature records. A, Pathological frozen section of the resected tumor(20x), indicating pituitary adenoma. Immunohistology staining (Figures not shown): Syn (+), ACTH (−), GH (−), Ki 67 (LI < 1%). B, Lung CT scan, 5 d post operation, on January 11th, showed multiple ground glass opacities, effusion and consolidation. C, the peak axillary temperature starting January 1st through 19th, the horizontal dotted line intercepted y-axis at 37.3°C, the cutoff for fever. D, Chest X-ray at bedside, 7 d post operation, on January 13th, after the patients’ symptoms deteriorated, showed multiple bilateral opacities, mainly located in right lung. D, ©2020 Xiaobing Jiang. Used with permission.

FIGURE 3.

Time-line of main event of the patient. Numbers in the middle square blocks represent the date of month. Grey color square blocks denote the day with fever and white color block denote the day without. The fever is defined that the axillary temperature greater than 37.3°C. CT, Computed Tomography; WBC, white blood cell count; FT3, free triiodothyronine; TSH, thyroid-stimulating hormone.