Invasive Fungal Sinusitis in Post COVID-19 Patients: A New Clinical Entity

Abstract

Objectives: Occurrence of invasive fungal respiratory superinfections in patients with COVID-19 has gained increasing attention in the latest studies. Yet, description of acute invasive fungal sinusitis with its management in those patients is still scarce. This study aims to describe this recently increasing clinical entity in relation to COVID-19 patients.

Study design: Longitudinal prospective study.

Methods: Prospective longitudinal study included patients diagnosed with acute invasive fungal rhinosinusitis after a recent COVID-19 infection. Antifungal agents given included amphotericin B, voriconazole, and/or posaconazole. Surgical treatment was restricted to patients with PCR negative results for COVID-19. Endoscopic, open, and combined approaches were utilized to eradicate infection. Follow-up for survived patients was maintained regularly for the first postoperative month.

Results: A total of 36 patients with a mean age of 52.92 ± 11.30 years old were included. Most common associated disease was diabetes mellitus (27.8%). Mycological analysis revealed infection with Mucor and Aspergillus species in 77.8% and 30.6% of patients, respectively. Sino-nasal, orbital, cerebral, and palatine involvement was found in 100%, 80.6%, 27.8%, and 33.3% of patients, respectively. The most common reported symptoms and signs are facial pain (75%), facial numbness (66.7%), ophthalmoplegia, and visual loss (63.9%). All patients were treated simultaneously by surgical debridement with antifungal medications except for two patients with PCR-positive swab for COVID-19. These two patients received antifungal therapy alone. Overall survival rate was 63.89% (23/36).

Conclusion: Clinical suspicion of acute invasive fungal sinusitis among COVID-19 patients and early management with antifungal therapy and surgical debridement is essential for better outcomes and higher survival.

Level of evidence: 4 Laryngoscope, 131:2652-2658, 2021.

Keywords: COVID-19; Invasive fungal infection; SARS-CoV-2; sinusitis.

Fig 1

Different patterns of palatal involvement with invasive fungal infection; (A) small palatal ulcers. (B) Unilateral large palatal necrosis. (C) Central palatal ulceration with necrosis. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]

Fig 2

Skin necrosis and ulceration as a complication of post COVID‐19 AIFR. (A) Necrosis involves cheek area. (B) Large skin necrotic area over cheek, lateral nasal wall and eye with edematous inflammatory changes. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]

Fig 3

Important radiological findings and variations found in post COVID‐19 AIFR cases. (A) Axial CT showing right subperiosteal abcess. (B) T1‐weighted axial MRI showing right orbital invasion with proptosis. (C) MRV of the same patient demonstrated in (B) showing left side transverse and sigmoid sinus thrombosis (white arrows). (D) T2‐weighted axial MRI shows right orbital invasion with right temporal lobe abscess (yellow arrow) with occlusion of the right internal carotid artery.