Fungal Sinusitis with COVID-19: Not Always Mucor!

Abstract

Background: Invasive fungal sinusitis is a rare but possibly fatal complication of Covid-19 infection. We report an extremely rare case of invasive fungal sinusitis due to an uncommon pathogen, Alternaria. Case Presentation: Patient is a 49-year-old female with a history of poorly controlled diabetes presenting with right maxillary fungal sinusitis with abscess. One month prior, after recovering from COVID-19 pneumonia, she developed right facial swelling, diplopia, blurry vision, and pain with extraocular movements. She was admitted at an outside hospital for diabetic ketoacidosis and facial cellulitis with right maxillary sinusitis, which was treated with piperacillin-tazobactam and vancomycin. She also received micafungin for possible fungal infection, which was discontinued after culture showed no growth at 1 week. Later, the patient had progressive facial symptoms prompting her to return to the emergency room. MRI of the orbit showed acute abscess with concerns for meningeal involvement in her right orbital structures and she was restarted on antibiotics. Fungal culture from prior admission was noted to have grown Alternaria species. She was transferred to our hospital and was treated with multiple surgical debridements and 2 weeks of voriconazole, amphotericin B, and daptomycin with improvement in her symptoms. She was discharged to a SNF to continue receiving treatment. Discussion: While studies on fungal sinusitis in association with COVID-19 have been limited, Mucor and Aspergillus appear to be the most common pathogens. Possible risk factors for COVID-19 associated fungal sinusitis include steroid use, diabetes, renal failure, and hypertension. Alternaria is a dematiaceous hyphomycete commonly involved in human infection. The most frequent clinical manifestations are cutaneous and subcutaneous infections, followed by oculomycosis, rhinosinusitis, and onychomycosis. Important risk factors include solid organ transplantation, Cushing’s syndrome, and bone marrow transplants. A noted complication in the care of our patient was the delayed recognition of fungal sinusitis; her fungal culture did not show growth until after discharge. Many species involved in fungal sinusitis, including Alternaria, are detected after 1 week of culture; however, fungi can be detected after longer incubation periods. In patients with multiple risk factors and COVID-19 infection, it may be important to continue monitoring for fungal isolates, even if patients are improving clinically.