An unpremeditated complication of COVID-19 and mucormycosis: a case report, brief review, and warning for tunnel vision

doi:10.21203/rs.3.rs-3131079/v1

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Case Report

An unpremeditated complication of COVID-19 and mucormycosis: a case report, brief review, and warning for tunnel vision

https://doi.org/10.21203/rs.3.rs-3131079/v1

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Over the course of the Coronavirus disease 2019 (COVID-19) pandemic, numerous complications have been documented. In this report, we have detailed an unexpected complication of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection that occurred in a 73-year-old female patient who was simultaneously afflicted with mucormycosis and another unanticipated problem. Due to the lack of recovery of the patient after receiving mucormycosis treatment and continued fever, cough and hemoptysis, bronchoscopy was performed for her. During bronchoscopy, we encountered a foreign body that was the cause of the patient's fever, cough, and hemoptysis. Rigid bronchoscopy was performed and a foreign body (2.7 x 1.2 cm) was removed from the left main bronchus. Although research has showed fewer cases of pediatric Foreign Body Aspiration (FBA) during lockdown periods, there is not enough evidence about FBA risk in elderly patients with comorbidities. Finally, in the treatment of cases of COVID-19 infections co-infected with opportunistic fungal and maybe even bacterial infections, we should not look at the patient through a tunnel vision and consider all possible scenarios for the patient.

COVID-19

Mucormycosis

Foreign Body Aspiration

Tunnel Vision

Bronchoscopy

Since the beginning of Coronavirus disease 2019 (COVID-19) pandemic, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has resulted in the death of over 6 million people and led to a great variety of complications [1]. Patients who have respiratory viral infections are at risk for secondary infections, particularly those caused by bacterial and fungal organisms [2]. A previous study found that without-a-known-reason secondary pneumonia could occur in about 30% of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infected cases [3]. SARS-CoV-2 infection and its management with corticosteroids can disrupt the immune system's normal functioning, which could increase the risk of fungal infections [4, 5]. Our previous case report showed that how incompetent immunity due to COVID-19 and rituximab could lead to a severe complication of Pneumocystis jirovecii pneumonia [4]. Furthermore, evidence highlights the danger of opportunistic fungi infections, such as pulmonary aspergillosis and mucormycosis, which can accompany viral symptoms and cause mortality by disrupting multiple organ systems [5].

Few cases of foreign body aspiration (FBA) have been reported throughout COVID-19 pandemic [6–8]. It is a medical emergency that necessitates fast diagnosis and treatment planning. In the event of total obstruction, FBA carries a high mortality risk. But it is possible to tolerate it and become undetectable, particularly in adults with partial obstruction [9]. Choking, coughing, and vomiting are just a few examples of the symptoms; nevertheless, the patient could also be asymptomatic. Recurrent hemoptysis and pneumonia, and bronchiectasis are just a few of the complications that a patient with FBA may experience. This condition is more likely to happen on the right-sided airways. The foreign body removal should be performed immediately [9, 10].

Here, we described an unpremeditated complication of SARS-CoV-2 infection in an elderly patient who was also infected with mucormycosis.

A 73-year-old female patient with a chief complaint of bloody sputum, started 2 hours prior to the admission (2nd admission), was admitted to our hospital in April 2022. In the first admission, she had weakness, chills, fever, cough, decreased consciousness, and dyspnea. She was admitted with the primary diagnosis of COVID-19 and treated with remdesivir and glucocorticoid. The patient was being treated for a week, and during this period her fever, cough and dyspnea stopped; therefore, she was discharged. About two weeks after the discharge, the patient developed mild hemoptysis (along with fever, cough and dyspnea) which made her to admit in hospital for the second time.

She was a known case of diabetes mellitus (diagnosed since 10 years ago; on oral agents), hypertension (controlled by medication), ischemic heart disease (had a positive history of coronary artery bypass grafting (CABG)), and hyperlipidemia (controlled by medication). She had no positive social and family history; meanwhile, had a positive history of drug reaction to penicillin.

On the review of systems (2nd admission), she had fever, weight loss, fatigue and weakness, loss of appetite, high blood pressure, cough, dyspnea, and a history of anemia.

On physical examinations (2nd admission), the patient was an old lady, lying on bed, ill but not toxic, and answered to the questions. Her blood pressure was 125/80 mmHg; respiratory rate, 22 breaths per min; temperature, 38.2°C; pulse rate, 99 beats per min; and oxygen saturation, 95% (without any oxygen therapy). She had symmetric chest wall movement along with wheezing (detected on left upper lobe). The abdomen was soft, not distended, without tenderness, rebound, or organomegaly. Her neurological examinations revealed no abnormal findings. She had elevated LDH (545 U/L) and White Blood Cells (17000 per µL; neutrophil percentage of 65% and lymphocyte percentage of 33%) at the time of admission (Table 1).

Table 1

Laboratory data on admission day
	Admission day
WBC (per µL)	17000
Neutrophil (%)	65
Lymphocyte (%)	33
Hb (mg/dL)	10.7
MCV (fL)	77.6
PLT (per µL)	342000
LDH (U/L)	545
CRP (mg/dL)	3.0
ESR (mm/h)	35
Bilirubin (Total) (mg/dL)	0.5
Bilirubin (Direct) (mg/dL)	0.2
AST (U/L)	15
ALT (U/L)	12
ALP (U/L)	230
Troponin	Negative
BUN (mg/dL)	13
Creatinine (mg/dL)	1
PT (sec)	12
PTT (sec)	25
INR	1
WBC: White Blood Cells, Hb: Hemoglobin, PLT: Platelets, LDH: Lactate Dehydrogenase CRP: C-Reactive Protein, ESR: Erythrocyte Sedimentation Rate, AST: Aspartate transaminase, ALT: Alanine transaminase, ALP: Alkaline phosphatase, BUN: Blood Urea Nitrogen, PT: Prothrombin Time, PTT: Partial Thromboplastin Time, INR: International Normalized Ratio, MCV: mean corpuscular volume

In the second admission, diagnostic work-up and supportive care were provided. The PCR test for COVID-19 was negative. However, considering the lesions in the patient's Computed tomography (CT) scan (Fig. 1.A and B) and the continued fever, we suspected the addition of hospital-acquired pneumonia, and for this reason, Tavanex was administered. Nevertheless, due to persistent fever, hemoptysis, and pulmonary lesions after 3 days, we suspected coinfection with fungal agents and the first bronchoscopy was performed for the patient.

Mucosal irregularity, erythema, and edema, along with dark and dirty ulcerative endo-bronchial lesion were observed at the end of left main bronchus (Fig. 2), through which the scope could not pass. Multiple biopsies (from the margins of the lesion) and bronchoalveolar lavage (BAL) were provided for further investigation. The pathology report revealed presence of nonseptated and broad based fungal hyphae consistent with mucormycosis (Fig. 3). Cytology analysis showed an acute inflammatory process, which was negative for malignant cells.

According to pathology report, mucormycosis treatment was started with liposomal amphotericin B (3oo mg IV daily). Liposomal amphotericin B was administrated for 14 days and patient discharged with fair general condition and recommendation of taking itraconazole (200 mg orally twice a day). Paranasal sinus (PNS) CT scan showed no involvement of oral cavity and sinuses with mucormycosis (Fig. 4).

In the 3rd admission (two weeks following the 2nd discharge), the hemoptysis, weakness and fatigue were continued. Moreover, The CT scan showed that the orifice of the upper lobe of the left lung had still irregularity (Fig. 1.C). Therefore, the second bronchoscopy was performed. In the 2nd bronchoscopy, due to the persistence of the obstruction and lesion after mucormycosis treatment, multiple biopsies were performed from the depth of the lesion, and two small objects were accidentally removed. In the left main bronchus, two foreign bodies with dimensions of 0.5 x 0.5 cm, hard density, and cream color were removed (Fig. 5.A). Hence, rigid bronchoscopy was recommended. Rigid bronchoscopy was performed and the result was surprising. A foreign body (Chicken bone) with dimensions of 2.7 x 1.2 cm was removed from the left main bronchus (Fig. 5.B).

Since the beginning of the first COVID-19 pandemic wave, there have been numerous publications on the topic of COVID-19-fungi co-infection. Aspergillosis was the principal co-infection that was examined, and previous studies identified a number of potential risk factors such as an immunological storm (increased inflammatory cytokines), tocilizumab, azithromycin (for a 3-day duration), high-dose corticosteroids, and intubation and mechanical ventilation [11].

Mucormycosis, a rare but potentially fatal invasive fungal infection, is brought on by mold fungi of the genus Mucor, Rhizopus, Rhizomucor and Absidia, which are all members of the Mucorales order of the zygomycetes class [12]. Rhizopus oryzae was the most prevalent kind, accounting for 60% of human cases of mucormycosis and 90% of cases of the rhinocerebral variant [13]. We noticed an increase in mucormycosis among COVID-19 infected individuals globally during this coronavirus disease pandemic. It is usually seen in immunosuppressed individuals, especially those who have diabetes, haematological cancer, and are receiving corticosteroid treatment and immunosuppressive medications. Rarely does it occur in healthy people [14].

Rigid bronchoscopic procedure is crucial in the removal of bronchial foreign objects. Flexible bronchoscopes, however, can access more narrow bronchi. For more effective removal of foreign objects, use the rigid bronchoscope's grasping forceps. Additionally, when the patient is under general anesthesia and there is a risk of coughing, the procedure can still be done [15].

The two symptoms that are frequently present in COVID-19 and FBA are cough and dyspnea. All suspect individuals have a chest CT scan since coughing is the most common early sign of COVID19. The most prevalent lung alterations detected on imaging are interstitial pneumonia with many patchy, flocculent, or stripped ground glass shadows and a predominately bilateral predominance. The boundaries of the lesions were indistinct in the peripheral regions. When the condition was severe, the lungs showed consolidation and there was minimal accumulation of fluid in the pleural space [9].

FBA is a medical issue that can cause significant harm and even death. Although it is not a common occurrence in adults, certain circumstances such as altered mental state, trauma resulting in decreased consciousness, dental procedures, and neurological diseases that affect airway reflexes can increase the likelihood of its occurrence [16, 17].

Aspirated foreign bodies often result in coughing, which is a common symptom. In addition, there may be infective complications that lead to other symptoms such as chest pain, hemoptysis, foul-smelling sputum, fever, and more [17]. This condition is more likely to happen on the right-sided airways [9]. However, in the case we described, an aspirated foreign body was observed in the orifice of the upper lobe of the left lung, which was interesting. It can be stated as a hypothesis that COVID-19 infection and mucormycosis may elevate the risk of FBA in left-sided airways, but more organized and extensive studies are needed to prove it. In fact, weakness and malaise, decreased level of consciousness and dizziness that occurs following severe COVID-19 disease and its complication with opportunistic infections, as well as feeding the patient in these conditions can increase the risk of aspiration. Another important point that should be taken into account is that in the treatment of cases of COVID-19 infection that are suffering from co-infection with opportunistic fungal and maybe even bacterial infections, we should not look at the patient through a tunnel vision and consider all possible scenarios for the patient.

The most frequent foreign objects that are inhaled by healthy adults are food particles like bone chips, nut shells, and food boluses. During a challenging laryngoscopy under anesthesia, broken teeth and dentures may also be aspirated, which can have legal consequences. Organic materials that are aspirated cause severe inflammation in the surrounding tissues, making them easier to detect. Inflammation from organic materials can lead to complications like stenosis or airway obstruction due to moisture absorption, resulting in an acute emergency [17]. Interestingly, in the case we reported, the inflammation made it more difficult to detect the foreign body.

Although research has showed fewer cases of pediatric FBA during lockdown periods [18], there is not enough evidence about FBA risk in elderly patients, especially those who have other conditions like diabetes mellitus, hypertension, ischemic heart disease, and hyperlipidemia.

Here, we described the first case of COVID-19, who experienced FBA along with mucormycosis co-infection. It is our expectation that the present case report will engender an enhanced acknowledgement of the pivotal significance of comprehensive diagnostic examinations amongst clinicians, particularly within the context of the current Covid-19 pandemic, which has resulted in a notable surge in the responsibilities of them.

Ethics approval and consent to participate

This study has been approved by the Babol University of Medical Sciences, Babol, Iran. For participation in this article, we obtained written informed consent from the patient to release any potentially identifiable data.

Consent for publication

For publication of this article, we obtained written informed consent from the patient to release any potentially identifiable data.

Data availability statement

The Data supporting the findings of this study are available upon request from the corresponding author and with permission from Babol University of Medical Sciences, Babol, Iran.

Funding

This study received no Funding.

Conflict of interest disclosure

The authors declare no conflict of interest.

Author’s contributions

Hamed Mehdinezhad and Reza Mohseni Ahangar: treating the patient, collecting the medical history, helped with manuscript writing and revision. Mohammad Golparvar Azizi and Mohammad Ghasemian: collecting the medical history and helped with manuscript writing and revision. Ali Tavakoli Pirzaman: collecting the medical history, writing the main part of the paper, and revising the content of manuscript.

Acknowledgements

Not applicable

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No competing interests reported.

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An unpremeditated complication of COVID-19 and mucormycosis: a case report, brief review, and warning for tunnel vision

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