A Unique Triad of Invasive Sinusitis, Brain Abscess with Focal Cerebritis, and COVID-19

BACKGROUND We present a case of invasive sinusitis with rhinocerebral infection in a patient who had mild symptoms of COVID-19 infection and did not receive any immunosuppressive therapies. CASE REPORT A 49-year-old man with a history of uncontrolled diabetes presented to the hospital with multiple generalized tonic clonic seizures. He had recently been diagnosed with mild COVID-19 and was treated at home with supportive care only. He was found to have cerebritis in the right frontal lobe along with right fronto-ethmoid sinusitis. He underwent extensive testing with nasal endoscopy with gram stain and culture, cryptococcal studies, 1-3-Beta-D glucan, blood cultures, fungal CSF studies, Lyme disease, HIV, Fungitell assay, and galactomannan studies, which were all negative. He was started on i.v. antibacterial therapy with cefepime, vancomycin, and metronidazole along with amphotericin B. After 2 weeks, his repeat imaging revealed progression of cerebritis along with new early abscess. Given these findings, his antibiotics were changed to meropenem and the amphotericin B dose was increased. He was recommended debridement and sinus surgery but refused. During the course of treatment, he developed acute kidney injury and was switched to Posaconazole. Unfortunately, the patient decided to leave against medical advice 6 weeks into admission. He was advised to continue Posaconazole and levofloxacin but he could only afford levofloxacin. He was then recommended long-term levofloxacin. He has since recovered, with resolution of cerebritis noted in follow-up imaging 1 year later. CONCLUSIONS Our patient had mild COVID-19 infection and presented with secondary infective complications, which are usually associated with an immunocompromised state, despite receiving no immunosuppressives. It is imperative that all clinicians treating COVID-19 be watchful for fungal or bacterial co-infections in patients with active SARS-CoV-2 infection, even if the presenting symptoms are mild, particularly if other risk factors are present.