Secondary Infection in Patient with COVID-19

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Cervical Infection
Physical examination findings on day 14 of hospitalization. On physical examination, redness and swelling were noted in the neck area, which the patient reported as painful (triangle) (A). Pus was present around the insertion site of the peripheral catheter (arrow) (B).

Cervical infection post-COVID-19 treatment

The general treatment approach for COVID-19 includes anti-viral and immunosuppressive drugs. However, patients being treated with the drugs are at an increased risk of developing secondary infections and masked inflammatory responses. In addition, the diagnosis of the infection may also be masked because of the treatment. This article describes the case of a neck abscess in a patient secondary to sternoclavicular arthritis while undergoing treatment for COVID-19. Based on the investigation findings, the patient had developed a cervical infection post-treatment.

Deep neck abscess is a fatal disease that is usually caused secondary to the oral cavity and upper respiratory tract infections—for example, tonsilitis, or dental infection. While only a few cases of pyogenic sternoclavicular arthritis have been reported to date, it can be a cause of deep neck abscess. Similarly, there are limited reports of cervical infections associated with COVID-19, with only 1 reported case of cervical abscesses.

Case report: cervical infection

This article described the case of a 55-year-old COVID-19 patient who was admitted to the hospital because of hypoxemia. The patient had further complaints of fever and malaise. Doctors further referred the patient for a reverse transcriptase-polymerase chain reaction test for SARS-CoV-2. The test results came back positive. The patient was being followed up at home before admission and he struggled with hypertension and sleep apnea. The patient had no history of smoking. Doctors referred the patient for a computed tomography (CT) which showed ground-glass opacities in the pleura of both lungs. The findings are a typical presentation of COVID-19. The patient was started on treatment for COVID-19 with nasal high flow. However, the patient was weaned off from nasal high flow without intubation on the 12th day of hospitalisation. Though on the 12th day of hospitalisation, the patient developed pain in the left shoulder.

The patient’s pain worsened despite analgesics with redness and heat in the left neck

The patient’s pain worsened despite being on analgesics. Moreover, the patient developed redness and heat sensation in the left neck. The patient’s white blood cell (WBC) count was elevated, however, the C-reactive protein level was within normal range. Doctors further referred the patient for a CT scan which showed swelling of the left sternocleidomastoid muscle and left strap muscle. In addition, there was an increase in the fatty tissue concentration in the superior mediastinum. Based on these findings, the doctors suspected cervical cellulitis and the patient was started on intravenous ceftriaxone and vancomycin.

On the 17th day of hospitalisation, the patient’s WBC count decreased, however, the pain persisted

On the 17th day of hospitalisation, the patient’s WBC count decreased, however, the pain persisted. There were also signs of pus around the site of peripheral catheter insertion. Doctors referred him for a contrast-enhanced CT which was significant for left sternocleidomastoid arthritis with an abscess in the left sternocleidomastoid muscle, superior mediastinum and left strap muscle. Doctors performed an emergency incisional drainage under general anaesthesia on the same day.

The drainage was performed in the swollen area of the sternocleidomastoid muscle and extraction of pus was observed. There was also the excretion of pus near the sternoclavicular joint. Whereas the pus in the superior mediastinum was opened manually. The operation was completed with a thorough lavage with saline and placement of a drain each in the sternocleidomastoid muscle, left side of the thyroid cartilage and superior mediastinum. The wound was washed daily with the help of drain tubes.

Prognosis

The pus sample was sent for culture which showed the presence of methicillin-susceptible Staphylococcus aureus. Doctors prescribed the patient cefazolin 4 g/day, this was initiated on the 17th day of hospitalisation. The patient’s white blood cell count showed significant improvement after surgery and on the 26th day of hospitalisation, all the drains were removed.

After the abscess was treated, the patient showed significant improvement in pain. The pain was only present on the physical movement of the neck. Doctors referred the patient for postoperative magnetic resonance which showed a high signal intensity on the sternoclavicular joint. Based on these findings, the doctors suspected pyogenic sternoclavicular arthritis. The patient was discharged after staying at the hospital for 32 days. In addition, he was introduced to home oxygen therapy because he needed oxygen supplementation.

A few cases of cervical infections after COVID-19 have been reported since the virus outbreak. However, most of these cases are of deep neck abscesses that require immediate attention because they can be fatal. Secondary infections post COVID-19 are a common occurrence with immunosuppressive drugs. Therefore, physical examination should rule out secondary infections in COVID-19 patients to avoid any misdiagnosis.

Source: American Journal of Case Reports

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Dr. Aiman Shahab is a dentist with a bachelor’s degree from Dow University of Health Sciences. She is an experienced freelance writer with a demonstrated history of working in the health industry. Skilled in general dentistry, she is currently working as an associate dentist at a private dental clinic in Karachi, freelance content writer and as a part time science instructor with Little Medical School. She has also been an ambassador for PDC in the past from the year 2016 – 2018, and her responsibilities included acting as a representative and volunteer for PDC with an intention to make the dental community of Pakistan more connected and to work for benefiting the underprivileged. When she’s not working, you’ll either find her reading or aimlessly walking around for the sake of exploring. Her future plans include getting a master’s degree in maxillofacial and oral surgery, settled in a metropolitan city of North America.

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