key: cord-0727720-l3gjlu25
authors: Renner, Andreas; Lamminmäki, Satu; Ilmarinen, Taru; Khawaja, Tamim; Paajanen, Juuso
title: Acute epiglottitis after COVID‐19 infection
date: 2021-07-10
journal: Clin Case Rep
DOI: 10.1002/ccr3.4419
sha: 0252115cc3f10e0896adbfabe0169060180d0eaf
doc_id: 727720
cord_uid: l3gjlu25

In patients with acute epiglottitis, the possibility of COVID‐19 should be ruled out. Repeated nasofiberoscopy examinations or a tracheostomy, which may produce infectious aerosols, may be required.

the vallecula and the pyriform sinuses, raising suspicion of a left-side internal abscess of the epiglottis. The epiglottis and the swollen arytenoids blocked the view into the vocal cords ( Figure 1) .

Laboratory workup at presentation showed an elevated Creactive protein level (169 mg/L) and white blood cell count (31.3 × 10 9 /L) with 87% neutrophils. Within three hours, mild respiratory distress was followed by worsening airway obstruction with stridor, and urgent surgical tracheostomy was performed in local anesthesia. Nasopharyngeal swab still tested positive for SARS-CoV-2 by RT-PCR. The operating theatre personnel used standard personal protection with surgical gowns, gloves, type IIR surgical masks, and plastic eye shields. Empirical intravenous antibiotic treatment with a combination of cefuroxime and metronidazole was begun. Bacterial cultures of blood and throat swabs obtained at presentation were negative. In six days, the swelling of the epiglottis decreased, and the tracheostomy was decannulated successfully. The patient was discharged on the 8th postoperative day in good condition (for timeline see Figure 2 ). This case report did not meet the criteria to require IRB approval. Written informed consent was obtained from the patient.

Epiglottitis is a rare, but potentially life-threatening infection that causes sudden inflammation and swelling of the epiglottis. It is usually caused by bacteria, although other etiologies have been reported. As with other viral infections, SARS-CoV-2 can predispose to secondary bacterial superinfections. A meta-analysis representing 3338 patients identified secondary bacterial infection in 6.9% of COVID-19 patients. 2 Tracheostomy is an aerosol-generating procedure with an increased risk of transmission of airborne diseases to healthcare workers. 4 Infectiousness of COVID-19 is considered to be highest around the time of onset of symptoms after which it rapidly decreases. Viral RNA can be detected by RT-PCR for weeks or even months after symptom onset, especially from lower airway tract samples, but that does not necessarily correlate well with infectiousness or even the presence of culturable virus. 5 There have been a few reports of isolation of viable virus more than ten days after symptom onset but none after twenty. 5 Our patient underwent surgical tracheostomy three weeks after COVID-19 symptom onset. The decision to use standard personal protection for the operating theatre personnel during the awake tracheostomy was justified in the light of the above. None of those that participated in the tracheostomy were subsequently diagnosed with COVID-19 infection. The duration of risk of transmission from patient to healthcare personnel during surgical tracheotomy is yet unclear. Thus, enhanced PPE measures may be justified when tracheostomy is performed after COVID-19 infection.

Both the case published by Fondaw et al 3 and the one presented here had a life-threatening epiglottitis with severe upper airway obstruction and a positive COVID-19 swab test. However, in the case by Fondaw et al 3 epiglottitis was the first symptom and lead to the COVID-19 diagnosis, while the patient described here presented with epiglottitis two weeks after recovering from the initial COVID-19 infection. The latter disease course is more in line with other secondary bacterial infections after COVID-19 such as secondary bacterial pneumonia. Based on these two cases, patients with epiglottitis should be tested for COVID-19, not only for the sake of the patient, but also to protect healthcare personnel.

We present the case of a young man with likely COVID-19-associated epiglottitis. In COVID-19 patients with respiratory distress, physicians should also keep in mind other possible underlying disorders. On the other hand, in patients with acute epiglottitis, the possibility of COVID-19 should be ruled out. While RT-PCR is the gold standard for detecting SARS-CoV-2 RNA, detection of viral RNA does not necessarily mean that person is infectious and able to transmit the virus. However, enhanced PPE measures may be justified during tracheotomy since the risk of transmission to healthcare personnel is yet unclear.

Analysis of the clinical characteristics of 77 COVID-19 deaths

Bacterial co-infection and secondary infection in patients with COVID-19: a living rapid review and meta-analysis

COVID-19 infection presenting with acute epiglottitis

Tracheostomy in the COVID-19 era: global and multidisciplinary guidance

Understanding viral shedding of severe acute respiratory coronavirus virus 2 (SARS-CoV-2): review of current literature

The authors wish to thank Mira Naukkarinen, MD for the medical image.

The authors declare no conflicts of interest.

AR: wrote the first draft of the manuscript. SL, TI, TK and JP: critically reviewed and edited the manuscript.

All data for which the patient has provided informed consent to be published have been included in this article. No more data can be shared for privacy reasons.

This case report did not meet criteria to require IRB approval. Written informed consent was obtained from the patient.

https://orcid.org/0000-0002-1414-5433