Discussion
Rare disease processes and manifestations have been reported in COVID-19
positive patients. Peptoniphilus indolicus, a type of bacteria normally
found in the vagina and stomach1, was found within our
patient’s orbit. There are now more than 15 Peptoniphilus species within
the genus, seven of which were discovered in 2012 2-9.
Still, up until now, none of the 15 species have been seen within the
orbit. To date, Peptoniphilus species have most commonly been associated
with diabetic skin and soft tissue infections, bone and joint
infections, and surgical site infections 10-13. A
recent study of pre-term labor and early neonatal sepsis also
isolated Peptoniphilus from amniotic fluid causing
choramnionitis 14. Only recently did a case series
of Peptoniphilus causing bloodstream infection (BSI), either alone or as
part of a polymicrobial infection, become available15.
We believe that our case is the first to document Peptoniphilus within
the orbit. Physicians should therefore add it to their differential when
COVID-19 patients present with sinusitis and orbital abscess. An
Infectious Disease team should also be a part of the care team in order
to adequately cover unusual organisms.
Of note, the avascularity of the nasal tissue was of significant
interest and very peculiar to the surgeons involved with the case. Limb
ischemia and avascular surgical fields have been noted during the
COVID-19 pandemic, as evidenced in the Italian Lombardy
region16. In Lombardy, the incidence of acute limb
ischemia (ALI ) significantly increased during the COVID-19 pandemic and
successful revascularization was lower than expected, believed to be due
to a virus-related hypercoagulable state16. As
reported by Silingardi and colleagues, the increased thromboembolic
complications in COVID-19 patients have been reported even in those
receiving anticoagulant therapy and in nonatherosclerotic
patients16-19. In turn, precautions must be taken when
performing surgery on COVID-19 positive patients, specifically from a
vascular standpoint.
Finally, the Ophthalmology service made note of the peculiarity of the
spontaneously-draining orbital abscess. Typical orbital abscess
presentations include red eye, proptosis, ophthalmoplegia, and
pain20-21. In severe cases, the optic nerve can become
compressed, leading to compressive optic
neuropathy21. The incidence of abscess formation among
sinus disease patients varies from 6.25% to 20%, to as high as
78.6%22-25. Rarely, however, does an orbital abscess
drain on its own. According to the American Academy of Ophthalmology,
current guidelines recommend surgical drainage in conjunction with
intravenous antibiotics to achieve complete resolution of the infection
in patients over the age of fourteen26. Still, there
are very few studies with high power looking at orbital abscess drainage
in adults. For example, from a study by Kayhan and colleagues with ten
total patients, external drainage of the abscess was needed in six of
the patients in the study27. Nevertheless, zero of the
six orbital abscesses that needed draining did so spontaneously, further
supporting the rarity of the type of orbital abscess found in the
COVID-19 positive patient in our study.