A rare case of invasive and necrotizing Pseudomonas sinusitis in an immunocompetent COVID-19 patient

We report a rare case of an invasive bacterial and thrombotic necrotizing sinusitis in a healthy, immunocompetent 27-year-old female in the setting of a COVID-19 infection. And describe the reconstruction approach after her partial rhinectomy. We performed a comprehensive literature review and case study to explore the incidences of necrotizing sinusitis in the setting of COVID-19. The patient presented to the emergency room with known COVID-19 positivity and left-sided nasal and peri-orbital edema and erythema that progressed to nasal tip and sinonasal necrosis. MRI showed thrombi in bilateral orbital veins. She underwent a partial rhinectomy and multiple endoscopic debridements. Tissue specimen pathology showed invasive P. aeruginosa. The patient subsequently underwent staged reconstruction with placement of a folded paramedian forehead flap for both external nasal tip and internal nasal lining reconstruction. Later stages included recreation of the bilateral lower lateral cartilages with auricular cartilage grafting and tip contouring. P. aeruginosa can cause an aggressive, necrotizing infection that can present in a similar fashion to invasive fungal sinusitis due to similar vascular invasion and subsequent ischemia. In the case of the presented patient, it is theorized that the COVID-19 infection led to a thromboembolic state resulting in confirmed orbital vein thrombosis and likely additional sub-clinical microthrombi. In the setting of the COVID-related thrombo-emboli, she likely became predisposed to the invasive necrotizing bacterial infection. This is the first reported case of invasive Pseudomonas rhinosinusitis depicted in a young immunocompetent adult patient with COVID-19 without other comorbidities.