Otogenic Brain Abscess and Concomitant Acute COVID-19 Infection: Case Report and Review of the Literature

Abstract

Background 2019 coronavirus disease (COVID-19) has attracted global attention primarily because of the severe acute respiratory symptoms associated with it. However, nearly one third of the patients also present with neurological symptoms. This report describes a case of a previously healthy woman with acute COVID-19 infection, who developed acute facial nerve palsy and rapid progression to coma due to otogenic brain abscess.

Case Description A 63-year-old woman with acute COVID-19 infection exhibited acute facial nerve paresis, high fever, and purulent secretion from her left ear within 48 hours after COVID-19 onset. Cranial computed tomography scan confirmed acute mastoiditis, precipitating an urgent mastoidectomy. A postoperative contrast-enhanced magnetic resonance imaging on the same day revealed a subdural empyema, which prompted an urgent craniotomy and decompression. Intraoperative microbiological swabs confirmed a Streptococcus pyogenes infection; however, reverse transcription polymerase chain reaction was negative for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). After immediate intravenous antibiotic treatment, extubation was achieved 4 days after operation, and the patient was discharged without neurological deficits 19 days after postoperatively.

Conclusion This finding adds a layer of insight into the specific nature of the infection, suggesting a potential absence of SARS-CoV-2 involvement in otogenic subdural empyema. However, the impact of SARS-CoV-2 in otogenic brain abscess cannot be excluded to date and should be further prospectively investigated. The complete recovery of neurological status emphasizes the importance of prompt and interdisciplinary interventions in managing rare and severe complications associated with COVID-19.

Keywords

coronavirus disease 2019 - facial nerve paresis - encephalitis - mastoiditis - subdural empyema

Consent to Participate

Informed consent was obtained from the patient.

Ethics Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Authors' Contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by D.D., S.-Y.W., F.G. and R.M. The first draft of the manuscript was written by A.R. S.T., B.B., S.B., C.B., D.A.R., L.Z., T.M.F. commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Publication History

Received: 21 March 2024

Accepted: 19 November 2024

Accepted Manuscript online:
20 November 2024

Article published online:
26 May 2025

• References

• 1 Ge H, Wang X, Yuan X. et al. The epidemiology and clinical information about COVID-19. Eur J Clin Microbiol Infect 2020; 39 (06) 1011-1019
• 2 Ochani R, Asad A, Yasmin F. et al. COVID-19 pandemic: from origins to outcomes. A comprehensive review of viral pathogenesis, clinical manifestations, diagnostic evaluation, and management. Infez Med 2021; 29 (01) 20-36
• 3 Harapan BN, Yoo HJ. Neurological symptoms, manifestations, and complications associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease 19 (COVID-19). J Neurol 2021; 268 (09) 3059-3071
• 4 Liotta EM, Batra A, Clark JR. et al. Frequent neurologic manifestations and encephalopathy-associated morbidity in COVID-19 patients. Ann Clin Transl Neurol 2020; 7 (11) 2221-2230
• 5 Bernard-Valnet R, Perriot S, Canales M. et al. Encephalopathies associated with severe COVID-19 present neurovascular unit alterations without evidence for strong neuroinflammation. Neurol Neuroimmunol Neuroinflamm 2021; 8 (05) e1029
• 6 Aghagoli G, Gallo Marin B, Katchur NJ, Chaves-Sell F, Asaad WF, Murphy SA. Neurological involvement in COVID-19 and potential mechanisms: a review. Neurocrit Care 2021; 34 (03) 1062-1071
• 7 Desforges M, Le Coupanec A, Stodola JK, Meessen-Pinard M, Talbot PJ. Human coronaviruses: viral and cellular factors involved in neuroinvasiveness and neuropathogenesis. Virus Res 2014; 194: 145-158
• 8 Gupta A, Madhavan MV, Sehgal K. et al. Extrapulmonary manifestations of COVID-19. Nat Med 2020; 26 (07) 1017-1032
• 9 Ljubimov VA, Babadjouni R, Ha J. et al. Adolescent subdural empyema in setting of COVID-19 infection: illustrative case. J Neurosurg Case Lessons 2022; 3 (04) CASE21506
• 10 Meguins LC, Rocha AS, Laurenti MR, de Morais DF. Ventricular empyema associated with severe pyogenic meningitis in COVID-19 adult patient: case report. Surg Neurol Int 2021; 12: 346
• 11 Palma S, Bovo R, Benatti A. et al. Mastoiditis in adults: a 19-year retrospective study. Eur Arch Otorhinolaryngol 2014; 271 (05) 925-931
• 12 Widdrington JD, Bond H, Schwab U. et al. Pyogenic brain abscess and subdural empyema: presentation, management, and factors predicting outcome. Infection 2018; 46 (06) 785-792
• 13 Dietler S, Willms J, Brandi G, Wang S, Burkerth A, Keller E. Spontaneous empyema and brain abscess in an intensive care population: clinical presentation, microbiology, and factors associated with outcome. Acta Neurochir (Wien) 2023; 165 (03) 651-658
• 14 Nathoo N, Nadvi SS, Gouws E, van Dellen JR. Craniotomy improves outcomes for cranial subdural empyemas: computed tomography-era experience with 699 patients. Neurosurgery 2001; 49 (04) 872-877 , discussion 877–878
• 15 French H, Schaefer N, Keijzers G, Barison D, Olson S. Intracranial subdural empyema: a 10-year case series. Ochsner J 2014; 14 (02) 188-194
• 16 Tsuchiya K, Osawa A, Katase S, Fujikawa A, Hachiya J, Aoki S. Diffusion-weighted MRI of subdural and epidural empyemas. Neuroradiology 2003; 45 (04) 220-223
• 17 Al-Olama M, Rashid A, Garozzo D. COVID-19-associated meningoencephalitis complicated with intracranial hemorrhage: a case report. Acta Neurochir (Wien) 2020; 162 (07) 1495-1499
• 18 Scharnhorst V, Van De Laar PJ, Vader HL. Detection of SARS coronavirus RNA in the cerebrospinal fluid of a patient with severe acute respiratory syndrome. Clin Chem 2003; 49 (12) 2107-2108
• 19 Göre B, Yenigün EC, Cevher SK, Çankaya E, Aydın N, Dede F. IGA nephropathy and spinal epidural abscess after COVID-19 infection: a case report. Future Virol 2022; 17 (09) 611-615
• 20 Sampogna G, Tessitore N, Bianconi T. et al. Spinal cord dysfunction after COVID-19 infection. Spinal Cord Ser Cases 2020; 6 (01) 92
• 21 Erok B, Kıbıcı K. COVID-19 infection manifesting with lumbar spondylodiscitis complicating with psoas abscess without pneumonia. Indian J Neurosurg 2024; 13 (03) 252-254
• 22 Popovici GC, Georgescu CV, Arbune AA, Vasile MC, Olteanu I, Arbune M. Post-COVID-19 spondylodiscitis: a case study and review of the literature. Medicina (Kaunas) 2023; 59 (03) 616
• 23 Naderi S. COVID-19 infection leading to lethal spondylodiscitis with spinal abscess. Indian J Neurosurg 2020; 6 (03) 151-154
• 24 Gennaro N, Bonifacio C, Corato M, Milani D, Politi LS. Quadriparesis caused by retropharyngeal and epidural abscess in COVID-19 patients. Neurol Sci 2021; 42 (05) 1683-1685
• 25 Chu ECP, Trager RJ, Chen ATC, Shum JSF. A 60-year-old man with gingivitis and poorly controlled diabetes developing low back pain 1 week following recovery from COVID-19 diagnosed with spinal abscess due to Streptococcus oralis . Am J Case Rep 2022; 23: e937517
• 26 Mohamed Ramlee FA, Harun MHB, Nagaretnam V, Lim TS, Aris HF, Tan CN. A case series of spinal infections following COVID-19: a delayed complication. Cureus 2022; 14 (09) e29272
• 27 Soh P, Doan N, Manning B, Doan H. Spinal cord injury from an epidural abscess as a serious complication of COVID-19 infection. Cureus 2020; 12 (11) e11327
• 28 Talamonti G, Colistra D, Crisà F, Cenzato M, Giorgi P, D'Aliberti G. Spinal epidural abscess in COVID-19 patients. J Neurol 2021; 268 (07) 2320-2326
• 29 Issa M, Kalliri V, Euteneuer S. et al. The association of COVID-19 pandemic with the increase of sinogenic and otogenic intracranial infections in children: a 10-year retrospective comparative single-center study. Neurosurg Rev 2024; 47 (01) 205
• 30 Angelo SJ, Anderson MG, Sutter PA. et al. Changes in the epidemiology of pediatric sinogenic and otogenic intracranial infections during the COVID-19 pandemic: a single-institution study. J Neurosurg Pediatr 2023; 32 (02) 231-241
• 31 Cohen R, Ashman M, Taha MK. et al. Pediatric Infectious Disease Group (GPIP) position paper on the immune debt of the COVID-19 pandemic in childhood, how can we fill the immunity gap?. Infect Dis Now 2021; 51 (05) 418-423
• 32 Lindeboom RGH, Worlock KB, Dratva LM. et al. Human SARS-CoV-2 challenge uncovers local and systemic response dynamics. Nature 2024; 631 (8019): 189-198
• 33 Romani L, Del Chierico F, Pane S. et al; CACTUS Study Team. Exploring nasopharyngeal microbiota profile in children affected by SARS-CoV-2 infection. Microbiol Spectr 2024; 12 (03) e0300923
• 34 Rocafort M, Henares D, Brotons P. et al. Impact of COVID-19 lockdown on the nasopharyngeal microbiota of children and adults self-confined at home. Viruses 2022; 14 (07) 1521
• 35 Hernández-Terán A, Mejía-Nepomuceno F, Herrera MT. et al. Dysbiosis and structural disruption of the respiratory microbiota in COVID-19 patients with severe and fatal outcomes. Sci Rep 2021; 11 (01) 21297
• 36 Park MB, Sim B. Vaccine effectiveness of COVID-19 and rebound in the real world. Clin Exp Med 2023; 23 (08) 4975-4983
• 37 Külper-Schiek W, Piechotta V, Pilic A. et al. Facing the omicron variant-how well do vaccines protect against mild and severe COVID-19? Third interim analysis of a living systematic review. Front Immunol 2022; 13: 940562
• 38 Gessler F, Schmitz AK, Dubinski D. et al. Neurosurgical considerations regarding decompressive craniectomy for intracerebral hemorrhage after sars-cov-2-vaccination in vaccine induced thrombotic thrombocytopenia—VITT. J Clin Med 2021; 10 (13) 2777