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.