Lung Abscess as a Delayed Complication in a COVID-19 Pneumonia Patient: A Case Report

Notably, this complication manifested 2 weeks after the patient was discharged. COVID-19 can have several unexpected complications, including lung abscess. It is crucial to monitor patients after discharge for such complications, especially if they are symptomatic .


INTRODUCTION
On 11 February 2020, the World Health Organization (WHO) declared that the novel coronavirus 2019-nCoV was the cause of coronavirus disease 2019 . They declared the disease a pandemic in March 2020. 1 One of the nations that is still dealing with the COVID-19 outbreak is Indonesia; with the first peak of cases in January 2021, the recorded population of Indonesians testing positive for COVID-19 reached 14,000 new cases. The second peak of the Indonesian COVID-19 pandemic was in July 2021, reaching 51,000 people and 2,000 patients died. 1 The presence of fever, cough, and dyspnea often heralds the acute viral illness of COVID-19. 2,3 A large percentage of COVID-19 patients experience numerous complications, such as thromboembolism, arrhythmias, encephalopathy, pneumothorax, and lung abscess. 2

CASE REPORT
A lung abscess is a type of pulmonary infection in which a cavity forms in the pulmonary parenchyma and develops an air-fluid level. 3 Lung abscess has been reported as a late complication of COVID-19. In this case report, we presented a case of lung abscess as a delayed complication in a COVID-19 pneumonia patient, which was first reported in Indonesia. To our knowledge, lung abscess is a relatively rare complication of COVID-19. It occurred 2 weeks after the patient was discharged from the hospital.

CASE
A 30-year-old man was admitted to the emergency department with the complaint of breathlessness. Symptoms began approximately 3 days before presentation and had progressively worsened, with no associated or alleviating factors noted. He also had nausea and vomiting and a productive cough with an increasing amount of yellowish sputum over 3 days. He tested positive via rapid antigen test 1 day before his hospital visit. He denied any prior history of traveling to other cities or any countries.
On initial physical examination, the patient was alert, with a Glasgow Coma Scale (GCS) score of 15 (E4V5M6); the respiratory rate was increased to 26 breaths/minute, with an oxygen saturation of 95% on ambient air, blood pressure of 140/90 mmHg, heart rate of 89 beats per minute, and axillary temperature of 36°C.

Parameter
Blood and sputum culture tests were negative and indicated no growth of bacteria ( follow-up chest X-ray was performed. We were surprised to find an air-fluid level in the upper lobe of the right lung, indicating a lung abscess ( Figure 1E). We hypothesized that this abscess was due to aspiration and bacterial infection secondary to COVID-19. The patient was treated with oral metronidazole 500 mg three times a day, levofloxacin 500 mg once a day, Ambroxol 30 mg three times a day, and combination therapy of salmeterol and fluticasone. The combination of salmeterol and fluticasone was given to the patient due to airway obstruction and increased VEP1 percentage on spirometry from 42% to 68% after the bronchodilator test. The therapies were prescribed for 2-3 weeks.
Clinical follow-up four weeks after treatment revealed no symptoms, and the chest X-ray showed significant improvement ( Figure 1F).

DISCUSSION
Lung abscess is a relatively uncommon complication of COVID-19 pneumonia. It is a type of pulmonary infection in which a cavity forms in the lung parenchyma and develops an air-fluid level. 2  He had nausea and vomiting and a productive cough with an increasing amount of green-yellowish sputum over 3 days. Fever, reduced general well-being, and respiratory symptoms, such as cough (90%), sputum production (66%), and dyspnea (66%), are all manifestations of pneumonia. 5,7 On examination, the respiratory rate was increased to 26 times per minute with an oxygen saturation of 95% on ambient air. Auscultation of the chest revealed rhonchi in both lung fields. Chest X-ray revealed ground-glass opacities on both sides of the lung, indicating typical COVID-19 pneumonia. The patient's rapid antigen test result was positive 1 day before presenting at the hospital. A PCR test was performed to confirm the result, and the patient tested positive with a CT value of 23.93. A microbiological examination is crucial when assessing a COVID-19 patient. 8 A PCR test is utilized to detect SARS-CoV-2 nucleic acids. 9,10 Lower respiratory tract secretions, throat swabs, and sputum samples can all be used to detect SARS-CoV-2 viral nucleic acids. 8 This patient's nasopharyngeal swab revealed the presence of SARS-CoV-2 nucleic acid. Ddimer was increased on day 2 and 7 of hospitalization.
Within five days, heparin was administered at a therapeutic dose. According to research and clinical observations, there may be a link between COVID-19 and substantial thrombotic risk. 7 Our key diagnostic assumption is that COVID-19 pneumonia was followed by the development of a lung abscess. Bacterial superinfections following COVID-19 pneumonia have been described since the COVID-19 outbreak began in China. 11,12 Lung abscesses frequently form in the posterior segment of the right upper lobe and middle lobe, followed by the superior segment of the right lower lobe, and less frequently in the left lung following aspiration of oropharyngeal contents. 2 Acute lung abscess is typically surrounded by poorly defined lung parenchyma filled with thick necrotic detritus. 2 Lung abscess can be diagnosed via plain radiograph, which typically shows a cavity containing an air-fluid level, CT scan with contrast to identify abscess margins, and sputum and blood culture to identify the causative organism, such as Staphylococcus aureus, Klebsiella, Pseudomonas, and Proteus. 2 To confirm a lung abscess due to COVID-19 in a patient, a positive result of a COVID-19 PCR swab test is needed to prove that the patient may be suffering from super-infection, and other risk factors for lung abscess should be excluded. 13 The lung abscess in this patient developed after being discharged. The patient's only recent illness was a COVID-19 infection. Of note, this complication manifested 2 weeks after the patient was discharged and after symptoms had resolved. Several antibiotics were then administered to the patient. Despite CoV-2 being identified in several case reports, this case emphasizes the need to be observant of late infection sequelae following COVID-19 pneumonia. A recent study found that patients who developed lung abscesses after COVID-19 pneumonia could not be treated empirically because no bacteria could be detected. 13,14 In this case, no bacterial growth was detected via bacterial culture study; therefore, we used an empirical approach to treatment. 15

Consent
Written informed consent was obtained from the patient.