key: cord-0694378-c3kqtcuy
authors: Rizki, N. A.; Lukito, P. P.; Helsa, K.; Rustandi, D.
title: Republication de : COVID-19 patient with recurrent anosmia and its impact on management
date: 2022-02-22
journal: nan
DOI: 10.1016/j.aforl.2022.02.005
sha: 52c16337d102a1111db93b7e336aa12ae76cc137
doc_id: 694378
cord_uid: c3kqtcuy

nan

We would like to share a case of COVID-19 patient that experienced recurrent olfactory dysfunction. Many COVID-19 patients complained of olfactory dysfunction and possible recurrence poses a new challenge on its management in our field of specialty.

A 37-year-old woman came with smell impairment for 9 days and cough for 1 day. Anosmia was confirmed by Alcohol Sniff Test (AST). Nasoendoscopy revealed insignificant secretion and absence of endonasal pathology. Her nasopharyngeal swab was positive for SARS-CoV2 on RT-PCR test. She was admitted and treated with oseltamivir oral 75 mg twice a day and mometasone furoate intranasal spray 100 g twice a day. She also carried nasal irrigation and underwent olfactory training. She responded well to the therapy and by the 17th day after onset, her anosmia had resolved. However, 5 days later she reported another sudden smell impairment. AST confirmed she was once again anosmic while nasoendoscopy finding was similar with previous result. CT scan was performed on the second episode and revealed no significant pathologies (Fig. 1) . Two days after recurrence, her cycle threshold value decreased (Fig. 2) . This was later followed by fever and myalgia. Therapy was continued throughout this second episode and her second anosmia completely resolved 19 days later. All nasopharyngeal swabs were done by the same otorhinolaryngologist and RT-PCR tests were carried with the same machine and reagent, hence reducing procedural variability.

There are three possible causes for recurrence: excessive inflammation, reinfection, or viral replication rebound. Excessive inflammation was unlikely since we administered intranasal corticosteroid throughout her admission. Additionally, detection of viral RNA before and after recurrence rather point to the two other causes. Recently, reinfection was confirmed by one study finding genomically different virus on the second episode [1] . Unfortunately, we did not perform genome sequencing but since our patient was under strict hospital quarantine, there was very little chance for reinfection. Moreover, the presence of viral RNA before recurrence followed by several low cycle threshold values afterward and the short period between episodes indicate that replication rebound was the more likely cause. SARS-CoV2 was speculated to persist in "sanctuary site" and reactivates in the future [2]. Our finding differs in which it was possibly caused by an active virus. Our limitation is we used cycle threshold value, so we can only describe the trend. Further studies with viral culture to confirm virus viability and infectivity during recurrence would help guide management and containment strategies.

Anosmia is a frequent complaint of COVID-19 patients [3] but literature search revealed that this is only the fifth COVID-19 patient reported to experience recurrent olfactory dysfunction [4, 5] . Our patient was the first one to experience recurrent olfactory dysfunction with reinfection ruled out, showing that recovered patient with little exposure to the virus might still be vulnerable. Because of the growing evidence, we suggest clinicians to continue a close followup on the olfactory aspect of clinically recovered COVID-19 patient. Moreover, many COVID-19 recurrences have been reported [6] . The possibility that COVID-19 patients might have anosmia as the only presenting symptoms during recurrence even when they did not experience it on the first episode cannot be dismissed and this further highlights the importance of olfactory follow-up. It would be a great contribution from us, otorhinolaryngologist, to be able to help identify and manage COVID-19 patient with recurring symptoms.

Rizki NA, et al Annales françaises d'oto-rhino-laryngologie et de pathologie cervico-faciale xxx (xxxx) xxx-xxx 

The authors declare that they have no competing interest.

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