What is the next step in managing a 23-year-old woman with fever, nasal congestion, rhinorrhea, and myalgia for three days, negative COVID-19 (Coronavirus Disease 2019) and influenza testing, and tenderness over the right maxillary sinuses?

From the Guidelines

The next step in managing this 23-year-old woman with symptoms of acute rhinosinusitis is to initially manage her with supportive care, including analgesics for pain, antipyretics for fever, and adjunctive therapies such as intranasal saline irrigation or intranasal corticosteroids, without immediate antibiotic treatment, given her symptoms have only lasted for three days and do not meet the criteria for antibiotic therapy as outlined by the American College of Physicians and the Centers for Disease Control and Prevention 1.

Given her presentation of fever, nasal congestion, rhinorrhea, myalgia, and tenderness over the right maxillary sinuses, along with negative COVID-19 and influenza testing, the most appropriate initial approach is to provide symptomatic relief. This can include:

• Analgesics such as acetaminophen 650 mg every 6 hours as needed for pain and fever
• Intranasal saline irrigation 2-3 times daily to help alleviate nasal congestion
• An intranasal corticosteroid such as fluticasone 1-2 sprays per nostril daily to reduce inflammation

Antibiotic treatment should be reserved for patients with persistent symptoms for more than 10 days, onset of severe symptoms or signs of high fever (>39 °C) and purulent nasal discharge or facial pain lasting for at least 3 consecutive days, or onset of worsening symptoms following a typical viral illness that lasted 5 days that was initially improving, as suggested by the guidelines for high-value care 1.

If the patient's condition worsens or does not improve within the expected timeframe, reassessment and consideration of antibiotic therapy, such as amoxicillin-clavulanate, may be necessary. However, given the current duration and nature of her symptoms, supportive care is the most appropriate initial management strategy.

From the Research

Clinical Presentation

The patient presents with fever, nasal congestion, rhinorrhea, and myalgia for three days, with negative COVID-19 and influenza testing, and tenderness over the right maxillary sinuses. These symptoms are suggestive of acute rhinosinusitis.

Diagnostic Considerations

• The patient's symptoms and physical examination findings, such as tenderness over the right maxillary sinuses, are consistent with acute rhinosinusitis 2.
• The negative COVID-19 and influenza testing helps to rule out these viral infections as the primary cause of the patient's symptoms.
• However, it is essential to consider the possibility of co-infections or secondary bacterial infections, as seen in some cases of COVID-19 3.

Management

• The next step in managing this patient would be to consider imaging studies, such as a computed tomography (CT) scan or magnetic resonance imaging (MRI), to confirm the diagnosis of acute rhinosinusitis and to evaluate the extent of the disease.
• Antibiotic therapy may be considered, especially if there is evidence of bacterial infection, such as purulent discharge or elevated white blood cell count.
• It is crucial to note that antibiotic resistance patterns may have changed during the COVID-19 pandemic, and antibiotic sensitivity testing may be necessary to guide treatment 4.
• In severe cases or cases with complications, such as invasive fungal sinusitis, more aggressive treatment, including surgical debridement and antifungal therapy, may be necessary 5.

Risk Factors

• The patient's age and lack of underlying medical conditions do not appear to increase her risk for complications.
• However, it is essential to consider the possibility of underlying conditions, such as diabetes mellitus, that may increase the risk of complications, such as invasive fungal sinusitis 5, 2.

Further Evaluation

• A thorough medical history and physical examination are necessary to identify any underlying conditions that may increase the risk of complications.
• Laboratory tests, such as complete blood count and blood cultures, may be necessary to evaluate the patient's overall condition and to guide treatment.
• Imaging studies and antibiotic sensitivity testing may be necessary to confirm the diagnosis and to guide treatment.