What is the appropriate management for a 46-year-old COVID-19 positive patient presenting with three days of pharyngitis, purulent rhinorrhea, sinus pressure, and headache?

Management of COVID-19 with Upper Respiratory Symptoms

This 46-year-old COVID-19 positive patient with pharyngitis, purulent rhinorrhea, sinus pressure, and headache should receive symptomatic management with paracetamol for fever/pain, adequate hydration (up to 2 liters daily), honey for cough suppression if not contraindicated, and close monitoring for progression to pneumonia or secondary bacterial infection. 1, 2

Initial Symptomatic Management

Primary interventions:

• Use paracetamol rather than NSAIDs for fever, headache, and sore throat until more evidence is available 1, 2
• Ensure adequate fluid intake (no more than 2 liters per day) to avoid dehydration and help thin mucus secretions 1, 2
• Start with simple measures such as honey to suppress cough if not contraindicated 1, 2

Managing Specific Symptoms

For sore throat and nasal congestion:

• These are common ENT manifestations in COVID-19, with sore throat occurring in 30% and nasal congestion in 28.3% of patients 3
• The purulent rhinorrhea and sinus pressure suggest acute rhinosinusitis, which is significantly associated with headache in COVID-19 (odds ratio 3.5) 4

For persistent distressing cough:

• Avoid lying flat on back as this makes coughing ineffective 1, 2
• If simple measures fail, consider short-term use of codeine linctus or codeine phosphate tablets 1, 2

For headache:

• Headache is highly prevalent (72%) in COVID-19 and strongly associated with acute rhinosinusitis symptoms 4
• The headache mechanism likely involves systemic inflammatory response with cytokine release rather than direct sinus pressure 4, 5

Critical Monitoring for Disease Progression

Watch for red flags indicating deterioration:

• Development of shortness of breath, which may indicate progression to pneumonia 1, 2
• Fever typically peaks around 5 days after exposure; persistent fever beyond 3-5 days warrants reassessment 1, 2
• Symptoms worsening after initial improvement may indicate secondary bacterial infection 2

This patient is at moderate risk given:

• Age 46 years places them in middle-age category where complications can occur 6
• Purulent nasal discharge and sinus symptoms raise concern for bacterial superinfection 2

When to Consider Antibiotics

Secondary bacterial sinusitis should be suspected if:

• Symptoms persist beyond 7-10 days without improvement 2
• Symptoms worsen after initial improvement (double-worsening pattern) 2
• Laboratory markers show elevated C-reactive protein and procalcitonin 2

Important Precautions

Isolation and follow-up:

• Ensure appropriate isolation measures to prevent transmission 1
• Advise patient to return or seek evaluation if symptoms worsen, fever persists beyond 3-5 days, or new symptoms develop, particularly shortness of breath or chest pain 2

Common Pitfalls to Avoid

• Do not dismiss nasal symptoms as trivial - they are common COVID-19 manifestations and associated with headache 4, 3
• Do not use NSAIDs as first-line - paracetamol is preferred until more safety data available 1, 2
• Do not overlook fungal superinfection risk - though rare, acute invasive fungal sinusitis can occur post-COVID, especially in diabetic patients or those receiving steroids 7