Improbable Happens All The Time
Mark Crislip
This month I have seen two patients with lung abscess/empyema present simultaneously with their COVID. Fevers, cough, shortness of breath for about a week who went to the ER and are had COVID and a lung abscess. After maybe a decade since I have seen a good lung abscess, here are two in as many weeks.
Causal? Doubt it.
There are cases of lung abscess in COVID, mostly late and associated with Aspergillus.
There is one early case credited to COVID, but this one was still several weeks after the initial infection and was thought to be due to COVID as no other etiology was found.
Both my patients had the usual suspects grow out of the pus: oral Streptococci and anaerobes, and I can find no cases of concomitant lung abscess and COVID.
So what did the patients have in common besides acute COVID?
Bad dentition, a classic risk factor for lung abscess
Excessive alcohol use. Another classic risk factor and a reason for the delay in presentation. Given the large size of these abscesses, I suspect they had been festering under the inebriated radar for a while.
And NSAIDs. My favorite risk for lung abscess and empyema. Two of many examples:
In multivariate analyses, two factors were independently associated with the development of pleuroparenchymal complications: NSAIDs intake [Odds Ratio (OR) = 2.57 [1.02–6.64]; _p_ = 0.049] and alcohol abuse (OR = 2.68 [1.27–5.69]; _p_ = 0.01).
and
In conclusion, we found that NSAID use was associated with an increased risk of pleuropulmonary complications in patients hospitalized with CAP.
While it is so tempting to credit the acute COVID for the lung abscesses, it is just the usual reasons and a bit of the Improbability Principle:
the paradoxical idea that extremely improbable events happen frequently.
Which explains why I never run out of infections to write about.
Rationalization
Lung cavitation due to COVID-19 pneumonia https://casereports.bmj.com/content/13/7/e237245
Non-steroidal Anti-inflammatory Drugs may Worsen the Course of Community-Acquired Pneumonia: A Cohort Study https://link.springer.com/article/10.1007/s00408-016-9973-1
Nonsteroidal Antiinflammatory Drug Use and Clinical Outcomes of Community-acquired Pneumonia https://www.atsjournals.org/doi/full/10.1164/rccm.201802-0229LE
The Improbability Principle https://thatsmaths.com/2017/04/06/the-improbability-principle/
It’s Not Actually a Miracle https://slate.com/technology/2014/02/the-improbability-principle-rare-events-and-coincidences-happen-all-the-time.html