Melissa Pruski*, Joseph Rogers*, Ebru Nayci*, Ricardo Ramirez*, Sabina Shukurova*

* American University of the Caribbean School of Medicine

A 20-year-old obese female without significant past medical history presented to the emergency department complaining of 2-month history of unresolved headache, nasal congestion, bilateral otalgia, right being worse than left, and intermittent fevers. Patient was afebrile and vitals were normal at ED. Patient complains of a sore throat consistent with right-sided lymphadenopathy. Patient reports 20 lb unintentional weight loss within 2 months and denies any further symptoms. She has taken Tylenol, Mucinex, Zyrtec without relief. Patient was previously diagnosed with sinusitis which did not resolve after a course of doxycycline. Physical exam revealed right sided otitis externa, oropharyngeal exudate and posterior oropharyngeal erythema otherwise was unremarkable.

CBC showed minimal leukocytosis and CRP was slightly elevated, otherwise bloodwork was within normal limits. Covid-19, Strep, and Mono tests were negative. Following the covid swab, the patient had significant epistaxis which prompted further evaluation. Bedside nasal endoscopy was significant for polyps and bleeding, which led to prompt ordering of a CT scan of the sinus, without contrast demonstrating a soft tissue mass consistent with nasopharyngeal carcinoma. A CT scan of soft tissue of the neck was performed which was also consistent with nasopharyngeal carcinoma with nodal metastases. Patient was sent to ENT clinic for a biopsy which was positive for EBV squamous cell carcinoma. Patient is currently undergoing chemotherapy with neuro-oncology, and was evaluated by neurosurgery for any remaining interventions.

90 to 95% of nasopharyngeal carcinomas are linked to EBV virus. Even with the high infection rate of EBV within the population, the rate of nasopharyngeal carcinoma is only 2 in 100,000 in the US and Western Europe. These statistics have therefore not given rise to routine screening in these areas which makes the incidental finding in this case, via a covid swab, even more significant.