ereberospinal Fluid Leakage After COVID-19 Nasal Swab Testing: A Case Report

A woman in her 40s took a nasal COVID-19 test before her hernia surgery and shortly afterwards she developed rhinorrhea (runny nose) and headache; after visiting the hospital her runny nose turns out to be a cerebrospinal fluid (CSF) leakage from her brain.

The coronavirus disease 2019 has been emerging and the need for assessment of the infected individuals is growing; there are several ways to diagnose the COVID-19 with reasonable certainty; One of which is to use a nasal swab and collect mucus samples by inserting it into the nose.

For higher accuracy the swab should be inserted deep into a nostril and twirled a few times until it’s covered in secretions, therefore this procedure might cause some discomfort. After collecting the samples, they are brought into a lab where virus molecular detection is done.

anatomical demonstration of nasal cavity

Figure 1. Anatomical demonstration of paranasal sinuses in a CT scan. Source: StartRadiology

A case report published on 1 October in JAMA Network reported the first case of an “iatrogenic CSF leak after a nasal swab for COVID-19”. Down below, we will be describing this case.

A woman around 40 years old, took a nasal COVID-19 test prior to an elective hernia repair surgery, as it is a norm to rule out COVID-19 testing before elective surgeries to suppress the spread of the disease. Shortly after that she was presented with unilateral rhinorrhea, metallic taste, headache, neck stiffness and photophobia. She had a history of intracranial hypertension and removal of nasal polyps from 20 years ago. After physical examination and nasopharyngoscopy, rhinorrhea from the right side and a mass in the right middle meatus (between the middle concha and the inferior concha, see Figure 1) was found.

MRI and CT of the mentioned patient

Figure 2. A: CT image from 2017 (prior to testing for COVID-19) demonstrating encephalocele situated over the fovea ethmoidalis. B, C: MRI images during hospital admission in 2020

Nasal Fluids tested positive for Beta-2 transferrin a specific marker of cerebrospinal fluid. Computed tomography (CT) and magnetic resonance imaging (MRI) displayed a 1.8 cm encephalocele (sac-like protrusion of the brain and its membranes) extending through the right ethmoid fovea into the middle meatus and a right sphenoid wing pseudomeningocele (abnormal collection of cerebrospinal fluid that connects to the CSF space)(Figure 2).

endoscopic imaging

Figure 3. A: Intraoperative photograph of right ethmoid sinus with visible encephalocele. B: encephalocele identified by intrathecal fluorescein. C: Intraoperative photograph of right ethmoid sinus after repair

Fluorescein (an organic fluorescent tracer) was infused through a lumbar drain to identify the encephalocele (Figure 3. B). This skull based defect was repaired with acellular dermal matrix (ADM) and polylactide (PLA, a type of plastic)(Figure 3. C). After the endoscopic transnasal repair the patient was admitted for neurological monitoring and lumbar drain management.

There was a history of encephalocele prior to COVID-19 testing, so we can conclude that the swab did not cause the defective skull, however the invasive test caused trauma to a preexisting defect.

This study found that “prior surgical intervention, or pathology that distorts normal nasal anatomy, may increase the risk of adverse events associated with nasal testing for respiratory pathogens, including COVID-19”.

1 reply
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