Cerebrospinal Fluid Leak After Nasal Swab Testing for Coronavirus Disease 2019

https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/2771362

In March 2020, coronavirus disease 2019 (COVID-19) emerged as a global pandemic. Testing for presence of active severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is 1 pillar of the global response.¹ In particular, nasopharyngeal, anterior nasal, and midturbinate swabs are 3 of the 5 methods for initial diagnostic specimen collection recommended by the US Centers for Disease Control and Prevention (CDC).² However, complications associated with nasal swab testing are not well characterized. We describe the first case of a cerebrospinal fluid (CSF) leak after nasal testing for COVID-19, to our knowledge.

A woman in her 40s presented with unilateral rhinorrhea, metallic taste, headache, neck stiffness, and photophobia. The patient had recently completed nasal COVID-19 testing for an elective hernia repair. Shortly after, she developed unilateral rhinorrhea, headache, and vomiting. The patient’s medical history was notable for idiopathic intracranial hypertension and removal of nasal polyps over 20 years before presentation. Physical examination revealed clear rhinorrhea from the right side. Flexible nasopharyngoscopy revealed a mass in the right anterior middle meatus, but did not identify the source of the fluid. The nasal drainage tested positive for β₂-transferrin. Computed tomography (CT) and magnetic resonance imaging (MRI) identified a 1.8-cm encephalocele extending through the right ethmoid fovea into the middle meatus and a right sphenoid wing pseudomeningocele. Comparing these images to findings on CT performed in 2017 revealed that the encephalocele dated at least to that time (Figure 1). The 2017 CT diagnosis was paranasal sinus disease but not an encephalocele. The patient was admitted to the hospital for endoscopic surgical repair. At the beginning of the procedure, intrathecal fluorescein was infused through a lumbar drain. An encephalocele was identified in the right anterior ethmoid cavity (Figure 2). After reduction of the encephalocele, a skull base defect in the fovea ethmoidalis was repaired with a combination of acellular human dermal matrix and a poly(D,L-lactic) acid. The patient was admitted postoperatively for neurological monitoring and lumbar drain management.

Figure 1.  Imaging Prior to Cerebrospinal Fluid (CSF) Leak

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A, Brain computed tomographic image from 2017 in the coronal and sagittal planes demonstrating encephalocele situated over the fovea ethmoidalis prior to nasopharyngeal testing for COVID-19. The arrowhead demonstrates skull base defect. B and C, High-resolution magnetic resonance imaging (T2 sequence) in the sagittal plane during hospital admission in July 2020 after development of iatrogenic CSF leak. The yellow arrowheads indicate the encephalocele.

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