From a cotton bud to a pool of blood COVID-19 testing, a double-edged sword?

ABSTRACT

Introduction: Coronavirus Disease 2019 (COVID-19) testing has grown exponentially in the United States since the dawn of the pandemic, with the vast majority of samples being obtained via nasopharyngeal swab. Although convenient and widely used, the test itself carries potential adverse effects, particularly those at high risk of bleeding. We present a patient who developed several arrays of complications after being tested for COVID-19 using the nasal swab sampling technique. Case Presentation An 80-yo female presented from home with a complaint of hematuria. Her past medical history includes rheumatic heart disease status post repair on warfarin, atrial fibrillation and stroke. Vital signs were normal. She had benign head and neck exam, clear lung sounds, an irregular heart rhythm and a normal abdominal exam. Labs were at baseline with hemoglobin of 10.4. Chest x-ray and CT abdomen were unremarkable. She received a PCR nasopharyngeal swab in the emergency room and subsequently developed profuse epistaxis. Initial nasal packing and Afrin sprays failed to control the bleeding and she required emergent intubation for airway protection. She also needed vasopressors due to hypotension. Repeat hemoglobin was 7.5 and lactic acid was 10.4. Bleeding eventually stopped after continuous nasal packing, transfusional support and IV vitamin K. In the following days, she developed fever, leukocytosis and lung infiltrates. She received empiric antibiotic coverage, although no growth from cultures. Endoscopy findings were consistent with ischemic colitis. Later, she stabilized hemodynamically but was unable to be liberated from the ventilator. She was discharge to a long-term care facility after 43 days of stay. Discussion: Nasopharyngeal swabs are the mainstay of testing for COVID-19, however, little has been discussed regarding its procedural risks. Common adverse effects include headaches, nasal pain, ear discomfort and rhinorrhea. Recent studies have suggested that the incidence of epistaxis can be as high as 10% after the test. Alternatively, multiple research centers, including Yale and University of Illinois have released promising data on saliva-based testing. Their evidence supported high sensitivity comparable to the nasopharyngeal method with simpler and safer nature. Also, the saliva-based testing can be done at home, which is believed to reduce healthcare cost and lower the risk of cross infection. This case vividly demonstrates that even the most common procedure can result in devastating outcomes. As such, health care providers should be cognizant of these complications and consider alternative testing method when possible.