Khanal Resha, Oli Sharad, Lawal Halimat, Bhandari Binita, Komanduri Saketram
Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, USA.
Internal Medicine, Maimonides Medical Center, Brooklyn, USA.
Cureus. 2021 Mar 15;13(3):e13908. doi: 10.7759/cureus.13908.
We present the first-ever reported case of massive epistaxis following nasopharyngeal (NP) swabbing requiring intubation and tracheostomy. A 67-year-old male with a mechanical aortic valve on warfarin presented from a nursing home to the emergency department with hypoxia. NP swab for coronavirus disease 2019 (COVID-19) was obtained, immediately followed by significant epistaxis. Patient desaturated to low 80s requiring intubation for airway protection and hypoxemic respiratory failure. Anterior nasal packing was performed. The COVID-19 test resulted negative. Extubation was unsuccessful on days four and nine. The patient subsequently underwent tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube placement. The patient was transferred to sub-acute rehabilitation with a tracheostomy tube on minimal ventilator support. The World Health Organization (WHO) has recommended obtaining an NP swab in COVID-19 suspects to test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) using reverse transcriptase polymerase chain reaction (PCR).A study found that NP swabbing was associated with epistaxis in approximately 5-10% of the cases. Nursing home populations are at higher risk for COVID-19 and also reported to have increased use of oral anticoagulation for chronic atrial fibrillation with other co-morbidities (high CHADVASc score) which may increase bleeding risk with NP swabbing. Less invasive methods such as salivary and mid-turbinate sampling, nasal swab or saliva can be a better alternative sample for detecting SARS-CoV-2 as recommended by the Centers for Disease Control and Prevention (CDC) and suggested by FDA. Positive PCR testing beyond nine days of illness is likely due to persistent dead virus particles and thus repeat testing is not suggested. Obtaining a history of bleeding diathesis, use of oral anticoagulants and consideration of NP anatomy is advised before swabbing. This case report raises the concern against inadvertent NP swabbing in cases with a low pretest probability of COVID-19 infection with higher bleeding risk.
我们报告了首例经鼻咽（NP）拭子采样后出现大量鼻出血并需要插管和气管切开术的病例。一名67岁男性，因机械主动脉瓣置换术后服用华法林，从疗养院被送往急诊科，伴有低氧血症。采集了用于检测2019冠状病毒病（COVID-19）的NP拭子，随后立即出现大量鼻出血。患者血氧饱和度降至80%以下，因气道保护和低氧性呼吸衰竭需要插管。进行了前鼻孔填塞。COVID-19检测结果为阴性。在第4天和第9天拔管均未成功。患者随后接受了气管切开术和经皮内镜下胃造口术（PEG）置管。患者带着气管切开套管，在最低限度的呼吸机支持下被转至亚急性康复病房。世界卫生组织（WHO）建议对COVID-19疑似患者采集NP拭子，以使用逆转录聚合酶链反应（PCR）检测严重急性呼吸综合征冠状病毒2（SARS-CoV-2）。一项研究发现，NP拭子采样在约5%-10%的病例中与鼻出血有关。疗养院人群感染COVID-19的风险较高，而且据报道，由于慢性房颤合并其他共病（CHADVASc评分高），口服抗凝药的使用增加，这可能会增加NP拭子采样时的出血风险。如美国疾病控制与预防中心（CDC）推荐并经美国食品药品监督管理局（FDA）建议，唾液和中鼻甲采样、鼻拭子或唾液等侵入性较小的方法可能是检测SARS-CoV-2的更好替代样本。发病九天后PCR检测呈阳性可能是由于持续存在死亡病毒颗粒，因此不建议重复检测。在拭子采样前，建议了解出血性疾病史、口服抗凝药的使用情况，并考虑NP的解剖结构。本病例报告引发了人们对COVID-19感染预检概率低且出血风险较高的病例中无意进行NP拭子采样的担忧。
