A woman from Iowa with a rare skull condition had her spinal fluids leaking after a COVID-19 nasal swab test, in the first recorded injury of its kind.
"To our knowledge, this is the first report of an iatrogenic CSF leak after a nasal swab for COVID-19," said the case study, published in the journal JAMA Otolaryngology-Head & Neck Surgery. The condition was due to a rare congenital disease where a section of the woman's skull was open.
Investigating a Rare Case
The unnamed woman from The Hawkeye State reported being 40 years of age, first reported experiencing a runny nose, stiff neck, headaches, sensitivity to light, as well as a weird, metallic taste lingering in her mouth. She was soon subjected to examinations that revealed a mass on the right side of her nasal cavity, with later tests on specimens taken from her revealing the presence of spinal fluid.
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Further investigation from the woman's recent activities showed that she underwent a mandatory COVID-19 screening, a standard operating procedure before her elective hernia operation. She started displaying a runny nose and headaches soon after, with an episode of vomiting.
She later took a magnetic resonance imaging (MRI), which showed the surprising result: the woman had encephalocele. The woman had a 1.8-centimeter pouch of cerebrospinal fluid (CSF) protruding down into her sinus cavity.
Doctors behind the case study raised the possibility that the COVID-19 nasal swabbing had punctured the pouch in the gap of her skull, causing the leak of her spinal fluids. This led to a condition known as intracranial hypotension, a change in her cerebral equilibrium caused by the drop of CSF pressure inside her skull. The patient also reportedly had high pressure in her brain due to the encephalocele.
The doctors later helped the woman by filling the hole in her skull using a soft tissue skin graft procedure.
Encephalocele
It is a rare disorder where the bones comprising the skull do not entirely close, creating a sac-like protrusion from the gap containing brain matter, cerebral spinal fluid, and the meninges, or the membrane that covers the brain.
According to the National Organization for Rare Disorders (NORD), this rare hole in the skull is believed to only affect one in every 10,000 babies born in the United States. NORD also explains that the exact cause of encephaloceles remains unknown, but primarily considered to be a combination of several contributing factors.
It is classified as a defect in the neural tube - a narrow channel that serves as a precursor to the brain and spinal cord in developing fetuses. The neural tube, according to NORD: "folds and closes early during pregnancy."
These gaps can appear anywhere in the skull, usually detected via ultrasound or shortly after the baby is delivered. However, as with the Iowa woman, some holes develop around the nasal cavity, remaining undetected for extended periods. Her medical history showed that the gap was detected on a CT scan back in 2017, but was diagnosed as a sinus infection.
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According to the doctors in the report, this rare case report highlights the necessity of adequately training clinicians and the general public about nasal swab testing. The report also suggested using alternative procedures, especially for patients with sinus problems and skull conditions.
