Positive tracheal SARS-CoV-2 RNA test after three negative SARS-CoV-2 RNA tests in a patient with COVID-19
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CORRESPONDENCE
Positive tracheal SARS-CoV-2 RNA test after three negative SARS-CoV-2 RNA tests in a patient with COVID-19 Navin G. Vigneshwar, MD . Martin Krause, MD . Karsten Bartels, MD, PhD
Received: 25 May 2020 / Revised: 2 June 2020 / Accepted: 3 June 2020 Ó Canadian Anesthesiologists’ Society 2020
To the Editor, Perioperative guidelines for patients with suspected coronavirus disease (COVID-19) often rely on nasopharyngeal swab testing for the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA. Herein, we report the case of a patient with three consecutive negative nasopharyngeal swab tests followed by a positive tracheal aspirate test for SARS-CoV-2 RNA (Figure 1). Consent for this report was given by the patient’s healthcare power of attorney. A 78-yr-old male with a history of smoking, chronic obstructive pulmonary disease, and anemia presented with respiratory insufficiency. Two weeks prior, the patient was diagnosed at an outside hospital with COVID-19 through a positive real-time polymerase chain reaction test (RTPCR). He continued to decompensate at his skilled nursing facility, eventually presenting to our emergency department. On admission, a viral respiratory panel and two nasopharyngeal swab SARS-CoV-2 RT-PCR tests separated by four hours were negative. With an increasing oxygen requirement and a chest radiograph revealing N. G. Vigneshwar, MD Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA M. Krause, MD Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA K. Bartels, MD, PhD (&) Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA e-mail: [email protected] Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
multifocal opacities, the patient was admitted to the inpatient COVID service. On hospital day 1, the patient’s hypoxia improved, and results from a repeat SARS-CoV-2 RT-PCR test from a nasopharyngeal swab were negative. On the morning of hospital day 2, the patient developed worsening hypoxia requiring 100% fraction of inspired oxygen delivered via high flow nasal cannula, and a repeat chest radiograph showed worsening patchy infiltrates. As he was presumed SARS-CoV-2-negative, levofloxacin and doxycycline were started for community-acquired pneumonia. As his oxygenation worsened, he was trialed on bi-level positive airway pressure ventilation but ultimately required endotracheal intubation. His post-intubation PaO2/FiO2 fraction was 85. A tracheal aspirate sample was collected for a repeat SARS-CoV-2 RT-PCR test. By hospital day 3, results of the fourth SARS-CoV-2 test were positive. Negative RT-PCR results in SARS-CoV-2-positive patients range from 20% to 70%. This variability in RTPCR results is attributed to the anatomic location and viral load of the sample, RNA stability, the duration of viral shedding, and technical limitations within the a
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