Hemorrhagic Shock Following Nasopharyngeal Swab

A 49-year-old man with intellectual disability was admitted to the hospital for treatment of persisting epistaxis following routine collection of a nasopharyngeal swab specimen for SARS-CoV-2 screening. Although the specimen collection had been performed by trained personnel and no abnormalities had been noted during the procedure, epistaxis had commenced immediately thereafter. Progressive hemorrhagic shock and hypoxemic respiratory failure due to aspiration of blood necessitated intubation and norepinephrine therapy. Of note, the patient was on edoxaban therapy (60 mg/day) for paroxysmal atrial fibrillation. In addition, low-dose aspirin was being administered (100 mg/day). The bleeding was associated with recurring hemodynamically significant tachyarrhythmias. On endoscopy, the hemorrhage appeared diffuse, originating primarily from the nasopharynx and the left nasal cavity. There was no interventional option to directly control the bleeding. After nasal tamponade for three days and discontinuation of anticoagulant and antiplatelet therapies, hemostasis could eventually be achieved. Because of aspiration pneumonia, invasive mechanical ventilation was necessary for a total of seven days. Currently, nasopharyngeal swab specimens for SARS-CoV-2 testing are being collected very frequently. The presented case demonstrates a life-threatening complication of these procedures. Especially in patients with hemorrhagic diathesis, collection of alternative specimen types should be considered. Anticoagulant and antiplatelet therapies and, in particular, combined therapies should be reviewed on a regular basis.

Figure

Computed tomography of the head and neck region (sagittal reconstruction) three days after the emergency situation (soft tissue window)

Dr. med. Sebastian Sewerin, Bereich Nephrologie, Klinik und Poliklinik für Endokrinologie, Nephrologie, Rheumatologie, Universitätsklinikum Leipzig; [e-mail]

Dr. med. Markus Wehner, Abteilung für Anästhesie und Intensivtherapie, Krankenhaus Wurzen, Muldentalkliniken GmbH

Dr. med. Lorenz Weidhase, Interdisziplinäre Internistische Intensivmedizin, Universitätsklinikum Leipzig

Conflict of interest statement: The authors declare that no conflict of interest exists.

Cite this as: Sewerin S, Wehner M, Weidhase L: Hemorrhagic shock following nasopharyngeal swab. Dtsch Arztebl Int 2021; 118: 560. DOI: 10.3238/arztebl.m2021.0276