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This case report highlights the diagnostic limitations of nasopharyngeal swabs in diagnosing COVID-19. This patient had a positive travel history, typical symptoms (fever, dry cough, dyspnea) and two negative nasopharyngeal swabs (NPS). He deteriorated clinically and required intubation. After intubation, bronchoalveolar lavage was used to sample the lower respiratory tract, which confirmed the diagnosis of COVID-19. This case demonstrates the diagnostic limitation of reliance on nasopharyngeal swab PCR alone for the diagnosis of COVID-19. NPS tests may result in false negatives with incorrect sampling technique or if the sampling is done while the upper tract viral load is low, such as very early or late during the illness course. During this pandemic, we posit that clinicians should maintain a high degree of suspicion based on supportive clinical findings despite negative PCR testing as this has implications for hospital infection control procedures. Resume Ce rapport de cas met en évidence les limites diagnostiques des écouvillons nasopharyngés dans le diagnostic de la COVID-19. Ce patient avait des antécédents de voyage positifs, des symptômes typiques (fièvre, toux sèche, dyspnée) et deux écouvillons nasopharyngés négatifs (NPS). Son état clinique s’est détérioré et a nécessité une intubation. Après l’intubation, un lavage bronchoalvéolaire a été utilisé pour prélever un échantillon des voies respiratoires inférieures, ce qui a confirmé le diagnostic de COVID-19. Ce cas démontre les limites diagnostiques de la seule utilisation de la PCR sur écouvillon nasopharyngé pour le diagnostic de la COVID-19. Les tests NPS peuvent donner des faux négatifs si la technique de prélèvement est incorrecte ou si le prélèvement est effectué alors que la charge virale des voies supérieures est faible, par exemple très tôt ou très tard dans l’évolution de la maladie. Pendant cette pandémie, nous posons comme principe que les cliniciens doivent maintenir un haut degré de suspicion basé sur des résultats cliniques favorables malgré des tests PCR négatifs, car cela a des implications pour les procédures de contrôle des infections hospitalières. C a n a d i a n J o u r n a l o f G e n e r a l I n t e r n a l M e d i c i n e V o l u m e 1 5 , I s s u e 2 , 2 0 2 0 5 C h u e n e t a l . CJGIM_V2_2020_174310.indd 5 21/04/20 11:34 PM Background COVID-19 is a pandemic driven by a rapidly spreading, severe respiratory illness caused by a novel coronavirus: SARS-CoV2. Polymerase chain reaction (PCR) for SARS-CoV2 using nasopharyngeal swabs (NPS) samples is the current standard for diagnosis diagnosis.1 Assessment of the World Health Organization’s PCR assays demonstrated high specificity (100%), and sensitivity of 61-–68%, which increases to 71–79% with repeated testing testing.2 In one study, 33% of suspected COVID-19 patients with negative PCR testing had computed tomography (CT) findings consistent with COVID-193.19.3 Others concluded COVID-19 could not be reliably diagnosed using PCR alone, given its low sensitivity,4 which is affected by the time of sampling relative to onset of (i.e., when viral shedding, correct sampling technique and assays with a poor limit of detection.  In an analysis of site sampling, lower respiratory tract samples were positive more often than NPS. However, testing in this study is biased towards severely ill, intubated patients, where endotracheal tube sampling is feasible.1 There is only one published report of COVID-19 diagnosed with bronchoalveolar lavage (BAL) after numerous negative.NPS.5 We report what we believe is the first case in North America.

Diagnosis of COVID-19 by Bronchoalveolar Lavage after Two Negative Nasopharyngeal Swabs