Diagnostic testing for SARS-CoV-2 infection in HHT patients: nasopharyngeal versus oropharyngeal swab

Abstract

On March 11, 2020, WHO has defined the novel coronavirus disease SARS-CoV-2 (COVID-19) outbreak as a pandemic that still today continues to affect much of the world. Among the reasons for the rapid spread of SARS-CoV-2 infection, there is the role of asymptomatic or minimally symptomatic carriers. Therefore diagnostic testing is central to contain the global pandemic. Up to now real-time reverse transcriptase polymerase chain reaction-based molecular assays for detecting SARS-CoV-2 in respiratory specimens is the current reference standard for COVID-19 diagnosis. Based on current knowledge regarding the sensitivity of the molecular test, the highest positive detection rate is from lower respiratory tract specimens; alternatively it is possible to perform a nasopharyngeal or oropharyngeal swab. Nasopharyngeal swab is the preferred choice for SARS-CoV-2 testing since it seems to have a greater sensitivity; however the procedure is not always free of complications and an epistaxis can occur. Among patients with greatest risk of massive nosebleed there are HHT patients. Hereditary hemorrhagic telangiectasia is an autosomal dominant disease that leads to multiregional mucocutanous telangiectases and visceral arteriovenous malformations. Clinically, the presence of telangiectases in nasal mucosa is the cause of recurrent epistaxis. In HHT patients the execution of the nasopharyngeal swab can determine from little or no consequences to a massive epistaxis leading to the necessity of nasal packing generally followed by hospital admission. In HHT patients undergoing a diagnostic test to evaluate the SARS-CoV-2 infection status, especially in those patients with frequent epistaxis with a history of anemia and repeated hospitalizations, it is therefore advisable to perform an oropharyngeal swab. This, compared to the nasopharyngeal swab, exposes to a lower risk of severe nosebleeds related treatments, such as blood transfusions or invasive procedures. According to the risk-benefit assessment and based on our experience, we consider that, despite a lower diagnostic sensitivity, oropharyngeal swab is preferable to nasopharyngeal swab for the diagnosis of SARS CoV-2 infection in patients with HHT.

Characterization of epidemiological distribution and outcome of COVID-19 in patients with hereditary hemorrhagic telangiectasia: a nationwide retrospective multi-centre study during first wave in Italy

“…Summary measures regarding infection-related clinical manifestations included both general COVID-19-associated symptoms and more specific HHT-typical features, concerning bleeding profile change and sense of dryness/discomfort of the nasal and oral mucosa. Specific questions distinguished ascertained COVID-19 cases, based on laboratory test confirming molecular and/or serological diagnosis (namely, SarS-Cov-2-specific Polymerase Chain Reaction (PCR)-based molecular assay on Nasopharyngeal/Oropharyngeal Swab [ 31 ], and/or anti-SarS-Cov-2 Ab serological test [ 32 ], respectively), from suspected cases, characterized by the subjective reporting of COVID-19-suggestive symptoms lacking molecular/serological confirmation. Since the main objective of the study was focused on the first pandemic wave, only the cases occurring in this study period were included (2020, January 1st–June 30th).…”

Complications of Nasal SARS-CoV-2 Testing: A Review

“…The literature search strategy yielded 199 citations, of which 11 articles were eligible for review (figure 2). [4][5][6][7][8][9][10][11][12][13][14]…”

“…All cases were performed under local anesthesia 5. Pagella and colleagues do not provide data related to the incidence of epistaxis after nasal swabbing for SARS-CoV-2, but highlight the increased risk of significant hemorrhage in patients with hereditary hemorrhagic telangiectasia (HHT) 6…”

“…The literature search strategy yielded 199 citations, of which 11 articles were eligible for review (figure 2). [4][5][6][7][8][9][10][11][12][13][14] All included articles related to complications from transnasal swab testing for SARS-CoV-2 (table 1).…”

Der Nasen- oder Rachenabstrich in der COVID-19-Pandemie – Aspekte für den HNO-Arzt/die HNO-Ärztin – SARS-CoV-2, Coronavirus, Nasenabstrich, Rachenabstrich, Komplikationen

“…Bei Patienten mit einem hohen Risiko für ein Nasenbluten, wie z. B. einer hereditären hämorrhagischen Teleangiektasie (M. Osler), wird in Abwägung zwischen Sensitivität und Komplikationen eher zu einem Rachenabstrich geraten [39].…”