Cunning Covid: A case of false negative covid testing in chronic trach patient. Urmil Patel MD, SangHwa Himchak MD, Azka Sadiq MD, Manish Trivedi MD Many aspects of diagnosing and treating COVID-19 are ● For patients with pre-existing tracheostomy, still uncertain. To date, the nasopharyngeal swab specimen collection should not be limited to remains the nearly universal site for COVID-19 virus upper respiratory tract by either oropharyngeal or testing. However other sites including oral pharyngeal nasopharyngeal swabs. swab, nasal mid turbinate swab, nasopharyngeal wash or ● Additional sampling of the lower respiratory tract aspirate as well as lower respiratory tract specimens especially in high suspicion cases with negative should be kept in mind for the patient with high clinical COVID-19 results and exclusion of other suspicion for COVID-19 with negative nasopharyngeal pneumonia causes should also be considered. testing. In this report, a case of a patient with repeated ● This is exemplified in this patient where there is false negative nasopharyngeal COVID-19 test swabs is no airflow through the nose or mouth. In such discussed. a sample through his tracheostomy. This sample cases the chances of having a false negative yielded a positive result. nasopharyngeal swab could be significantly higher. Patient is a 37-year-old male with past medical history of ● False negative results can be avoided by using anoxic brain injury status post cardiac arrest, history of lower respiratory tract specimens for COVID-19 ● This is a case of an individual coming from a tracheostomy, percutaneous gastric tube placement, testing. COVID-19 infested nursing home who presented remote IV drug use, chronic sacral wound, chronic with hypoxia but tested negative for COVID-19 indwelling Foley catheter. He presented with hypoxia and twice during the hospital course. However a third fever as high as 102 degrees from a nursing home where sample was obtained by swabbing through his multiple residents were reported positive for COVID-19. tracheostomy which yielded a final positive On admission, he was tested for COVID-19 through a COVID-19 result. nasopharyngeal swab which was negative on admission ● It is possible especially in cases when there is no but was noted to have lymphopenia on his CBC. airflow occurring through the nose, there may be Throughout the hospital course, the patient's oxygen no colonization of the virus in the nasopharynx or saturation worsened and mechanical ventilation was oropharynx. initiated through his tracheostomy. He underwent a ● Tracheal colonization is still possible if the stoma second nasopharyngeal COVID-19 test given high becomes colonized with either hand contamination clinical suspicion which was also negative. He began Hussain MH, Siddiqui S, Mahmood S, et alTracheal swab from front of neck airway such as touching which is required during for SARS-CoV-2; a bronchial foreign bodyBMJ Case Reports CP 2020;13:e237787 treatment for hospital-acquired pneumonia with phonation, routine trach care, or aerosolized broad-spectrum antibiotics. When his condition continued https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html. exposure if they come in close contact with an to worsen, a third attempt was made to obtain individual carrying the virus. .