When COVID Goes Undetected

Introduction: COVID-19 was declared a global pandemic by the WHO in March 2020. The gold standard for diagnosis relies heavily on clinical suspicion along with PCR based assays of respiratory swabs. This nucleic acid study is highly sensitive and specific, however, there are faults, especially during the incubation period, during which the virus is hard to detect. Here we present a case of a patient, presenting with signs and symptoms of pneumonia, with serial negative viral swabs spaced out over time, who was ultimately diagnosed with COVID-19 infection via more invasive means. Case: A 49-year-old female with no significant past medical history presented to the emergency department with cough and shortness of breath for 2 days which developed when she returned to New York from Florida. Her personal history was significant for her occupation as an ER nurse and a history of vaping for 5-6 years.After arrival to the emergency department, the patient was febrile to 103.3 F, tachycardic, and hypoxic, saturating 89% on room air. Her laboratory work was significant for a mildly elevated D-dimer level, elevated CRP (11.23), normal procalcitonin level, and two negative COVID-19 swabs over 2 days. Her initial chest X ray showed multifocal pneumonia and a CT chest showed ground glass opacities amid dense consolidation. The patient was empirically treated for community-acquired bacterial pneumonia with antibiotics. The patient's respiratory and hemodynamic status started to decline, despite treatment. Ultimately, the patient required further investigation - a bronchoalveolar lavage was ultimately found to be positive for the COVID-19 virus, and the patient was immediately started on Remdesivir. Discussion: In this day and age, countries are increasingly utilizing the COVID-19 reverse-transcriptase PCR and are pushing for widespread testing for case detection, but how sensitive and specific is this test, really? Serial testing with swabs performed at intervals should be the answer as the viral load of the COVID RNA steadily rises and peaks over 0-9 days after onset of symptoms. However, this may not be the case in a majority of patients and more invasive testing using bronchoscopy and bronchoalveolar lavage may be the only way to truly diagnose COVID-19 pneumonia. The delay in confirmation, however, could prove to be truly fatal, subjecting patients to painful measures like intubation. This case brings to light the realization that nasopharyngeal/oropharyngeal swabs may not be sufficient to detect the virus with full certainty.