Cerebrospinal fluid (CSF) leak is rare but frequently complicated of meningitis, notably pneumococcal meningitis. Iatrogenic CSF leaks are rare and occur most frequently after endoscopic cranial base surgery for less than 1%. The cribriform plate and ethmoid bone are the most commonly injured, followed by the frontal and sphenoid sinuses. Some cases occurred after nasal swab testing for COVID-19.

A 62-year-old woman with history of hypertension, chronic glaucoma and COVID-19 in January, 2022, was admitted for meningeal syndrome with confusion. First symptoms appeared 10 days before with flu-like syndrome.

At admission, the physical examination showed temperature at 40.7°C, SaO2 at 90% with 4L/min of oxygen, respiratory rate at 40/min, and Glasgow score at 10.

Lumbar puncture revealed a leukocyte count of 1700/mm3 with predominance of neutrophils, hypoglycorachia and hyperproteinorachia at 2.86g/L. Direct examination found Gram positive diplococcus and pneumococcal antigenuria was positive in CSF and urine. Neutrophils count was at 16g/L, C-reactive Protein at 88mg/L.

Antibiotic treatment was rapidly started with high doses of cephalosporin and amoxicillin, associated to corticosteroids during 4 days. Then, only cephalosporin was continued after bacteriological results.

Brain MRI was performed and showed right maxillary acute sinusitis, without abscess neither thrombophlebitis.

Patient was transferred in ICU for 2 days. Blood culture at admission was positive with Streptococcus pneumoniae and Minimum Inhibitory Concentration (MIC) for amoxicillin was 0.5 allowing to switch treatment with amoxicillin 16g by day for 10 days. Rapid clinical improvement was obtained and patient was transferred in infectious diseases unit at Day-2. The patient declared rhinorrhea of clear and colorless liquid for many months. Beta-transferrin test was not performed. A control brain MRI identified a skull base defect in the left posterior part of the cribriform plate with CSF leak, without meningocele or intracranial hypotension signs. After further interrogation, only swab testing for COVID-19 in January 2022 was found as trauma for explaining CSF leak. Indeed, rhinorrhea started from this test until this meningitis. After Pneumococcal vaccination, surgery was performed by a left side endonasal endoscopy approach following a lumbar drainage. Under neuronavigation guidance, the osteodural defect was identified. The mucosa around the defect was removed to expose the bony borders. A fascia lata was then used inlay and overlay to close the defect. A piece of muscle was used to pack the fascia lata.

Two days after surgery, post-operative pneumococcal meningitis was confirmed by CSF sampling in the lumbar drainage, but this time with decreased sensitivity to penicillin (MIC amoxicillin 0.75). Empiric treatment was started then switched to high doses of cephalosporin for 7 days after derivation material removal. Finally, the patient was discharged at Day-30 after a return to basic statement.

To our knowledge, this is the second case reported of meningitis after CSF leak due to swab test of COVID-19. Few iatrogenic CSF leaks are described since the beginning of COVID epidemic and the large number of nasal swab testing performed. We should be aware of these risks and these tests must be performed by trained healthcare providers. Furthermore, patients should be informed of signs and symptoms of CSF rhinorrhea.