Shemika Rodriguez was frustrated and getting nowhere.

An employee of a bicycle-based food-delivery service in New York City, Rodriguez had gone to two clinics near her Brooklyn apartment seeking help for a persistent runny nose.

The treatments prescribed – first for an allergy and later a virus – hadn’t helped. After three months, the episodic drip had turned into a constant, distressing flow.

So in August 2023, when Rodriguez found herself in Manhattan’s Greenwich Village making an afternoon delivery a block from a hospital, she decided she had nothing to lose by slipping into the emergency room. Maybe, she thought, someone there could tell her why she wasn’t getting better.

“I walked in, and it was empty,” Rodriguez recalled, hoping that the temporary absence of patients was a good omen.

It would take a second trip to the Lenox Health Greenwich Village emergency room and visits to two affiliated doctors to pinpoint the reason for the constant runny nose that made Rodriguez feel like she was drowning when she lay down.

“I wish I hadn’t waited three months,” said Rodriguez, now 44, who came to suspect she knew the cause. Eight years earlier, one of her relatives had been diagnosed with a similar problem that had an unfortunate ending.

Rodriguez’s case would have a different outcome.

A summer cold?

At first Rodriguez assumed her runny nose was the sign of an annoying cold.

But after several weeks, the drip from her left nostril became nearly constant, and Rodriguez decided she needed to see a doctor.

Her first stop in early June was an urgent care clinic where she was told she had an allergy and was given allergy medication and a nasal spray.

The woman's first stop was at an urgent care clinic where she was told she had an allergy and was given allergy medication and a nasal spray. Stock photo / 123rf

Neither helped. Rodriguez, who has high blood pressure, began noticing that when she bent over, she felt pressure in her forehead. She also began experiencing dizzy spells and periodic balance problems.

A week later, Rodriguez returned to the clinic saying she still felt sick. She was told to continue taking allergy medication and return in a week if she didn’t feel better.

Rodriguez decided to ditch the first clinic and try her luck at a second. She saw a nurse practitioner who told her she didn’t have allergies, but was battling a virus.

The nurse was concerned that Rodriguez had skipped her blood pressure medicine – headaches can be a sign of a hypertensive crisis caused by very high blood pressure – and urged her to resume taking it.

A week later, back on blood pressure medication, she returned to the second clinic. The runny nose and other symptoms had not abated, she told the nurse, who reiterated the viral infection diagnosis and predicted that with time it would resolve.

“I kept moving on with my life, and I thought, ‘It’ll go away,’” Rodriguez recalled.

But she felt a prickle of apprehension that something more serious might be wrong. The drip, which did not affect her right nostril, was clear and didn’t seem like mucus.

“I felt like I was drowning when I lay down,” she said, adding that liquid ran down her throat resembling what happens with postnasal drip. She needed a tissue at all times, and people on the subway sometimes stared at her as she repeatedly blew her nose.

By early August “it was like a leaky faucet”, Rodriguez recalled.

Her partner, searching online for an explanation, had unearthed a possible cause that was disturbingly familiar.

‘Dripping nonstop’

Rodriguez was worried that the substance leaking out of her left nostril wasn’t mucus but cerebrospinal fluid (CSF), which bathes, cushions and nourishes the brain and spinal cord.

A cranial CSF leak is caused by a tear in the brain’s outermost layer, causing fluid to leak from the nose or ears. Because a leak allows direct communication between the nasal cavity and the brain, bacteria can invade the brain and cause bacterial meningitis, a serious infection of the lining of the brain that can be fatal.

Some of Rodriguez’s symptoms seemed consistent with a leak: only one side of her nose was affected, and the fluid was clear and runny. But unlike allergies and viral infections, which are extremely common, CSF leaks, which can also occur along the spine, are not. They are estimated to affect five in 100,000 people per year.

“I didn’t want to believe it,” Rodriguez recalled.

A cranial CSF leak is caused by a tear in the brain’s outermost layer, causing fluid to leak from the nose or ears. Stock photo / 123rf

During her first visit to the Greenwich Village ER on August 9, Rodriguez told the doctor she was worried she had a CSF leak and requested an MRI scan. The doctor, who noted her headaches and history of hypertension, may have thought an MRI wasn’t necessary and ordered a CT scan instead.

It ruled out a brain bleed or hydrocephalus, a build-up of spinal fluid in the brain that can lead to a leak. The scan revealed what appeared to be an infection in the left sphenoid sinus, located behind the nose and between the eyes. Rodriguez was prescribed an antibiotic for a sinus infection.

She took it for a week and, feeling “much worse”, returned to the ER.

“I said, ‘I’m dripping nonstop’,” Rodriguez recalled. When she said she didn’t have a primary care doctor, Rodriguez was referred to a hospital-affiliated internist whom she saw at the end of August.

He noted her symptoms and made an appointment for her with his colleague Charles Tong, an ear, nose and throat surgeon who specialises in treating the nose and sinuses and in performing skull base procedures.

A memorable encounter

Rodriguez and Tong have different recollections of their initial meeting September 8, 2023. Rodriguez said she was vigorously blowing her nose as she had been for weeks when Tong walked into the examination room.

“He said, ‘No! What are you doing? You could blow brain tissue out of your nose!’” she recalled. (Tong said later that another risk is that a patient could blow air into the brain that could get trapped, causing the brain to herniate or shift, triggering a medical emergency that can end in death.)

Tong recalls that Rodriguez “was the first patient of the day. I remember clearly that she had a tissue lodged in her nose. And I thought, ‘Hey, what’s going on here?’ She leaned forward, and liquid poured out, and she said, ‘I think this is brain fluid going out’, and I said, ‘I think you’re right’,” Tong said.

The surgeon collected the fluid in a sterile cup for testing and ordered CT and MRI scans, which were performed that day. All confirmed what “we already knew”, Tong said. Rodriguez had a cranial CSF leak.

The MRI revealed a large encephalocele, a condition in which the brain protrudes through a gap in the base of the skull. The gap might have been caused or exacerbated by a defect in a bone in the wall of the sphenoid sinus. Such a defect has been linked to CSF leaks.

“We look really, really carefully at someone with that,” Tong said.

Rodriguez had other risk factors, including a history of head trauma. She had suffered severe whiplash and other injuries in a 2015 car crash, and three months before the leak started had fallen off her bike and smashed her face. She also was overweight and had high blood pressure, each a risk factor for a leak.

Tong said that the CT scan performed in the ER three weeks earlier is a quick scan used in emergency departments primarily to rule out a stroke; it did not involve the use of contrast dye, so it was probably not sensitive enough to show what later imaging revealed.

Tong called Rodriguez at 8 the next morning, a Saturday, with the results of her tests and to tell her that she would need an operation to repair the leak, Rodriguez said. (Some small leaks can be treated without surgery.)

“I didn’t want surgery,” she said, but she was unwilling to live with the risk of an untreated leak. “I knew what could happen.”

In June 2023, Rodriguez’s aunt, who was in her 50s, was found dead in her apartment. Only after her death did the family discover that she had been diagnosed with a CSF leak in 2015 but had spurned treatment. Her family believes the untreated leak contributed to her death.

Rodriguez’s operation, which involved patching the leak using tissue harvested from her nasal cavity, was performed o September 22 at Northwell Lenox Hill Hospital by Tong and John Boockvar, vice-chair of neurosurgery.

Rodriguez spent about a week in the hospital and several months recovering at home.

“My head feels a lot better, and I’m much stronger now,” she said.

The experience, she said, taught her to be vigilant about her health. “If you see anything off with your body, get it checked out.”

Tong estimates that he’s treated between 50 and 100 patients with CSF leaks in the eight years he’s been practising.

Unlike Rodriguez, he said, patients sometimes minimise the diagnosis and are “reluctant to have surgery. They say, ‘It’s just a runny nose’.”

“But,” he noted, “not all runny noses are created equal”.