Conclusion and Results:
Due to dramatic response to lumbar tap test, the patient would be a good candidate of surgery for ventriculoperitoneal or ventriculoatrial shunt insertion. However, we refuse the referral of patient for shunt insertion after considering prominent comorbidity and negotiation with family members. In addition, the significant improvement after removal of CSF helped us to give the decision of serial lumbar tap as the subsequent treatment procedure. The third lumbar tap performed on 21 January 2020. The family members reported significant improvement in daily activities after each episode of lumbar tap. At February 2020, we encounter with the emergence of COVID-19 pandemic. Consequently, the serial lumber taps were stopped temporarily. Although the gait deteriorated gradually again, but the situation was not ideal for performing new lumbar tap.
On the last days of March 2020, an interesting event occurred. The patient had several sudden sneezing which result in spontaneous CSF rhinorrhea with the amount of approximately 30 to 40 ml CSF. With respect to the reports of family members, this event led to significant improvement in gait and cognition, described as a “miracle” and lasted for about 3 months. Afterwards, the symptoms were returned gradually that he could not walk independently.