Case Presentation
The patient is a 3-week-old female baby, a product of full-term pregnancy and uneventful normal vaginal delivery. She was delivered to a 37-year-old healthy GBS negative mother and was discharged after 24 hours in good condition. She presented to the emergency department with a high-grade fever, hypoactivity, and poor oral intake for a one-day duration. Physical examination at that time was significant for fever reaching 38.9 and tachycardia, which improved after a bolus of 10 ml\kg normal saline 9%. The rest of the examination was unremarkable, the fever responded to antipyretics, and the patient was doing well. A full septic workup was done, and cultures from blood, urine, and CSF were taken. Her initial blood workup, including blood gas and CSF study, was reassuring (Table 1). Her SARS-CoV-2 RT-PCR was positive (CT value 17.77). Both parents were COVID-19 positive, and the father was symptomatic. She received the first doses of IV ampicillin 50mg\kg\dose and cefotaxime 50 mg\kg\dose along with IV fluid and paracetamol for fever. Shortly after admission to the pediatric ward, the patient was noticed to have frothy bloody secretion coming out of the mouth and she suddenly developed cardiopulmonary arrest. CPR was initiated, and the patient was intubated. She was found to have a pulmonary hemorrhage, as evidenced by the fresh blood from the endotracheal tube and the XR findings of ground-glass opacities and dense consolidation (Figure A). Suction yielded approximately 30 ml of bloody secretion. She was given adrenaline and cold normal saline to control the bleeding and transferred to PICU for further care. After initial brief initial stabilization, the patient started deteriorating, requiring escalation of respiratory support to HFOV. Her sensorium had improved, necessitating initiation of IV continuous sedation, as the child was requiring high pressures and oxygen requirements. Given that the patient had a pulmonary hemorrhage and severe coagulopathy, ECMO was not initiated. The patient continued to deteriorate and developed bilateral pneumothorax requiring bilateral chest tube insertion (Figure B). After chest tube insertion, there was mild improvement in oxygenation with a reduction of FiO2 to 0.8 transiently, but it was again increased back to 1.0 due to desaturation. The patient was on the maximum ventilatory settings of MAP of 28, frequency of 8.0, and amplitude of 47, but she kept having frequent desaturation, requiring frequent manual bag to tube ventilation. Echocardiography was done and showed good cardiac function with no evidence of heart disease. Later, she started developing progressive hypotension, that required support with maximum doses of inotropes. Adrenaline doses were increased from 0.05 mcg/kg/min up to 1.8 mcg/kg/min. In addition, noradrenaline was started at 0.1 mcg/kg/min and increased to 0.5 mcg/kg/min. Her urine output started to decrease, for which IV frusemide bolus followed by continuous infusion were started with no response. Blood investigations showed a severe DIC picture. She received platelet transfusion, packed RBC transfusion, fresh frozen plasma, and was empirically covered with meropenem and vancomycin along with remdesivir and dexamethasone for COVID 19 pneumonia. Eventually, the child developed progressive desaturation, hypotension, and poor perfusion. Blood gases showed worsening metabolic acidosis. She eventually developed cardiac arrest and was declared dead.