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.