OBSERVATION:
A 10-year-old boy with poor vascular access, had been on renal
replacement therapy for the past 6 years. The native kidney disease was
reflux nephropathy progressing to end-stage renal failure. Peritoneal
dialysis was initially started but had to be switched to hemodialysis
due to recurrent peritonitis with peritoneal catheter dysfunction.
The Patient was admitted to our emergency department for a sudden-onset
of a respiratory distress with chest pain. There was no history of
trauma. The patient had no contact with suspected or diagnosed COVID-19
patients.
On admission, his weight and height were 23 kg and 107 cm, respectively.
The patient’s heart rate was 137 bpm. His respiratory rate was 54
breaths per minute. He was grunting and had intercostal recession. blood
pressure was 110/50 mmHg and oxygen saturation in room air was 95%.
Dullness to percussion with decreased breath sounds on the left lung
field were also noted without crackles nor wheeze.
Blood analysis revealed a hemoglobin level of 64 g/L, a platelet counts
of 113.103 per mm3 with a
lymphopenia of 590/mm3
Prothrombin time (PT) was found to be normal. Partial thromboplastin
time (PTT) was high with a value of 46.5 seconds and a ratio of 1.55.
Liver function blood tests were normal and C reactive protein was found
to be normal.
Chest X-ray noted left sided pleural effusion with shift of the
mediastinum to the right (Figure 1). Thoracentesis was performed with
ultrasound guidance allowing the drainage of only few milliliters (ml)
of blood suggesting a clotted Hemothorax. Bacterial cultures of the
pleural fluid were negative for both non-specific organisms and
tuberculosis. Polymerase Chain Reaction (PCR) of the COVID 19 virus was
performed on both nasopharyngeal swab and on the removed fluid were
found to be positive.
The patient was transfused with packed red blood cells to achieve a
hemoglobin concentration of 92 g/L.
A thoracic CT scan was performed showing a massive and compressive
right-sided pleural effusion without extravasation of contrast agent
(Figure 2).
Thoracoscopy allowed the unclotting of the hemothorax and the evacuation
of 700 ml of blood. The pleural cavity per-procedure’s investigation
showed no active bleeding. A chest tube was inserted at the end of
procedure and was removed 5 days later.
The patient was discharged after 10 days and was clinically
asymptomatic.