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.