|Year : 2020 | Volume
| Issue : 4 | Page : 193-197
Critically ill infant with coronavirus disease 2019
Pallavi, Jerin C Sekhar, Urmila Jhamb
Department of Pediatrics, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India
|Date of Submission||05-Jun-2020|
|Date of Decision||18-Jun-2020|
|Date of Acceptance||27-Jun-2020|
|Date of Web Publication||13-Jul-2020|
Department of Pediatrics, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi - 110 002
Source of Support: None, Conflict of Interest: None
Coronavirus disease 2019 (COVID-19) is an acute infectious respiratory disease with manifestations ranging from mild respiratory symptoms to severe acute respiratory distress syndrome. The severity and mortality have been found to be higher in elderly people and those with comorbidities. Data on the pediatric population affected by the pandemic are limited. Most pediatric COVID-19 cases reported so far in the literature are mild or asymptomatic ones. Management of critically ill children is associated with a high risk of aerosol generation and secondary infection. We report a case of an infant with severe COVID pneumonia who was successfully managed in the pediatric critical care unit of a dedicated COVID hospital taking proper infection control measures.
Keywords: Acute respiratory distress syndrome, coronavirus, mechanical ventilation, pediatric intensive care unit, pneumonia, personal protective equipment
|How to cite this article:|
Pallavi, Sekhar JC, Jhamb U. Critically ill infant with coronavirus disease 2019. J Pediatr Crit Care 2020;7:193-7
| Introduction|| |
The recent outbreak of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus (SARS-CoV-2) originated from Wuhan, China, in December 2019 and expeditiously spread globally challenging healthcare systems. On January 30, 2020, the World Health Organization declared COVID-19 a public health emergency of international concern. As on June 4, 2020, there were 6,416,828 cases worldwide with 382,867 reported deaths. The number is mounting in India also with 226,770 confirmed cases and 6348 deaths as on June 5, 2020.
SARS-CoV-2 causes manifestations ranging from asymptomatic to severe acute respiratory distress syndrome (ARDS). All ages are susceptible, but severe illness is rare in children. Critically ill children require pediatric intensive care unit (PICU) care for ventilation and proper monitoring. Managing hypoxemic respiratory failure involves procedures with high aerosol generation putting healthcare workers at a formidable risk of infection. Herein, we report an infant with severe COVID pneumonia and discuss the strategy used in managing this infant requiring invasive ventilation.
| Case Report|| |
A 30-day-old male infant was referred to our hospital with mild cough, coryza, and sneezing for 4 days, fever for 2 days at onset, fast breathing for 3 days, lethargy and poor feeding for 2 days, and intermittent cessation of breathing with bluish discoloration for 1 day. He had no underlying heart disease, seizures, or gastrointestinal symptoms. Theirs was a nuclear family with no recent travel abroad or attending functions/religious events and no confirmed COVID cases in neighborhood. However, the father was a fruit vendor in a hotspot area, and the child had contact with a barber 2 days before symptoms. The infant was born preterm (35 weeks) weighing 2.4 kg by cesarean section due to preterm labor pains with nonprogression of labor. He had respiratory distress since birth requiring continuous positive airway pressure (CPAP) support for 3 days and was discharged on day 10. He was growing well on exclusive breastfeeds but was unimmunized.
For the current illness, he was taken to a hospital where he had intermittent apneas with cyanosis which improved after oxygenation by hood. Blood investigations were normal [Table 1]. Chest X-ray (CXR) showed nonhomogenous opacities in the right lower zone and perihilar area [Figure 1]a. Reverse transcriptase polymerase chain reaction (RT-PCR) of the nasopharyngeal and oropharyngeal swabs was positive for SARS-CoV-2, and hence, he was referred to our dedicated COVID hospital.
|Figure 1: Chest radiographs: (a) Done from other hospital: Nonhomogenous opacities in the right lower zone and perihilar area, (b) Day 1 (after intubation): Left upper and middle zone consolidation with patchy consolidation in the right upper zone, (c) Day 5: Consolidation in right upper zone with patchy air space opacities in bilateral perihilar areas, (d) Day 6 (postextubation): Haziness in the right upper, middle. and lower zones, (e) Day 8: Nonhomogenous opacities in the right upper and middle zones and left upper zone, (f) Day 14: Few nonhomogenous opacities in the right perihilar area|
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At admission (day 1), the child was lethargic, afebrile, with a heart rate of 180/min, respiratory rate of 34/min with mild subcostal and intercostal retractions, and cyanosis (SpO2– 45% under room air). A diagnosis of severe COVID pneumonia was made, and he was oxygenated by hood which improved his SpO2 to 85%. He was shifted to a heated humidified high-flow nasal cannula (HHHFNC) (flow – 6 L/min, FiO2– 80%), after which he stabilized momentarily with SpO2 of 99%. He was given ceftriaxone (100 mg/kg/day), amikacin (15 mg/kg/day), oral azithromycin (10 mg/kg/day), and chloroquine (total cumulative dose of 47 mg/kg over a period of 5 days). An electrocardiogram could not be done before these medications. Fluids were restricted to 80% maintenance aiming to prevent fluid overload.
An hour later, he had apneas with desaturation to 30%–35%. There were no abnormal body movements, and his temperature (98.6°F), dextrose, and total calcium were normal [Table 1]. Hence, the apnea was presumed to be due to pneumonia. In view of recurrent apneas and requirement of FiO2>60% on HHHFNC, he was intubated and started on pressure support synchronized intermittent mandatory ventilation. Arterial blood gas showed hypoxemia (PaO2– 65.3 mmHg) with an alveolar–arterial oxygen gradient of 394, PaO2/FiO2 ratio of 93, and oxygenation index of 8.6, suggestive of moderate ARDS. CXR done showed consolidation in the right upper zone and left upper and middle zones [Figure 1]b. Ventilatory settings were titrated aiming to ensure lung protective ventilation with low tidal volumes; adequate sedation was ensured. The maximum required settings were peak inspiratory pressure – 20 cmH2O, positive end-expiratory pressure – 8 cmH2O, inspiratory time – 0.45 s, rate – 45/min, and FiO2– 80%.
At 5 h of admission, he had seizures presumably due to initial hypoxic insult or meningitis, as metabolic profile was normal. Lumbar puncture was deferred due to lack of laboratory facilities for cerebrospinal fluid analysis. Seizures were controlled in 36 h with phenytoin and levetiracetam. He had hemodynamic instability requiring fluid boluses and inotropes for 24 h.
After a stormy initial course, he gradually stabilized over the next 48 h. Orogastric feeds were instituted on day 3 which he tolerated well. Serial CXRs showed improvement in pneumonia [Figure 1]c-f]. He was gradually weaned off ventilator support and shifted to oxygen by nasal prongs on day 6. However, he had tachypnea (64/min) with subcostal and intercostal retractions requiring HHHFNC.
On day 7, he developed pancytopenia with minimal hematuria and ecchymoses requiring packed red cell and platelet transfusion [Table 1]. Keeping a possibility of hospital-acquired infection, antibiotics were upgraded to meropenem. Markers of hyperinflammation (IL-6, ferritin, and D-dimer) could not be sent. He improved clinically, cytopenias resolved, and he was shifted to oxygen by nasal prongs on day 10. A repeat nasopharyngeal swab on day 11 and a rectal swab on day 14 were negative for SARS-CoV-2. Blood and urine cultures were sterile. As the child improved well after resolution of pneumonia and had no history or clinical signs suggestive of a heart disease, an echocardiography was not done. The child accepted breast feeds well, maintained saturation under room air, and was discharged on day 20.
The parents tested negative for SARS-CoV-2 by RT-PCR, but the barber with whom he had a contact could not be traced. The uncle who was in contact with the child only during the hospitalizations tested positive but was asymptomatic.
| Discussion|| |
SARS-CoV-2, like Middle East respiratory syndrome-coronavirus and SARS-CoV, is found to be less invasive in children. Possible speculations comprise low exposure, existence of asymptomatic or mildly symptomatic cases, immature immune system, immature angiotensin-converting enzyme-2 (ACE-2), and other unknown factors. In China, 2.2% of 44,672 cases were aged <19 years and the crude mortality rate in children was low (0.1%) compared to adults (2.3%–14.6%). Another Chinese case series of 2143 children reported severe disease in 5.8%, with infants being more vulnerable. Italian data showed that only 1.2% of 22,512 cases were children, with no deaths, while 5% of 4226 cases in the United States were children with pediatric cases accounting for <1% of their hospitalization., In India, children aged 0–9 years formed 3.6% of total COVID cases with an attack rate of 6.1 per 1,000,000.
The clinical presentation of COVID-19 varies from asymptomatic, paucisymptomatic, to critically ill children requiring ventilation and intensive care support. A prospective Chinese study comprising 171 children reported fever in 41%, cough in 48%, tachypnea in 28%, and diarrhea in 8.8%. It takes a mean of 8 days for the development of respiratory distress and 9 days for onset of pneumonia. Our child had fever, cough, and tachypnea without diarrhea. The onset of tachypnea was early (day 2 of illness) with radiographic changes detected on day 4 of symptoms.
Laboratory findings in COVID-19 are nonspecific. Lymphopenia was present in 85% of critically ill adults, while only in 3.5% among children. Elevation in C-reactive protein (CRP) was described in 20%, procalcitonin in 64%, and transaminases in 12%–14%., Radiological findings varied from unilateral to bilateral patchy shadows and ground-glass opacities. Our case did not have lymphopenia at admission but developed it on day 7 of stay (day 11 of symptom onset). Sterile blood cultures suggest that it could be attributed to COVID-19. We did not find elevated CRP, procalcitonin, or transaminases, while CXR showed bilateral pneumonia.
Children requiring invasive ventilation had comorbidities such as chronic pulmonary disease, cardiovascular disease, hydronephrosis, and intussusception or were on maintenance chemotherapy for leukemia., Our child, though was born preterm and required CPAP, had an uneventful course subsequently with no underlying immunocompromised state.
Our patient presented as a case of severe acute respiratory infection, which is the most common cause of ICU transfer among COVID-19 patients. Management guidelines are similar to that of any pneumonia with ARDS with more emphasis on minimizing risk of transmission, especially to treating healthcare workers. Early intubation and ventilation are recommended to prevent emergency intubation, which poses a higher risk of transmitting infection. Care was taken during intubation and ventilation to minimize the risk of aerosol exposure. The ventilator was kept ready on stand-by mode, the child intubated with a cuffed endotracheal tube after premedication with midazolam (0.1 mg/kg), and he was connected to the ventilator using a disposable ventilator circuit with a heat moisture exchanger. We did not have a video laryngoscope for intubation and a viral filter to be used in the expiratory limb of the circuit. Bag and mask ventilation was avoided. Besides, closed tracheal aspiration system was used to contain aerosol generation. Lung protective ventilation strategy with liberal sedation–analgesia was used in management.
HHHFNC leads to high aerosol generation; hence, full protection was ensured for frontline healthcare professionals. Moreover, some suggest to use oxygen hood to decrease dispersion of aerosols. We could use oxygen hood only intermittently as the child was irritable when it was used. Negative pressure isolation is recommended for the management of a suspected/proven COVID-19 patient. Due to nonavailability of this facility in our hospital, this child was managed in PICU with the staff using full personal protective equipment (PPE) and ensuring frequent disinfection using hypochlorite solution.
Another alarming fact is that children harbor large amounts of virus even if asymptomatic, and viruses can persist in feces for a long time even if they are absent from nasopharyngeal secretions., This necessitates strict preventive measures to avoid transmission of infection. However, in our child, rectal swab on day 14 was also negative for SARS-CoV-2 unlike prior reports.
Till date, there has been no definitive therapy for COVID-19. Antiviral drugs such as remdesivir and lopinavir/ritonavir are being used in critically ill patients without any strong evidence. Chloroquine interferes with ACE-2 receptors (binding site of SARS-CoV-2) and hinders virus cell fusion by raising endosomal pH. A combination of hydroxychloroquine and azithromycin has been proven to be effective in lowering viral load. Convalescent plasma from recovered patients is another tested treatment option. Considering the age of our patient, we treated him with chloroquine and azithromycin.
This case report highlights that COVID-19 can present with severe pneumonia and ARDS in infants. Critically sick children requiring mechanical ventilation can be effectively managed by adopting standard lung protective ventilation strategy, closed suction, and use of full PPE to contain further spread of the disease.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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