ARDS in an ex-premature infant with bronchopulmonary dysplasia and COVID-19
Abstract : SARS-CoV-2 infection has caused a pandemic which has resulted in more severe disease in adults than children. We report an ex-premature infant with bronchopulmonary dysplasia who developed COVID-19 associated severe acute respiratory distress syndrome causing bradycardic cardiac arrest and seizures.
Case report :
Our institutional review board waived informed consent for publication of this case. A four month old male infant with bronchopulmonary dysplasia (BPD) born premature at 28 weeks gestation with very low birth weight of 1.315kg, whose corrected age is 1 month, presented with severe respiratory distress and seizures. He was on non-invasive positive pressure ventilation for 90 days for respiratory distress syndrome at birth complicated by human metapneumovirus pneumonia and apnea. Patient had been sick for 5 days prior to admission with cough, nasal congestion and increased work of breathing. He was cared for by his parents who were sick with coronavirus disease (COVID-19) symptoms.
Patient presented to the emergency department of a referral hospital lethargic, seizing and hypoxemic with saturation by pulse oximetry of 77%. There was no history of fever, vomiting, diarrhea, rash or decrease in oral intake. He deteriorated and had a bradycardic cardiac arrest and was resuscitated. Initial arterial blood gas analysis was pH 7.20/pCO2 81 mm Hg/pO2 39 mm Hg/bicarbonate 25 mEq/L/base excess -6 on 1.0 fraction of inspired oxygen (FiO2) with PaO2/FiO2 ratio of 39 and oxygenation index of 41 . Blood and urine cultures were obtained, broad spectrum antibiotics and levetiracetam were started, fluid boluses were given and chest radiograph (CXR) revealed bilateral opacities with central predominance.
Upon arrival in our pediatric intensive care unit (PICU) he was placed on the ventilator using synchronized intermittent mandatory ventilation/pressure regulated volume control mode with FiO2 1.0, positive end expiratory pressure 10cm water, tidal volume 55, Rate 40/minute, inspiratory time 0.7sec to maintain saturations greater than 90%. Patient was sedated and placed on neuromuscular blockade. CXR showed significant worsening of bilateral infiltrates. (Figure) Within 24 hours of hospitalization patient became more hypoxemic, inhaled nitric oxide was started and within 36 hours patient’s oxygen saturation decreased to the 70s and patient was proned. Saturations improved and FiO2 was weaned to 0.40 within 8 hours of proning. He was proned for 12-14 hours each day for 4 days.
Rapid real-time reverse transcription polymerase chain reaction test was positive for COVID-19 on nasopharyngeal swab specimen and respiratory viral pathogen panel did not reveal any other viral co-infections. Initial white cell count was 19.6 x 103/mcL with 44% segmented neutrophils, 1% bands, 48% lymphocytes, and 6% monocytes. Hemoglobin was 10.5 g/dL and platelet count was 401 x 103 /mcL which decreased in a few hours to 115 x 103/mcL. Prothrombin time (PT), partial thromboplastin time (PTT) and international normalized ratio (INR) were slightly increased at 13.9 seconds, 1.41 and 26.8 seconds respectively. Patient received packed red blood cell transfusion, fresh frozen plasma and vitamin K. C-reactive protein was elevated at 3.68mg/dL and procalcitonin was high at 0.88 ng/ml. Blood urea nitrogen was 25mg/dL, serum creatinine was 0.35mg/dL and serum sodium was 126 mmol/L and they improved with volume resuscitation. Alanine transaminase (ALT) and aspartate transaminase (AST) increased significantly from <120 unit/L (U/L) and <60 U/L to peak of 1505 U/L and 2297 U/L respectively within 12 hours of hospitalization . These enzymes slowly decreased over a period of 3 weeks to near normal values. Albumin decreased from 3.8g/dL on admission to 2.1 g/dL in 24 hours . Video electroencephalogram did not show seizures, head ultrasound revealed normal study. Echocardiogram showed normal biventricular systolic function. Patient received methylprednisolone and hydroxychloroquine. Remdesivir was not approved by the manufacturer secondary to severe transaminitis. Patient was extubated on hospital day (HD) 8. Patient remained on non – invasive positive pressure ventilation until HD 22 . He was on supplemental oxygen via nasal cannula for another five days and discharged to home on albuterol and budesonide nebulizers, chlorothiazide, spironolactone, and levetiracetam. Patient was playful and interactive at the time of discharge from our hospital.