CASE 3
A 17-year-old-boy with a sensorineural hearing loss and no chronic systemic illness admitted to a hospital with a 7-day history of fever, abdominal pain and vomiting. Lumbar puncture was performed due to severe headache and CSF findings were normal. Later on, he had respiratory distress, hypotension and admitted to ICU. Diminished left ventricular function (EF:33%) was present. Bilateral consolidations compatible with COVID-19 pneumonia and pleural effusion were reported in the thoracic computed tomography (CT). He had a history of contact with a relative who had COVID-19 three weeks ago. During 10-day hospitalization SARS-CoV-2 RT-PCR was negative for three times. He was referred to our hospital for potential extracorporeal membrane oxygenation (ECMO) requirement. On admission he was intubated and had invasive respiratory support. He had 38.3°C fever with tachycardia (146/min). He was hypotensive and started on inotropic treatment. He had edema on the extremities, hepatomegaly and diminished respiratory sounds.
Marked laboratory findings are given in Table 1. Notably elevated cardiac enzymes were present; BNP was 5704 pg/mL, troponin 5927 ng/L, CK-MB 11.8 µg/L, myoglobin 559 µg/L. Left ventricular hypertropia and minimal pericardial effusion were reported on echocardiography (EF: 45%).
His SARS-CoV-2 RT-PCR was negative and SARS-CoV-2 IgG was positive; 8.9. Plasma exchange applied. He was started on plasma exchange, IVIg, steroid, anakinra, enoxaparin and antibiotics (ceftriaxone, teicoplanin and clarithromycin). Bone marrow aspiration revealed hemophagocytosis and increased number of free histiocytes (Figure 2 E&F). After two-month hospital stay, he was discharged very well.