ABSTRACT
Introduction: Multisystem Inflammatory Syndrome in Children (MIS-C) is a constellation of symptoms involving fever, laboratory evidence of inflammation, and >/= 2 organ systems involvement (cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic or neurologic) in a patient who is positive for current or recent COVID-19 infection by RT-PCR, serology or by antigen testing. The total number of cases reported in the United States with MIS-C is more than 3000 as of May 2021. We present a case of MIS-C presenting as a retropharyngeal abscess in a 17- year-old with dendritic cell neoplasm. Case Description: 17-yearold male with a past medical history of metastatic, recurrent, atypical dendritic tumor currently in remission presented with fever for 4 days, associated with headache, sore throat and dysphagia, with a normal examination except 3+ tonsils without midline shift. He had an asymptomatic COVID 19 infection 2 months prior to this presentation. On admit, labs revealed hyponatremic (129) dehydration and a CRP of 29. CT neck showed a well-defined retropharyngeal fluid collection. He was started on Vancomycin and Cefepime and was also given a dose of Dexamethasone. Due to clinical improvement on Day 3, the antibiotics were changed to Unasyn and Clindamycin for the presumed retropharyngeal abscess. He however became hemodynamically unstable and was taken for an emergent incision •drainage by ENT but there was no fluid to be drained. He remained intubated and admitted to the ICU. He required vasopressors because of his hemodynamic instability and broadspectrum antibiotics for concerns of sepsis. Further workup showed signs of end organ damage and inflammation including severe myocardial dysfunction (EF ∼ 20%) and a positive COVID 19 antibody. He was diagnosed with MIS-C and started on IVIG, steroids and Enoxaparin. He showed significant improvement in his clinical status, inflammatory markers and myocardial function over the next 24-48 hours following initiation of treatment. Discussion: MIS-C is believed to develop due to an abnormal immune response to the COVID 19 virus. There has only been a single case reported in a healthy individual presenting as a retropharyngeal abscess. Most of the cases of MIS-C are reported in primarily healthy children or with comorbidities like obesity and asthma but there have been very few cases reported in oncology patients possibly because of an inadequate immune response in these patients. Our case to the author's knowledge is the first case of MIS-C presenting as a retropharyngeal abscess in an oncology patient. Conclusion: It is important to identify the history of COVID 19 infection and have a high index of suspicion in unusual presentations so that early investigation and management is possible to prevent morbidity and mortality due to MIS-C.
ABSTRACT
Introduction: In 2020, coronavirus rapidly became a global pandemic leading to high mortality rates. Extensive studies done have yet to provide consistent and successful treatment options to improve disease progression and mortality. Convalescent plasma is being studied in adults with very minimal studies in the pediatric population. Here we report a case of a 16 year old with COVID-19 infection resulting in ARDS who showed drastic improvement after convalescent plasma therapy. Case Description: A 16 year old female with morbid obesity, presented to our pediatric emergency department (ED) for a 5 day history of fever, cough, congestion and respiratory distress, along with vomiting, diarrhea and diffuse abdominal pain. Patient arrived on 3 LPM (or litres/min) of oxygen, vitals stable and in no acute respiratory distress, with bilateral coarse breath sounds and diffuse abdominal pain. She tested positive on PCR test for SARSCoV-2 done via nasopharyngeal swab, otherwise unremarkable blood count and comprehensive metabolic panel. Imaging showed chest x-ray with multifocal pneumonia and an electrocardiogram was normal. She was admitted and treated Remdesivir and IV immunoglobulin (IVIG) due to the concern for multi system inflammatory syndrome in children (MIS-C). She was started on a 5 day course of low dose steroids. However, by the third day of hospitalisation, patient's respiratory status rapidly declined, eventually requiring intubation and mechanical ventilation. She was placed on Synchronised Intermittent Mandatory Ventilation (SIMV) mode, volume control with autoflow, tidal volume 550ml, requiring up to FiO2 of 80-90% and peak inspiratory pressure was ranging from 36-45. Following Mayo clinic protocol and attaining emergent FDA approval, she received Covid-19 convalescent plasma, following which she showed significant improvement in peak inspiratory pressure (ranging 20-30), within 24-36 hours of plasma therapy. Through the course of the next few days, the patient tolerated successful weaning of respiratory support and was extubated and gradually weaned to room air. She showed tremendous recovery and was discharged home. Discussion: COVID-19 infection continues to show high mortality rates. Studies show that obesity is a risk factor for severe illness as seen in case. The use of convalescent plasma along with significantly improved this patient's clinical status which is also seen on imaging. Convalescent plasma has previously been used successfully for the treatment of other viral infections including SARS-CoV, Middle East respiratory syndrome, influenza A (H1N1), and Ebola. Data from these infections also suggest that convalescent plasma is most effective when given early in the disease process. Conclusion: COVID-19 is a serious infection leading to multifocal pneumonia, ARDS and death, even in children. This case report shows the beneficial use of convalescent plasma therapy in a pediatric patient. There continues to be a need for further studies on pediatric patients on management, of which convalescent plasma is a considerable option.
ABSTRACT
Case Report Anorexia Nervosa is a mental health disorder with significant morbidity and mortality. Acute food refusal is one of the indications for admission. We present a patient who went to extreme lengths to restrict food intake, requiring intensive care sedation and ventilation to enable enteral feedings. 12 year old male, was admitted with symptoms of anorexia nervosa and BMI of 12.0, (<1%ile) with baseline BMI of 16 (25%ile), K of 3.3 and glucose of 54. He was treated with supervised eating on an inpatient pediatric floor with no need for enteral feeding. Psychiatry consultation confirmed the diagnosis of anorexia nervosa and recommended the addition of Olanzapine to his Sertraline. He was discharged pending placement in an eating disorder center after 21 days of hospitalization with discharge BMI of 14. He was followed as an outpatient by his pediatrician, dietician and counselor but unfortunately, he required readmission 11 days after discharge due to acute food refusal, with BMI that had dropped to 13.1. Patient was readmitted and started on nasogastric (NG) feeds but he became severely agitated, pulling NG out multiple times and continued to lose weight with BMI dropping to 12. Sedation was attempted to facilitate maintenance of NG feedings, with Benadryl, Haldol and Ativan, but was ineffective at levels deemed safe without compromising his airway and breathing. Due to severe malnourishment and unsuccessful NG feeds he was transferred to PICU for sedation, endotracheal intubation and continuous nasoduodenal (ND) tube feedings on two separate occasions while inpatient. He was able to wean from the ventilator but once awake he found ways to manipulate delivery of his calories, even finding scissors and cutting the ND tube. The patient ultimately agreed to eat in order to avoid replacement of the feeding tube. He was finally transferred to an eating disorder facility, with a BMI of 13.9 and persistent anorexia thinking with restriction of eating anything but pizza. Patient completed three months of an inpatient program and had significant improvement in BMI to 19.3 (70%ile). He was subsequently discharged for continued outpatient follow-up and since discharge from the eating disorder center, his BMI has shown steady improvement in outpatient follow-up. He shows no signs of food refusal and is doing well with Family Based Therapy. This case highlights several unique characteristics in management of eating disorder patients. The age and being male along with extreme food refusal and resistance to enteral feeding that led to the requirement of deep sedation are quite unusual and not well described in the medical literature. The severity of his illness was a significant barrier to inpatient placement. In addition, despite a nationwide attempt to find an inpatient facility for him, which took several weeks, we identified shortages in eating disorder beds that have been exacerbated by the COVID-19 pandemic.