ABSTRACT
Introduction COVID-19 infection with cardiac involvement in the pediatric population remains rare and it is most recognized for its association with Multisystem Inflammatory Syndrome in Children (MIS-C). Isolated pericarditis is a rare manifestation of COVID-19 infection, with a few cases being reported to date. Case description A 7-year-old black male presenting with chest pain and cough was found to have pericardial effusion. He had known exposure to COVID-19 five months prior, without developing symptoms of acute illness. On our evaluation, COVID-19 IgG titers were positive, SARS-CoV-2 PCR was negative, confirming prior asymptomatic infection. There was no evidence of MIS-C on laboratory analysis or on clinical examination. Pericardial fluid analysis and testing for infectious and rheumatological causes were unremarkable. Medical management with Ibuprofen, Colchicine, and Lasix initially failed and patient required pericardiocentesis. Pericardial effusion later recurred and was successfully managed medically. Discussion Our patient's case is atypical in that he developed a cardiac complication after acute asymptomatic COVID-19 infection, five months after his known exposure. Secondly, his cardiac complication was not in the context of MIS-C, which is relatively commonly described post-SARS-CoV-2 infection. COVID-19 related pericarditis presents with chest pain, pericardial rub, EKG changes. No specific biomarkers are available to diagnose pericarditis, however inflammatory markers like ESR, CRP, WBC and imaging like chest X ray, CT scan, ECHO are often utilized to diagnose and monitor response to treatment. Diagnostic pericardiocentesis can be avoided in most cases. Pericardial fluid analysis is mainly used to exclude other causes of pericardial effusion. Cardiac specific biomarkers such as troponin-I, BNP can be used to monitor the progression of the disease and response to treatment. Main treatment options include NSAIDs, steroids, and IVIG. NSAIDS-Colchicine combination has been successfully used in adults and children. Anakinra was used in Colchicine nonresponsive cases in adults. Conclusion It is important to maintain a high index of suspicion for cardiac complications in children with known COVID-19 contacts. In the context of high exposure in the general population during the pandemic, the development of cough and chest pain in a pediatric patient should trigger an evaluation with a CXR, as well as EKG and ECHO to properly investigate a cardiac complication. Such cases should be referred to Cardiology and Infectious Disease specialists for treatment and appropriate follow-up to resolution. Long-term Cardiology follow-up to monitor for sequelae may be warranted.
ABSTRACT
Case Report Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening condition that can occur as primary disorder or secondary to a variety of infections, rheumatic diseases, or malignancies. It is usually diagnosed among patients who are hospitalized with shock-like multiorgan dysfunction and unremitting fevers. It is associated with high mortality and morbidity. HLH secondary to toxoplasmosis is not uncommon in immunocompromised patients. However, it is rarely reported in immunocompetent patients. We herein, report a case of HLH triggered by toxoplasmosis in an immunocompetent patient. Case description A previously healthy 10-year-old male, who lives on a farm, presented with acute onset abdominal pain, vomiting, subjective fever, generalized myalgia, lymphadenopathy, and hepatosplenomegaly. Initial labs revealed thrombocytopenia, neutropenia, abnormal hepatic panel, and significantly elevated ferritin, which worsened upon recheck. Further workup revealed increased triglyceride and soluble IL-2 receptor and decreased fibrinogen, which confirmed the diagnosis of HLH. Toxoplasma testing showed positive IgM and IgG with low IgG avidity, indicative of a recent infection. Brain MRI and fundoscopy were unremarkable. Other infectious workup including hepatitis A, B, and C viruses, CMV, and respiratory pathogen panel including Covid-19 were negative. EBV serology was consistent with previous infection. Immunologic work up showed increased CD8 T cells and increased IgM. Treatment for HLH was not initiated since patient remained well-appearing and afebrile throughout the hospital stay. Treatment for toxoplasmosis was not indicated due to the absence of brain and retinal involvement. Subsequently, laboratory parameters started to improve on day 6 of hospitalization. The patient was discharged the following day. Five days later, platelet count, ANC, ferritin, and fibrinogen levels were normalized. Discussion Although meeting HLH-2004 diagnostic criteria, the course of illness was not typical, as this patient remained afebrile and clinically well with spontaneous recovery. This is in contrast to 95% of typical HLH cases that have high unremitting fever. The initial suspicion of HLH was low due to the atypical features. We proceeded with the HLH investigations due to hyperferritinemia on repeat testing, which has a 90% sensitivity for HLH. Soluble IL-2 receptor test further confirmed our suspicion. To our knowledge, there have been only a few pediatric case reports of HLH secondary to acquired toxoplasmosis without an underlying condition. No underlying immune deficiency disorder was found. Conclusion This case highlights the fact that toxoplasmosis can trigger HLH in immunocompetent children. Early diagnosis and prompt treatment are crucial in avoiding a fatal outcome.