ABSTRACT
INTRODUCTION: Injury from hydrocarbon inhalation, such as with tiki torch fuel, can range from asymptomatic requiring only observation to fatal due to severe acute respiratory distress syndrome. Treatment is largely supportive. DESCRIPTION: A 12-month-old male was found by a family member drenched in tiki torch fluid with suspected hydrocarbon inhalation. On presentation to the Emergency Department, he was lethargic but with a clear respiratory exam. Within an hour, he developed tachypnea and hypoxemia requiring endotracheal intubation. Chest radiography revealed interval increase in bilateral heterogeneous airspace opacities. He was also found to be parainfluenza 3 positive. Despite optimization of sedation and paralysis, administration of corticosteroids and bronchodilators, and increasing respiratory support, he had worsening hypoxemia and hypercarbia. On hospital day 2, he had an oxygenation index of 60 and a P/F ratio of 40, so he underwent cannulation with veno-arterial extracorporeal membrane oxygenation (ECMO). In addition to diuretics and chest physiotherapy, due to persistent fevers, elevated inflammatory markers, and severity of illness, he received antibiotics for 7 days. Over the next 3 days, he improved and was subsequently decannulated from ECMO. Sixteen days after initial injury, he was extubated and weaned from supplemental oxygen three days later. He has not had any respiratory complications in the 12 months since injury. However, he did require rehospitalization due to thrombotic stroke suspected to be secondary to recent COVID-19 infection, history of ECMO and family history of thromboembolic events. DISCUSSION: Although most children with injuries related to hydrocarbon ingestion and aspirations can be observed and discharged, some injuries can lead to significantly worse symptoms including pulmonary edema, bronchoconstriction, hypoxemia and worsening respiratory distress which may require invasive support or ultimately be fatal. Presentations can evolve rapidly over 6-8 hours and peak at 48 hours due to the disturbance of surfactant and consequences of inflammation. While bronchodilators may provide benefit, steroids and surfactant therapy is controversial. Therapy is largely supportive. Most children can be expected to have a full recovery.
ABSTRACT
INTRODUCTION: DiGeorge Syndrome is a relatively common microdeletion syndrome defined by a deletion in chromosome 22 at position 22q11.2 and clinically characterized by T-cell deficiency, unique facial features, congenital heart disease and hypocalcemia. Complete DiGeorge Syndrome refers to a subset that is athymic (< 1%) without any T cell function. The adaptive immune response is then disturbed leading to an increased susceptibility to infections given the lack of cytotoxic response to infected cells. In this population, pathogens can persist and have unique presentations due to the lack of an adaptive immune response. DESCRIPTION: We present a case of persistent COVID-19 in a 3-year-old male with complete DiGeorge syndrome. Two months prior to presentation, he was treated with remdesivir for a symptomatic COVID-19 infection. He later represented with severe persistent hypocalcemia despite aggressive IV electrolyte repletion as well as a new acute hemolytic anemia with positive Coombs and concern for Graft vs Host disease. During his hospital course, he had worsening respiratory status leading to re-intubation. Bronchoscopy with BAL showed significant SARS-CoV-2 viral load and he was started on a repeat course of remdesivir and convalescent plasma. Two weeks after initial bronchoscopy, repeat BAL samples showed unchanged SARS-CoV-2 viral load leading to another course of remdesivir and convalescent plasma. After a month of invasive ventilation, he was able to be successfully extubated and eventually discharged from the hospital, despite having persistently an elevated SARS-CoV-2 viral load and polymerase chain reaction testing positivity. DISCUSSION: This case illustrates a unique situation of COVID-19 in a patient without an adaptive immune response due to complete DiGeorge Syndrome. This patient population is athymic without any T cell function leading to a lack of cytotoxic response and a susceptibility to infections due to the inability to clear infected cells. With COVID's high mutation rate leading to multiple new strains, we present a case illustrating the possibility of new strain mutations developing due to persistent COVID in a patient with an inability to clear the viral infection.