More than COVID19

ABSTRACT

Introduction: COVID19, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), presents with widely varying severity of disease, with pediatric patients experiencing milder disease than adults. Most children requiring mechanical ventilation had underlying comorbidities, most commonly cardiovascular abnormality or obesity. We report an adolescent with severe obesity with COVID19 pneumonia, requiring mechanical ventilation, incidentally, found to have a Morgagni hernia. Case A 15-year-old male, with severe obesity (BMI 67) presented with acute hypoxemic respiratory failure secondary to SARS-CoV-2 infection leading to severe COVID19 pneumonia. Chest X-ray on admission was significant for bilateral reticulonodular opacities consistent with COVID19. His respiratory failure rapidly progressed despite high-flow nasal oxygen, leading to intubation for high pressure mechanical ventilation and adjunct inhaled nitric oxide to improve oxygenation. He was treated with Remdesivir and dexamethasone. He developed pulmonary edema, which was managed with aggressive diuresis and fluid restriction. He developed right axillary and basilic occlusive thrombi associated with hypercoagulability and was treated with subcutaneous enoxaparin sodium. Subsequent chest X-ray showed significant left hemidiaphragm elevation, concerning for diaphragmatic eventration. After 15 days of intubation, he was extubated to continuous non-invasive ventilation (NIV) before weaning to room air when awake and empiric nocturnal NIV with supplemental oxygen due to hypoxemia attributed to previously undiagnosed severe obstructive sleep apnea and atelectasis secondary to his illness and deconditioning. CT Chest demonstrated a massive Morgagni hernia containing mesenteric fat and multiple loops of bowel, with associated left lung compression and displacement of the heart and mediastinum into the right hemithorax. Lung parenchyma had scattered areas of air trapping and small airway obstruction. Gated cardiac CT showed low to normal systolic function without pulmonary hypertension. The patient was discharged with nocturnal NIV with supplemental oxygen with plans for outpatient polysomnography and titration. Surgical correction of the diaphragmatic defect was deferred as patient had no gastrointestinal symptoms and follow up CT Chest at discharge showed no evidence of obstruction or strangulation. Discussion: Limited data exists regarding risk factors for severe COVID19 disease in pediatric patients, but describes chronic cardiac conditions, respiratory disease and obesity as prominent risk factors, similarly described in adult populations. Despite severity of presentation, a high proportion of adolescents recover without sequelae thus far. We present a case of severe COVID19 in an adolescent with multiple comorbidities, incidentally, found to have a Morgagni hernia. This case represents a favorable outcome despite multiple risk factors and severe presentation requiring mechanical ventilation.