Multi-System Inflammatory Syndrome in Children Presented with Persistent Respiratory Alkalosis: A Case Report

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  • Open Access
  • Authors : Heba Alameer , Sajjad Alkadhem, Fatimah Almuhanna , Mahdi Alsuwailem, Abdullah Alkhawajah, Ali Bumejdad , Fadi Busaleh, Maali Alali, Abdullah Al Muaibid
  • Paper ID : IJERTV9IS090490
  • Volume & Issue : Volume 09, Issue 09 (September 2020)
  • Published (First Online): 03-10-2020
  • ISSN (Online) : 2278-0181
  • Publisher Name : IJERT
  • License: Creative Commons License This work is licensed under a Creative Commons Attribution 4.0 International License
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Multi-System Inflammatory Syndrome in Children Presented with Persistent Respiratory Alkalosis: A Case Report

Heba Alameer1, Sajjad Alkadhem1, Fatimah Almuhanna1, Mahdi Alsuwailem1, Abdullah Alkhawajap, Ali Bumejdad1, Fadi Busalep, Maali Alali1, Abdullah Al Muaibid2.

Paediatric Department, Maternity and Children Hospital of Alahsa, Saudi Arabia 1

Collage of Medicine, University of Albaha, Saudi Arabia2

Abstract:- Multi-System Inflammatory Syndrome in Children (MIS-C) was identified by the US Centers for Disease Control and Prevention (CDC) as a person <21 presenting with fever

24 hour with at least two multisystemic-organ involvement, including predominantly gastrointestinal and cardiovascular symptoms associated with high inflammatory markers. Frequently, these manifestations may correspond to severe acute respiratory syndrome due to coronavirus-2 (SARS-CoV- 2), which represent a challenge for any pediatrician or clinicians. In this report, we presented a five-year-old boy with persistent respiratory alkalosis. Moreover, we demonstrated the management protocol for such cases, which will aid in reducing the burden of such challenges.

Keywords: Case report, SARS-CoV-2, COVID-19, Saudi Arabia

INTRODUCTION

In March 2020, the World Health Organization (WHO) was declared the coronavirus disease of 2019 (COVID-19) as a pandemic, which is the responsible cause of severe acute respiratory syndrome coronavirus 2 (SARS- CoV-2) [1]. Fortunately, children represent only 2% of the whole case since the onset of the coronavirus (COVID-19) pandemic with milder symptoms compared to adults [2]. Later, in mid-April, Riphagen S. et al. reported eight children sharing Kawasaki shock syndrome-related features similar to SARS-CoV-2, such as delayed reaction [3]. These symptoms were subsequently reported worldwide; thus, Multi-System Inflammatory Syndrome in Children (MIS-C) was identified by the US Centers for Disease Control and Prevention (CDC) as a person <21 presenting with fever 24 hr with at least two multisystemic-organ involvement, including predominantly gastrointestinal and cardiovascular symptoms associated with high inflammatory markers, in addition to a history of contact to COVID-19 cases or history of recent infection [4]. In contrast, these variant manifestations corresponded to (SARS-CoV-2) [5], which represent a challenge for any pediatrician or clinicians. In this report, we present a five-year-old boy with persistent respiratory alkalosis.

CASE PRESENTATION

A 5-year-old boy, who was previously healthy, came to the emergency department with a history of persistent fever for six days associated with headache, fatigue, abdominal pain, maculopapular inguinal rash, and decreased oral intake and activity. SARS-COV-2 infection

was detected approximately two days ago. Table 1 shows the clinical and laboratory characteristics of the child. The patient was lethargic and had appeared sick. Vital signs were febrile (38.9°C), borderline normal blood pressure (88/55 mmHg), with normal respiratory rate, SPO2 and heart rate. Initial laboratory findings showed normal WBCs, mild increase in neutrophil count, anemia, mild thrombocytopenia, hyponatremia, hypokalemia, mild hypochloremia, hypoalbuminemia, and elevated LDH. Coagulation profile was within the reference range. However, the D-dimer was elevated, the inflammatory markers revealed ESR (77 mm/hour), CRP (>27 mg/dL), ferritin (438.4 ng/mL), and the CKMB was (33.4 mg/dL). Initial venous blood gas showed respiratory alkalosis, Ph (7.54), CO2 (26.6 mmHg/L), and HCO3 (26.2 mmol/L);

therefore, the patient was admitted to the Pediatrics ICU as a case of SARS-COV-2 with MIS-C. According to the Saudi MOH guidelines protocol for the treatment of MIS-C, ceftazidime, vancomycin, IVIG 2g/kg/dose, methylprednisolone (10mg/kg/dose), enoxaparin, tocilizumab, aspirin, and favipiravir were initiated. After a single dose of IVIG the patient began to improve; fever decreased on the second day of admission. During admission to PICU, despite the sufficient hydration & chemistry of the blood, the patient demonstrated a reduction in the blood pressure with wide pulse pressure (98/35). Therefore, the patient was administrated norepinephrine to maintain the blood pressure; moreover, potassium chloride was given to correct the hypokalemia; then patient became stable and improved, so norepinephrine weaned gradually after that patient shifted to an isolation room in the general pediatric ward. Then, he stayed in PICU for five days & a full hospital stay about eight days. Finally, he discharged home in good condition with a tapering dose of prednisolone and aspirin with cardiology and nephrology outpatient departments (OPD) follow up regarding persistent respiratory alkalosis and hypokalemia with renal ultrasound to exclude renal diseases.

DISCUSSION

Our patient fulfilled the CDC criteria in terms of MIS-C [4]. Evidence of current or recent SARS-CoV-2 infection is confirmed by reverse transcription-polymerase chain reaction (RT-PCR), serology test, or exposure to a suspected or confirmed COVID-19 case within the four weeks before the onset of symptoms. We considered our patient as a case of MIS-C, and we follow the Saudi MOH

guideline for treating MIS-C by pulse therapy of methylprednisolone (ranging from 2 to 30 mg/kg/day), intravenous immunoglobulin, 1 to 2 grams/kg, enoxaparin, tocilizumab, aspirin, and favipiravir.

MIS-C occurs as the delayed latent reaction to SARS-CoV-2 that triggers the immune system to generate antibodies that are the responsible cause of cytokines storm [6]. We assumed that the cytokines storm contributes to metabolic acidosis of SARS-CoV-2 patients; however, our patients presented by persistent respiratory alkalosis associated with hypokalemia and hypotension with wide pulse pressure despite adequate hydration. All of these indicators raised our suspicion of other underlying diseases affecting the acid-base balance, especially renal diseases such as Barrter syndrome and Gitelman syndrome (GS) [7,8]. Further investigations are needed to elucidate the pathophysiological mechanism of MIS-C in relation to other associated inherited renal diseases in pediatrics ages group.

Acknowledgement: None Conflict of Interest: None Funding Source: None

REFERENCES

  1. Valencia DN. Brief Review on COVID-19: The 2020 Pandemic Caused by SARS-CoV-2. Cureus 2020.

    https://doi.org/10.7759/cureus.7386.

  2. Posfay-Barbe KM, Wagner N, Gauthey M, Moussaoui D, Loevy N, Diana A, et al. COVID-19 in children and the dynamics of infection in families. Pediatrics 2020. https://doi.org/10.1542/peds.2020-1576.
  3. Riphagen S, Gomez X, Gonzalez-Martinez C, Wilkinson N, Theocharis P. Hyperinflammatory shock in children during COVID-19 pandemic. Lancet 2020;395:16078. https://doi.org/10.1016/S0140-6736(20)31094-1.
  4. Feldstein LR, Rose EB, Horwitz SM, Collins JP, Newhams MM, Son MBF, et al. Multisystem inflammatory syndrome in U.S. Children and adolescents. N Engl J Med 2020. https://doi.org/10.1056/NEJMoa2021680.
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  6. Liu L, Wei Q, Lin Q, Fang J, Wang H, Kwok H, et al. Anti-spike IgG causes severe acute lung injury by skewing macrophage responses during acute SARS-CoV infection. JCI Insight 2019. https://doi.og/10.1172/jci.insight.123158.
  7. Chhetri S, Khamis F, Pandak N, Al Khalili H, Said E, Petersen E. A fatal case of COVID-19 due to metabolic acidosis following dysregulate inflammatory response (cytokine storm). IDCases 2020;21:e00829. https://doi.org/10.1016/j.idcr.2020.e00829.
  8. Cunha T da S, Heilberg IP. Bartter syndrome: causes, diagnosis, and treatment. Int J Nephrol Renovasc Dis 2018;Volume 11:291 301. https://doi.org/10.2147/IJNRD.S155397.

Table 1: Clinical and laboratory characteristics

InvestigationsReference RangePatient Result
InitialFinal
Complete blood count
Total white blood cells4.5-13.5 ×103/µL9.4123.93
Neutrophil count1.5-8.5 ×103/µL8.3622.18
Lymphocyte count1.5-6.5 ×103/µL0.711.48
Hemoglobin12.5-13.7 g/dL9.99.4
Platelets150-350 ×103/µL136210
Biochemistry
Random serum glucose7-200 mg/dL84.7130
Creatinine44-88 µmol/L5353.08
Urea1.7-7.1 mmol/L4.23.0
calcium2.1-2.5 mmol/L2.271.96
sodium135-145 mmol/L132139
Potassium3.5-5 mmol/L4.113.3
Chloride97-107 mmol/L93.099
Magnesium0.63-1.05 mmol/L1.000.87
Phosphorus0.78-1.42 mmol/L1.361.2
LDH100-190 units/L306213
Total serum bilirubin0.2-1.5mg/dL0.460
Direct bilirubin0.0-0.2 mg/dL0.242
Albumin34.0-50.0 g/L29.029.2
AST13-35 unit/L38.215
ALT10-30 unit/L19.920
Alkaline phosphatase100-320 units/L91.074
Blood Gases
pH7.35-7.457.5447.435
Hco321-28 mmol/L26.224.6
PCo235-45 mmHg/L27.636.7
Coagulation Profile
PT11.0-13.5 seconds11.8 sec.
PTT30-40 seconds37.8 sec.
INR0.8-1.11.03
Inflammatory Markers
ESR0.0-20 mm/hour77
C-RP0.00.9 mg/dL>27.0
Ferritin7-140 ng/mL438.4
Cardiac enzymes
Troponins<0.2ng/mlNOT TAKEN
CKMB0-25U/L33.4
Cultures, Serology
COVID-19 PCRPositive twice
Blood cultureNegative
Urine Culture
Cytomegalovirus antibodies
Epstein-Barr virus antibodies
Herpes Simplex Virus Antibodies

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