Pleural Effusion and Empyema in an Adolescent Patient with Sickle Cell Disease and COVID-19
Authors: Vasquez Jessica , Ampem-Darko Cecilia , Orisamolu Fehintola , Minkowitz Sheera , Sundaram Revathy 
Published: June 2024

Abstract

Presentation Date: 6/8/2024
Presentation Start Time: 6:00:00 PM

Background
Respiratory complications such as acute chest syndrome (ACS) and pulmonary hypertension are associated with particularly high mortality rates in patients with sickle cell disease (SCD). COVID-19 is a disease caused by the SARS-CoV-2 virus which may result in pneumonia, acute respiratory distress syndrome, acute respiratory failure, and even death. Each of these disease processes have been extensively described separately in the literature. There remains much to be understood regarding the interplay between the two, especially in the pediatric population. This case report highlights severe pulmonary complications encountered in a patient with HbSS and COVID-19.

Methods
Case Description: A 16-year-old patient with HbSS and one dose of the COVID-19 vaccine two years prior presented with cough, fevers and worsening right-sided chest pain before testing positive for COVID-19. Initial chest x-ray was concerning for right middle lobe pneumonia vs acute chest syndrome and pleural effusion. The patient was placed on BiPAP due to increased work of breathing. His respiratory status declined steadily over the subsequent days, despite administration of Ceftriaxone, Remdesivir and dexamethasone. A percutaneous chest tube was placed on day four of admission due to worsening pleural effusion. The chest tube was also used to administer doses of tPA. Due to minimal improvement five days after chest tube placement, a chest CT was preformed, which showed a large multiloculated right-sided pleural effusion and empyema. The medial component of the effusion caused a mass effect on the right atrium and possibly on the superior vena cava. There was also a partial collapse of the entire right lung with possible developing necrotizing pneumonia. A video-assisted thoracoscopic surgery (VATS) was performed the following day for failure of chest tube and a loculated pleural effusion. The patient’s respiratory status began to improve shortly after the procedure, as evidenced by his transition from BiPAP to nasal cannula within days. Blood culture prior to antibiotics was negative. Empyema culture which was performed after initiation of antibiotics was also negative. Supportive measures also included seven units of packed red blood cells, two units of fresh frozen plasma and 22 days of antibiotics. The patient was discharged after a 24-day hospital course.

Results
People with sickle cell disease who are diagnosed with COVID-19 have been reported to have a spectrum of symptoms ranging from no symptoms to more commonly reported vaso-occlusive episodes and acute chest syndrome. More severe respiratory complications in pediatric patients are limited to fewer reported cases. The main complication experienced by this patient is pleural effusion with empyema, which is also a less common presentation of COVID-19. Patient’s with HbSS are at increased risk for infection with encapsulated organisms secondary to functional asplenia. Though this patient’s cultures remained negative, it is important to consider coexisting bacterial infection and manage accordingly.

Conclusions
Children with sickle cell disease who are diagnosed with COVID-19 may have more severe respiratory complications than patients without chronic disease. Vaso-occlusive crises and ACS have been found to be the main complications of patients with COVID-19 and SCD. This case highlights a less common but severe outcome of pleural effusion and empyema in the setting of COVID-19 and SCD.