Sex: M
Vaccine: COVID19, COVID19
Symptoms: White blood cell count, X-ray
Clinical narrative: respiratory viral panel was positive for COVID-19 PCR; COVID-19; This is a literature report for the following literature source(s):   A 16-year-old male patient received BNT162b2 (BNT162B2), as dose 2, single (Batch/Lot number: unknown) for covid-19 immunisation; coviD-19 vaccine (COVID-19 VACCINE), as dose 1, single (Batch/Lot number: unknown) for covid-19 immunisation. The patient's relevant medical history included: "non-verbal autism" (unspecified if ongoing); "attention-deficit disorder" (unspecified if ongoing); "gastrointestinal reflux" (unspecified if ongoing). The patient's concomitant medications were not reported. The following information was reported: DRUG INEFFECTIVE (hospitalization, life threatening), outcome "unknown", described as "respiratory viral panel was positive for COVID-19 PCR"; COVID-19 (hospitalization, life threatening), outcome "recovered". The patient was hospitalized for drug ineffective, covid-19 (hospitalization duration: 5 day(s)). The patient underwent the following laboratory tests and procedures: Bronchoalveolar lavage: positive for 10000 to 100000 colony forming unit, notes: (CFU) per ml of MRSA; Bronchoscopy: was performed, and was significant for purulent, notes: secretions starting in trachea, most evidently seen on right upper lobe (RUL); Chest X-ray: normal; Initial laboratories: were significant for leukocytosis (15.7),, notes: respiratory viral panel was positive for COVID-19 PCR; Nucleic acid test: Positive; Physical exam: was remarkable for tachycardia, wheezing and, notes: stridor; Respiratory viral panel: Positive, notes: for COVID-19 PCR; SARS-CoV-2 test: Negative, notes: but nucleic acid amplification test(NAAT) for COVID-19 from BAL of RUL was positive, and LLL indeterminate; White blood cell count: 15.7; X-ray: showed narrowing of the trachea. Therapeutic measures were taken as a result of covid-19. Clinical course: Introduction Although bacterial tracheitis is more frequently seen in the tracheostomy-dependent child, it is a disease that may occur in healthy children presenting with acute onset of stridor. Staphylococcus aureus is the most commonly isolated bacteria causing tracheitis. We present a case of a patient with autism who presented with acute stridor and dyspnea. He was found to have methicillin-resistant staphylococcus aureus (MRSA) and COVID-19 co-infection with tracheitis requiring mechanical ventilation despite being fully vaccinated against COVID-19. Case Presentation A 16-year-old male with non-verbal autism, attention-deficit disorder, and gastrointestinal reflux, presented with sudden onset of stridor, increased work of breathing and drooling. He had received his second injection of Pfizer COVID vaccine 2.5 weeks prior to onset of symptoms. Physical exam was remarkable for tachycardia, wheezing and stridor. Initial laboratories were significant for leukocytosis (15.7), respiratory viral panel was positive for COVID-19 PCR. Neck x-ray showed narrowing of the trachea, with a normal chest x-ray. He developed worsening respiratory distress with persistent stridor and tripod position, unresponsive to racemic epinephrine. Epiglottitis was suspected, and a secure airway was obtained; ceftriaxone and vancomycin were also started. Upper airway evaluation by otorhinolaryngology ruled out epiglottis and foreign body aspiration. Flexible Bronchoscopy was performed, and was significant for purulent secretions starting in trachea, most evidently seen on right upper lobe (RUL). Edema and erythema of right upper and left lower lobe (LLL), in addition to white plaques and edema of trachea; diagnosis of tracheitis was made. Bronchoalveolar lavage (BAL) positive for 10,000 to 100,000 colony forming units (CFU) per ml of MRSA. Repeat nasopharyngeal PCR for COVID-19 was negative, but nucleic acid amplification test (NAAT) for COVID-19 from BAL of RUL was positive, and LLL indeterminate. Antibiotic therapy was narrowed to clindamycin after sensitivities resulted. He was successfully extubated on day 2 of admission, and discharged home on day 5. Discussion Viral and bacterial coinfection in children with tracheitis is well-described in literature, particularly influenza with MRSA. Although rare, COVID-19 associated laryngotracheitis has been reported in the literature as well, however not generally seen in vaccinated individuals. The current report highlights the need to consider co-infection of COVID-19 and bacterial etiology in children presenting with stridor. Empirical antimicrobial agents should be initiated promptly given the risk of progression into acute respiratory failure.  No follow-up attempts are possible; information about lot/batch number cannot be obtained. No further information is expected.