Age: 6.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Bradycardia, Brain natriuretic peptide increased, Breath sounds abnormal, Bronchoalveolar lavage normal, Bronchoscopy
Clinical narrative: Patient was hospitalized 12/13/21 - 2/21/22. The day of admission happened to occur 4 days after his COVID vaccination (with initial symptoms beginning 2 days after vaccination, prompting this report),  for fevers and acute hypoxic respiratory failure; however ultimately these symptoms were found to be in the setting of respiratory infection with parainfluenza virus and chronic lung disease. He tested positive for parainfluenza virus by multiple molecular studies , and was treated also empirically for possible hospital-acquired pneumonia (with severe opacification of right lung seen on CXR, rapid onset of symptoms, recent hospitalization, in the setting of previous MRSA infection).   Prior to this admission, he had been recently hospitalized 12/7-12/10/21 following IR port placement for ketotic hypoglycemia. Notably, during sedation for port placement and during recovery afterward, he had difficulty clearing secretions and required deep suctioning, desaturated to the mid-80s and was placed on a facemask at that time; however, this had resolved by the time of his admission and he was saturating normally on RA. The day of his discharge, he received his first COVID vaccine.    Two nights prior to this re-admission as above, he was acting a sleepier than normal, had tactile fever, and one night prior to re-admission he developed a fever (Tmax 104F), was hypoxic to the mid-80s, developed increased work of breathing and was placed on increasing oxygen at home, stress dose solucortef, q4 hours albuterol, and was brought to the hospital.    Upon arrival to the ED, he was afebrile but slightly tachycardic (120s) and tachypenic (32) with suprasternal and intercostal retractions. He had poor air entry in the R lung field. Labs were obtained and notable for a leukocytosis to 17.2 with an elevated ANC, mild elevation in Cr to 0.62. BNP 265. High-sensitivity troponin was 5. CRP is severely elevated to 100. ESR of 8. COVID and flu testing were negative. EKG wnl. CXR with severe, complete opacification of the R hemithorax. Pulmonology was contacted from the ED, and recommended chest US which showed trace right pleural effusion. RVP resulted positive for parainfluenza, blood cultures were negative. He was given a dose of Ceftriaxone. He was placed on high flow. Due to FiO2 needs > 50%, he was admitted to the PICU for ongoing management.  Patient was admitted to the PICU on CPAP requiring between 60-100% FiO2 to maintain goal SpO2. Respiratory support was quickly escalated to BiPAP and then required intubation to maintain oxygenation within 6 hours of admission.     Respiratory course was complicated by infection and fluid overload/anasarca (limiting chest wall expansion ) plus pulmonary edema (discussed below.) Failed initial extubation attempt on (12/22) due to worsening hypoxia requiring reintubation within 5 hours. Pulmonology was consulted and followed throughout admission. He had 3 failed extubations during this hospitalization. He underwent tracheostomy placement on 1/27. He required regular pulmonary clearance throughout admission, which was continued at discharge.   He completed the following total course of antibiotics with the following agents during this admission: ceftriaxone, vancomycin, azithromycin, and cefepime. He was treated empirically with CTX, vancomycin and azithromycin on admission. There was initial concern for hospital-acquired pneumonia given recent admission, frequent hospitalization, and history of MRSA colonization and multiple prior infections (lung, ear, g-tube). Infectious disease was consulted. Respiratory viral mulitplex PCR panel returned positive for parainfluenza virus. Initial blood, respiratory and urine cultures were negative. He had a CT of his chest 12/14 showing multilobar pneumonia without abscess or empyema. Pulmonology performed a diagnostic and therapeutic bronchoscopy on hospital day 5 (12/17) with improvement in respiratory status. BAL infectious workup (bacterial, fungal, PJP) was largely negative. BAL RVP and Explify panel did return positive for parainfluenza virus.    He had a repeat sepsis evaluation overnight 12/18 after a hypothermic episode which was negative with the exception of MRSA which grew from his sputum culture. This isolate was sensitive to Vancomycin. This was felt to reflect ongoing colonization of the respiratory tract rather than persistent infection given ongoing clinical improvement following hypothermic episode. However, following failed extubation attempt on 12/22 he was restarted on vancomycin and cefepime which was narrowed to Vancomycin after 48h with respiratory culture continuing to grow MRSA. Vancomycin continued for 10d treatment course. He was given 7 days of cefepime and vancomycin from 1/10-1/17 for culture negative sepsis.    He was tested for COVID on admission and weekly during hospitalization with PCR evaluations, all returning negative.  During his early critical illness phase, he was also noted to have persistent bradycardia as low as the mid to high 50s. EKG was completed capturing period of bradycardia, but notable for sinus rhythm without heart block. He remained hemodynamically stable throughout admission and demonstrated good variability in HR.   He was also treated for multiple comorbidities during his hospital stay.