Endocarditis Leading to Cardiac Surgery
A 16-year-old boy with trisomy 21 and no additional medical condition, including no cardiac abnormalities, presented to the emergency room (ER) in early March 2020, with a 2-week fever accompanied by knee and hip pain. On examination a new heart murmur was detected, and lab tests revealed an elevated C-reactive protein (88 mg/L). The family was advised to admit their son for extended workup; however, they refused out of fear of being exposed to COVID-19 in the hospital and requested to continue workup in the community. Over the next seven weeks at home, the boy experienced recurrent fever and received two courses of amoxicillin prescribed by his family doctor due to positive group A streptococcus on throat culture. This resolved the fever; however, fever recurred when antibiotics were stopped. The patient was brought back to the hospital seven weeks after the previous visit, still with fever, a systolic murmur, and an elevated C-reactive protein (77 mg/L), thrombocytopenia of 79,000/μL, and a blood culture positive for Gram-positive cocci. Echocardiogram revealed signs of endocarditis with a large 2-cm vegetation on the mitral valve. Given insufficient response following four days of intravenous antibiotics, and given the large vegetation, the child underwent surgery for excision of the vegetation and reconstruction of the mitral valve.
Severe Hemolytic Anemia
A 2.5-year-old boy with a history of tetralogy of Fallot, which had been fully corrected at the age of eight weeks, with no cardiac sequela, presented to the ER following two weeks of fatigue, irritability, recurrent chest and abdominal pain, low energy, and reduced appetite. During the previous week, he had dark urine and his parents noticed yellowish skin color. Only after observing these symptoms for two weeks did they bring him to the hospital. The boy was pale with a yellowish skin color, and blood tests were consistent with severe hemolytic anemia: hemoglobin, 4 g/dL; reticulocyte, 15.7%; lactate dehydrogenase, 870 U/L; and total bilirubin, 3.2 mg/dL, mostly indirect. Indirect Coombs test was positive. The boy was treated with packed cells, which temporarily increased his hemoglobin to 10 g/dL. However, the boy’s hemoglobin level declined again after several days to 7 g/dL, at which point steroid treatment was started.
Severe Septic Hip
A 13-year-old boy presented to the ER following two weeks of right inguinal pain, which had become more severe with each passing day, first limping and eventually unable to bear weight. No fever was noted and no history suggesting rheumatic disease. On examination, pain on rotation of the hip joint was noted; he had a normal hip X-ray, normal complete blood count, and elevated C-reactive protein (250 mg/L). Ultrasound of the hip joint showed 8 mL of fluid collected in the joint, which was aspirated and consistent with septic arthritis; the aspirate contained 172,802 white blood cells with 93% polymorphonuclears and was culture-positive for methicillin-resistant Staphylococcus aureus
. After two joint aspirations, treatment with vancomycin, and very slow improvement, magnetic resonance imaging was performed which showed extensive joint disease, involvement of the surrounding muscles with abscesses, and signs of osteomyelitis of the femur, acetabulum, and sacrum. The patient underwent surgery to drain an additional 20 mL of pus, drilling holes in the femur and ileum, and perform lavage.
A 4-year-old boy was brought to the ER following ten days of severe quadriparesis. The boy initially complained of fatigue and difficulty walking, which deteriorated within two days to complete inability to walk or use his arms. He received two medical con-sultations by telemedicine and received antibiotic treatment and systemic steroids. He remained at home, bedridden and spoon-fed for a full ten days before presenting to the ER. On admission he was noted to suffer severe proximal quadriparesis. Magnetic resonance imaging of the spine was performed demonstrating a space-occupying lesion along the spinal canal along C2–4, which measured 3.6×3.2× 3.2 cm. A biopsy was performed, returning the diagnosis of Ewing sarcoma. When the parents were consulted regarding the reason for delay in presenting to the hospital despite two weeks of significant neurological deterioration, their response was that they feared the COVID-19 pandemic and did not want to leave the house.