Int J Clin Pediatr

International Journal of Clinical Pediatrics, ISSN 1927-1255 print, 1927-1263 online, Open Access

Article copyright, the authors; Journal compilation copyright, Int J Clin Pediatr and Elmer Press Inc

Journal website http://www.theijcp.org

Case Report

Volume 9, Number 2, June 2020, pages 41-49

SARS-CoV-2 in a Pediatric Patient Requiring Mechanical Ventilation and Multi-Drug Therapy

Figure 1. Chest X-ray, anteroposterior (AP) view on third presentation to emergency department showing signs of pneumonia with consolidation.

Figure 2. Chest X-ray, lateral view on third presentation to emergency department showing signs of pneumonia with areas of consolidation.

Figure 3. Chest X-ray, hospital day 1 showing signs of worsening acute respiratory distress syndrome (ARDS).

Figure 4. Chest X-ray, anteroposterior (AP) view on the day prior to start of remdesivir trial (hospital day 7).

Figure 5. Chest X-ray, anteroposterior (AP) view on the day with remdesivir trial commenced (hospital day 8).

Figure 6. Chest X-ray, anteroposterior (AP) view on the day following start of remdesivir (hospital day 9).

**Table 1.** Emergency Department Vital Signs and Examinations Results for Visit #1 Prior to Admission
Blood pressure (mm Hg)	-
Heart rate (beats per minute)	139
Respiratory rate (breaths per minute)	20
Temperature (°C)	39.6
Pulse Ox (%)	100% on room air
Weight (kg)	61
Constitutional	Active, no acute distress, alert, well hydrated
Head/ears/nose/throat	Bilateral tympanic membranes are normal without erythema or bulging. Oral mucosa is moist.
Eyes	Conjunctivae normal. Pupils are equal, round and reactive to light.
Neck	Musculoskeletal: normal range of motion and neck supple.
Cardiovascular	Rate and rhythm: normal rate and regular rhythm. Heart sounds: S1 normal and S2 normal.
Pulmonary	Pulmonary effort is normal. No respiratory distress or retractions. Normal breath sounds and air entry. No decreased air movement. No wheezing.
Abdominal	Bowel sounds are normal. There is no distension. Abdomen is soft and flat. There is no abdominal tenderness, guarding or rebound. No right lower quadrant tenderness. Able to hop, smiles while hopping.
Integumentary	Skin is warm and dry. Capillary refill takes less than 2 s. No petechiae or rash, purpura or mottling.
Neurological	Patient is alert with no focal neurologic deficits.

Table 1. Emergency Department Vital Signs and Examinations Results for Visit #1 Prior to Admission

Blood pressure (mm Hg)

Heart rate (beats per minute)

139

Respiratory rate (breaths per minute)

Temperature (°C)

39.6

Pulse Ox (%)

100% on room air

Weight (kg)

Constitutional

Active, no acute distress, alert, well hydrated

Head/ears/nose/throat

Bilateral tympanic membranes are normal without erythema or bulging. Oral mucosa is moist.

Eyes

Conjunctivae normal. Pupils are equal, round and reactive to light.

Neck

Musculoskeletal: normal range of motion and neck supple.

Cardiovascular

Rate and rhythm: normal rate and regular rhythm. Heart sounds: S1 normal and S2 normal.

Pulmonary

Pulmonary effort is normal. No respiratory distress or retractions. Normal breath sounds and air entry. No decreased air movement. No wheezing.

Abdominal

Bowel sounds are normal. There is no distension. Abdomen is soft and flat. There is no abdominal tenderness, guarding or rebound. No right lower quadrant tenderness. Able to hop, smiles while hopping.

Integumentary

Skin is warm and dry. Capillary refill takes less than 2 s. No petechiae or rash, purpura or mottling.

Neurological

Patient is alert with no focal neurologic deficits.

**Table 2.** Emergency Department Vital Signs and Examinations Results for Visit #2 Prior to Admission
Blood pressure (mm Hg)	116/79
Heart rate (beats per minute)	137
Respiratory rate (breaths per minute)	16
Temperature (°C)	39.5
Pulse Ox (%)	96% on room air
Weight (kg)	61
Constitutional	Active, in no acute distress. She is well-developed and well-groomed. She is not toxic-appearing.
Head/ears/nose/throat	Normocephalic and atraumatic. Right ear: tympanic membrane, ear canal and external ear normal. Left ear: tympanic membrane, ear canal and external ear normal. Nose: no congestion or rhinorrhea. Mouth: mucous membranes are moist. Pharynx: uvula midline. Pharyngeal swelling and posterior oropharyngeal erythema present. No oropharyngeal exudate or pharyngeal petechiae. Tonsils: 2+ on the right, 2+ on the left.
Eyes	General: visual tracking is normal. Lids are normal. Vision grossly intact. Right eye: no discharge. Left eye: no discharge. Conjunctiva/sclera: conjunctivae normal. Pupils: pupils are equal, round and reactive to light.
Neck	Full passive range of motion without pain, normal range of motion and neck supple. Normal range of motion. No neck rigidity or pain with movement.
Cardiovascular	Rate and rhythm: normal rate and regular rhythm. Pulses: normal pulses. Pulses are strong. Heart sounds: S1 normal and S2 normal. No murmur.
Pulmonary	Pulmonary effort is normal. No respiratory distress. Normal breath sounds. No stridor, decreased air movement or transmitted.
Abdominal	Bowel sounds are normal. There is no distension. Abdomen is soft. Abdomen is not rigid. There is no mass. There is no abdominal tenderness. There is no right costovertebral angle (CVA) tenderness, no left CVA tenderness, guarding or rebound.
Lymphadenopathy	Cervical: cervical adenopathy present. Right cervical: superficial cervical adenopathy present. Left cervical: superficial cervical adenopathy present.
Integumentary	General: skin is warm and moist. Capillary refill: capillary refill takes less than 2 s.
Neurological	Mental status: she is alert and oriented for age. Glasgow coma scale (GCS): eye subscore: 4. Verbal subscore: 5. Motor subscore: 6. No cranial nerve deficit. No sensory deficit.

Table 2. Emergency Department Vital Signs and Examinations Results for Visit #2 Prior to Admission

Blood pressure (mm Hg)

116/79

Heart rate (beats per minute)

137

Respiratory rate (breaths per minute)

Temperature (°C)

39.5

Pulse Ox (%)

96% on room air

Weight (kg)

Constitutional

Active, in no acute distress. She is well-developed and well-groomed. She is not toxic-appearing.

Head/ears/nose/throat

Normocephalic and atraumatic. Right ear: tympanic membrane, ear canal and external ear normal. Left ear: tympanic membrane, ear canal and external ear normal. Nose: no congestion or rhinorrhea. Mouth: mucous membranes are moist. Pharynx: uvula midline. Pharyngeal swelling and posterior oropharyngeal erythema present. No oropharyngeal exudate or pharyngeal petechiae. Tonsils: 2+ on the right, 2+ on the left.

Eyes

General: visual tracking is normal. Lids are normal. Vision grossly intact. Right eye: no discharge. Left eye: no discharge. Conjunctiva/sclera: conjunctivae normal. Pupils: pupils are equal, round and reactive to light.

Neck

Full passive range of motion without pain, normal range of motion and neck supple. Normal range of motion. No neck rigidity or pain with movement.

Cardiovascular

Rate and rhythm: normal rate and regular rhythm. Pulses: normal pulses. Pulses are strong. Heart sounds: S1 normal and S2 normal. No murmur.

Pulmonary

Pulmonary effort is normal. No respiratory distress. Normal breath sounds. No stridor, decreased air movement or transmitted.

Abdominal

Bowel sounds are normal. There is no distension. Abdomen is soft. Abdomen is not rigid. There is no mass. There is no abdominal tenderness. There is no right costovertebral angle (CVA) tenderness, no left CVA tenderness, guarding or rebound.

Lymphadenopathy

Cervical: cervical adenopathy present. Right cervical: superficial cervical adenopathy present. Left cervical: superficial cervical adenopathy present.

Integumentary

General: skin is warm and moist. Capillary refill: capillary refill takes less than 2 s.

Neurological

Mental status: she is alert and oriented for age. Glasgow coma scale (GCS): eye subscore: 4. Verbal subscore: 5. Motor subscore: 6. No cranial nerve deficit. No sensory deficit.

**Table 3.** Emergency Department Visit #2 Laboratory Workup
Test	Result	Reference range
^aGrossly hemolyzed.
Sodium	135	134 - 143 mmol/L
Potassium	6.5^a	3.4 - 5.1 mmol/L
Chloride	108	98 - 108 mmol/L
CO₂	21	21 - 31 mmol/L
Blood urea nitrogen	12	5 - 22 mg/dL
Creatinine	0.53	0.30 - 0.80 mg/dL
Glucose	88	70 - 110 mg/dL
Calcium	8.4	8.9 - 10.4 mg/dL
Anion gap	12.5	5.0 - 18.0 mEq/L
Red cell distribution width	13.1	11.5-14.5%
Streptococcus pyogenes group A PCr throat	Negative	Negative
Urinalysis	Specific gravity 1.032 Glu neg Bili neg Ketone trace Blood 3+ Protein 100 Nitrite neg Leukocyte esterase neg Urine red blood cell 193 Urine white blood cell 4 Urine bacteria 2+ Urine mucus 1+ Squamous epithelial cells 17	1.002 - 1.030 Negative Negative Negative Negative < 20 mg/dL Negative Negative 0 - 5/HPF 0 - 9/HPF None None 0/HPF
Urine culture	No growth

Table 3. Emergency Department Visit #2 Laboratory Workup

Test

Result

Reference range

^aGrossly hemolyzed.

Sodium

135

134 - 143 mmol/L

Potassium

6.5^a

3.4 - 5.1 mmol/L

Chloride

108

98 - 108 mmol/L

CO₂

21 - 31 mmol/L

Blood urea nitrogen

5 - 22 mg/dL

Creatinine

0.53

0.30 - 0.80 mg/dL

Glucose

70 - 110 mg/dL

Calcium

8.4

8.9 - 10.4 mg/dL

Anion gap

12.5

5.0 - 18.0 mEq/L

Red cell distribution width

13.1

11.5-14.5%

Streptococcus pyogenes group A PCr throat

Negative

Urinalysis

Specific gravity 1.032
Glu neg
Bili neg
Ketone trace
Blood 3+
Protein 100
Nitrite neg
Leukocyte esterase neg
Urine red blood cell 193
Urine white blood cell 4
Urine bacteria 2+
Urine mucus 1+
Squamous epithelial cells 17

1.002 - 1.030
Negative
Negative
Negative
Negative
< 20 mg/dL
Negative
Negative
0 - 5/HPF
0 - 9/HPF
None
None
0/HPF

Urine culture

No growth

**Table 4.** Emergency Department Vital Signs and Examinations Results for Visit #3 Prior to Admission
Blood pressure (mm Hg)	90/71
Heart rate (beats per minute)	129
Respiratory rate (breaths per minute)	26 - 35
Temperature (°C)	39.6
Pulse Ox (%)	89% on room air
Constitutional	Active. Not in acute distress. Non-toxic-appearing. Able to speak in full sentences.
Head/ears/nose/throat	Normocephalic and atraumatic. Right and left external ear normal. No congestion or rhinorrhea. Mucous membranes are moist. No oropharyngeal exudate or posterior oropharyngeal erythema.
Eyes	Right eye: no discharge. Left eye: no discharge. Extraocular movements intact. Conjunctiva/sclera: conjunctivae normal.
Neck	Normal range of motion and neck supple.
Cardiovascular	Regular rhythm. Tachycardia present. Pulses: normal pulses. Normal heart sounds.
Pulmonary	Tachypnea and respiratory distress present. No nasal flaring or retractions.
Abdominal	Abdomen is flat. Bowel sounds are normal. There is no distension or tenderness to palpation.
Lymphadenopathy	No cervical lymphadenopathy appreciated on exam.
Integumentary	Skin is warm and dry. Capillary refill takes 2 - 3 s.
Neurological	No focal deficit present. She is alert and oriented × 4. Mood normal. Thought content normal. Judgment normal.

Table 4. Emergency Department Vital Signs and Examinations Results for Visit #3 Prior to Admission

Blood pressure (mm Hg)

90/71

Heart rate (beats per minute)

129

Respiratory rate (breaths per minute)

26 - 35

Temperature (°C)

39.6

Pulse Ox (%)

89% on room air

Constitutional

Active. Not in acute distress. Non-toxic-appearing. Able to speak in full sentences.

Head/ears/nose/throat

Normocephalic and atraumatic. Right and left external ear normal. No congestion or rhinorrhea. Mucous membranes are moist. No oropharyngeal exudate or posterior oropharyngeal erythema.

Eyes

Right eye: no discharge. Left eye: no discharge. Extraocular movements intact. Conjunctiva/sclera: conjunctivae normal.

Neck

Normal range of motion and neck supple.

Cardiovascular

Regular rhythm. Tachycardia present. Pulses: normal pulses. Normal heart sounds.

Pulmonary

Tachypnea and respiratory distress present. No nasal flaring or retractions.

Abdominal

Abdomen is flat. Bowel sounds are normal. There is no distension or tenderness to palpation.

Lymphadenopathy

No cervical lymphadenopathy appreciated on exam.

Integumentary

Skin is warm and dry. Capillary refill takes 2 - 3 s.

Neurological

No focal deficit present. She is alert and oriented × 4. Mood normal. Thought content normal. Judgment normal.

**Table 5.** Emergency Department Visit #3 Laboratory Workup
White blood cell	5.47	4.5 - 13.5 × 10³/µL
Red blood cell	4.43	3.80 - 5.00 × 10⁶/UL
Hemoglobin	12.3	12.0 - 16.0 g/dL
Hematocrit	35.4 (L)	37.0-45.0%
Mean corpuscular volume	79.8	78.0 - 102.0 fL
Mean corpuscular hemoglobin	27.7	26.0 - 32.0 pg
Mean corpuscular hemoglobin concentration	34.8	31.0-37.0%
Red cell distribution width	13.1	11.5-14.5%
Platelet count	< 10 (LL)	150 - 450 × 10³/µL
Mean platelet volume	15.1 (H)	7.5 - 9.3 fL
Automated absolute neutrophil	4.60	1.80 - 7.97 × 10³/µL
Band	13.0 (H)	0-11%
Segmented neutrophils	70.0 (H)	40.0-59.0%
Lymphocyte	13.0 (L)	33.0-48.0%
Monocyte	4.0	0.0-6.0%
Absolute neutrophil manual	4.54	1.80 - 7.97 × 10³/µL
Red blood cell morphology	Normal
C-reactive protein	11.5
Urinalysis	Specific gravity 1.009 Glu neg Bili neg Ketone 1+ Blood 3+ Nitrite neg Leukocyte esterase neg Urine red blood cell 14 Urine white blood cell 2
Urine culture	No growth
Respiratory viral panel (RVP)	Negative	Ref range
Adenovirus PCr	Negative	Negative
Coronavirus 229E PCr	Negative	Negative
Coronavirus HKU1 PCr	Negative	Negative
Coronavirus NL63 PCr	Negative	Negative
Coronavirus OC43 PCr	Negative	Negative
HMPV PCr	Negative	Negative
Rhinovirus/enterovirus PCr	Negative	Negative
Influenza A PCr	Negative	Negative
Influenza B PCr	Negative	Negative
Parainfluenza 1 PCr	Negative	Negative
Parainfluenza 2 PCr	Negative	Negative
Parainfluenza 3 PCr	Negative	Negative
Parainfluenza 4 PCr	Negative	Negative
RSV PCr	Negative	Negative
Chlamydia pneumoniae PCr	Negative	Negative
Mycoplasma pneumoniae PCr	Negative	Negative

Table 5. Emergency Department Visit #3 Laboratory Workup

White blood cell

5.47

4.5 - 13.5 × 10³/µL

Red blood cell

4.43

3.80 - 5.00 × 10⁶/UL

Hemoglobin

12.3

12.0 - 16.0 g/dL

Hematocrit

35.4 (L)

37.0-45.0%

Mean corpuscular volume

79.8

78.0 - 102.0 fL

Mean corpuscular hemoglobin

27.7

26.0 - 32.0 pg

Mean corpuscular hemoglobin concentration

34.8

31.0-37.0%

Red cell distribution width

13.1

11.5-14.5%

Platelet count

< 10 (LL)

150 - 450 × 10³/µL

Mean platelet volume

15.1 (H)

7.5 - 9.3 fL

Automated absolute neutrophil

4.60

1.80 - 7.97 × 10³/µL

Band

13.0 (H)

0-11%

Segmented neutrophils

70.0 (H)

40.0-59.0%

Lymphocyte

13.0 (L)

33.0-48.0%

Monocyte

4.0

0.0-6.0%

Absolute neutrophil manual

4.54

1.80 - 7.97 × 10³/µL

Red blood cell morphology

Normal

C-reactive protein

11.5

Urinalysis

Specific gravity 1.009
Glu neg
Bili neg
Ketone 1+
Blood 3+
Nitrite neg
Leukocyte esterase neg
Urine red blood cell 14
Urine white blood cell 2

Urine culture

No growth

Respiratory viral panel (RVP)

Negative

Ref range

Adenovirus PCr

Negative

Coronavirus 229E PCr

Negative

Coronavirus HKU1 PCr

Negative

Coronavirus NL63 PCr

Negative

Coronavirus OC43 PCr

Negative

HMPV PCr

Negative

Rhinovirus/enterovirus PCr

Negative

Influenza A PCr

Negative

Influenza B PCr

Negative

Parainfluenza 1 PCr

Negative

Parainfluenza 2 PCr

Negative

Parainfluenza 3 PCr

Negative

Parainfluenza 4 PCr

Negative

RSV PCr

Negative

Chlamydia pneumoniae PCr

Negative

Mycoplasma pneumoniae PCr

Negative

**Table 6.** Antibiotic, Antimicrobial and Antiviral Therapy Received During Hospitalization in Chronological Order as Medication Was Added to Treatment Plan
Therapy	Dosage	Route of administration	Frequency	Duration of treatment	Days received
IV: intravenous; HD: hospital day; PRN: as needed.
Ceftriaxone	2 g	IV	Daily	7 days	Admission - HD 3
Ampicillin	2 g	IV	Daily	1 day	Admission - HD 1
Albuterol	2.5 g	Inhaled nebulizer therapy	Every 3 h PRN	14 days	Admission - HD 17
Vancomycin	20 mg/kg	IV	Every 8 h	5 days	HD 2 - 6
Cefepime	2 g	IV	Every 8 h	7 days	HD 3 - 10
Azithromycin	10 mg/kg	IV	Daily	2 days	HD 3 - 4
Azithromycin	5 mg/kg	IV	Daily	3 days	HD 5 - 7
Tocilizumab	600 mg	IV	Daily	1 day	HD 7
Tocilizumab	600 mg	IV	Every 12 h	1 day	HD 8
Hydroxychloroquine	400 mg	IV	Twice daily	3 days	HD 6 - 8
Clindamycin	10 mg/kg	IV	Every 8 h	3 days	HD 7 - 9
Remdesivir	200 mg	IV	Daily	1 day	HD 8
Remdesivir	100 mg	IV	Daily	9 day	HD 9 - 17

Table 6. Antibiotic, Antimicrobial and Antiviral Therapy Received During Hospitalization in Chronological Order as Medication Was Added to Treatment Plan

Therapy

Dosage

Route of administration

Frequency

Duration of treatment

Days received

IV: intravenous; HD: hospital day; PRN: as needed.

Ceftriaxone

2 g

Daily

7 days

Admission - HD 3

Ampicillin

2 g

Daily

1 day

Admission - HD 1

Albuterol

2.5 g

Inhaled nebulizer therapy

Every 3 h PRN

14 days

Admission - HD 17

Vancomycin

20 mg/kg

Every 8 h

5 days

HD 2 - 6

Cefepime

2 g

Every 8 h

7 days

HD 3 - 10

Azithromycin

10 mg/kg

Daily

2 days

HD 3 - 4

Azithromycin

5 mg/kg

Daily

3 days

HD 5 - 7

Tocilizumab

600 mg

Daily

1 day

HD 7

Tocilizumab

600 mg

Every 12 h

1 day

HD 8

Hydroxychloroquine

400 mg

Twice daily

3 days

HD 6 - 8

Clindamycin

10 mg/kg

Every 8 h

3 days

HD 7 - 9

Remdesivir

200 mg

Daily

1 day

HD 8

Remdesivir

100 mg

Daily

9 day

HD 9 - 17