Case presentation
A 5-year-old child with CAH presented to the emergency department with
fever and chills, abdominal pain, recurrent vomiting, cough and loss of
appetite since 5 days ago. He was a term baby with a history of CAH (21-
hydroxyprogesterone deficiency) from infancy and was operated for it and
was on treatment with corticosteroid (Hydrocortisone 10mg ½ tablet
t.i.d). He had two brothers with CAH who were about 21 years old and 23
years old with normal development. His parents reported symptoms of
cough and a runny nose for a few days prior to this. At presentation, he
had tenderness in right upper quadrant in abdominal examination. He had
hypotension (BP: 75/pulse) and tachycardia (HR=130/min) and hypoxemia
(85%) with tachypnea (RR=52/min). He had no symptoms of meningismus. He
had no dermatological involvement. His eyes and throat were normal in
exam. In right lung he had decrease in lung sound.
Pediatric endocrinology was consulted and according to his sepsis,
stress dose of hydrocortisone (100 mg/m2) was started. Oxygen therapy
was started and portable chest X-ray was done. It showed lower lobe
pneumonia in right lung with little pleural effusion which was confirmed
by chest sonography (consolidation was seen in lower and middle lobes of
right lung) (Figure1). Antibiotic therapy for him was started by
Ceftriaxone and Clindamycin. Vitamin C, famotidine and zinc gluconate
was started. He had a rise in creatinine (1.5 mg/dL) in his laboratory
exam with high CRP (66 mg/dL) with no leukocytosis or lymphopenia. His
other exam was in normal range. He received a normal saline bolus and
was then placed on maintenance IV fluids. His echocardiography showed no
pericardial effusion or low ejection fraction. According to
immunosuppressive status of patient (under treatment with long-term
corticosteroid) and pandemic of COVID19, PCR test for detection of
SARS-CoV-2 was sent. After 48 hours his CBC showed lymphopenia (ALC:
720), rise in CRP (97 mg/dL) and SARS-CoV-2 was detected on
nasopharyngeal swab. Blood culture, urinalysis, and urine culture were
negative. In his abdominal sonography which was done for his recurrent
vomiting, it showed two small stone in right kidney (the largest was 3.5
mm in size) and several lymphadenitis (the largest lymph node was 5cm in
size). After 24 hour of treatment, his hypoxemia was cured and he did
not dependent on oxygen. His tachypnea and respiratory distress was
resolved. He received acetaminophen and ondansetron for abdominal pain
and vomiting. According to hypotension, inotrope (Dopamine 5μg/Kg/min)
was started and patient was transferred to PICU for better monitoring
and isolation. His antibiotic was changed to Meropenem and Vancomycin.
After 72 hours of admission, his inotrope was discontinued and his fever
and vomiting was stopped. Over the course of his admission, he remained
hemodynamically stable. He fed appropriately and did not require
respiratory support. After 7 days of admission, his vital sign was
stable and he had no complaint of vomiting, cough or abdominal pain and
his lymphopenia was recurred. He was discharged by advice in quarantine
for 2 weeks, oral antibiotic therapy and stress hydrocortisone dose was
weaned down to his home regimen. He was followed on the day 14 after
admission in clinic and had no complaint and his CXR shows improvement
of pneumonia without effusion.