ABSTRACT

The Coronavirus disease-2019 (COVID-19) in children is more likely to be asymptomatic or to have mild-to-moderate symptoms; however, severe cases have also been reported. A 10-year-old boy previously diagnosed with pontocerebellar hypoplasia presented with respiratory distress after 2 days of fever. He underwent tracheal intubation. He was COVID-19 positive. On day 10, a cystic area was observed in his chest radiography and thorax computer tomography also showed a thick-walled pulmonary abscess. Percutaneous empyema drainage was performed. On day 20, an open surgical tracheotomy was performed. On day 25, the percutaneous drainage catheter was removed. On day 55, he was discharged on the home ventilator and his chest radiography was normal. Children with COVID-19 may develop a pulmonary abscess secondary to superinfections during intensive care follow-up.

Introduction

Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) causes Coronavirus disease-2019 (COVID-19) and has caused substantial morbidity and mortality in adults. Although children with COVID-19 are more likely to be asymptomatic or have a mild to moderate disease course, severe cases were reported (1). Here, we present a child who had a pulmonary abscess associated with superinfection after COVID-19 pneumonia.

Case Report

A 10-year-old boy, previously diagnosed with pontocerebellar hypoplasia, developed bilateral femoral fractures after falling off. His both legs were placed in a cast and he was discharged on the same day. Two days later, he presented with respiratory distress and fever ongoing since discharge. He was transferred to our pediatric intensive care unit due to his worsening dyspnea/hypoxia and underwent tracheal intubation. On physical examination, he was unconscious and in poor general condition. His blood pressure was 102/63 mmHg, heart rate was 142/min, body temperature was 38 °C, SpO₂ was 79%, and respiratory rate was 25/min. Chest examination revealed a reduced chest expansion, bilateral widespread crackles, and decreased breath sounds. His chest X-ray and computed tomography (CT) revealed diffuse ground-glass opacity bilaterally and peripheral zone consolidation (Figure 1). SARS-CoV-2 reverse transcription-polymerase chain reaction (RT-PCR) was positive on the nasopharyngeal swab. Laboratory parameters are shown in Table 1. Favipiravir, ceftriaxone, and azithromycin were initiated. He also received intravenous immunoglobulin (immunoglobulin G: 300 mg/dL) therapy. He required invasive mechanical ventilation for 10 days. On day 10, a cystic area was observed on his chest X-ray and thorax CT revealed a thick-walled pulmonary abscess accompanied by a consolidation and atelectasis zone in the lower lobe of the right lung (Figure 1). Percutaneous empyema drainage was performed by interventional radiology. His antimicrobial treatment was switched to vancomycin, meropenem, metronidazole, and liposome amphotericin B. On day 20 of intubation, an open surgical tracheotomy was performed. All of the bacterial cultures (hemocultures, tracheal aspirate, urine, and abscess drainage fluid), aspergillus serology, and antigen were negative. On day 25, the percutaneous drainage catheter was removed. On day 55, he was discharged on the home ventilator and his chest radiography was normal. The written informed consent to publication has been obtained from the parents on behalf of the patient.

Discussion

We presented a 10-year-old boy who developed a pulmonary abscess that had an air-fluid level, associated with superinfection after COVID-19 pneumonia. Our patient was immobilized and had poor oral hygiene. Superinfections and co-infections have been reported associated with COVID-19 during the pandemic. The study by Garcia-Vidal et al. (2) described the epidemiology and outcome of co-infections and superinfections accompanying hospitalized patients with COVID-19. In this study, co-infection with COVID-19 was uncommon and mainly related to bacterial infections. The most common bacteria isolated were S. pneumoniae and S. aureus. Although superinfections were rare, they had a worse outcome. The most frequently isolated bacteria were P. aeruginosa and E. coli. Our patient received antibiotic therapy in the pediatric intensive care unit admission; therefore, we did not isolate a pathogenic bacterium.

Renaud-Picard et al. (3) reported a 59-year-old woman with a pulmonary abscess. The case was the only COVID-19-associated pulmonary abscess reported in the literature so far. This case developed a pulmonary abscess while she was SARS-CoV-2 RT-PCR negative on nasopharyngeal swab on admission and 24 days later. Our patient developed a giant pulmonary abscess on day 10 of hospitalization while SARS-CoV-2 RT-PCR was still positive. Abscesses occurring in different regions have been reported during the COVID-19 pandemic (4,5). We think that our case report holds significance since it is the first child in the literature to have a pulmonary abscess linked to COVID-19.

We observed a superinfection of COVID-19 pneumonia. The reason for the development of a pulmonary abscess in our patient may be inadequate oral care and low immunoglobulin levels. The widespread use of antibiotics in COVID-19 pneumonia may exacerbate antimicrobial resistance and may increase morbidity and mortality.