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Life Threatening? No
Write-up: Patient is a previously healthy 13 month old boy who presented with respiratory failure, then developed ARDS and multiorgan dysfunction on VA ECMO, requiring vasoactive support and CRRT. Subsequently found to have multiple disseminated viral infections, including HSV, adenovirus, and low level positive CMV and EBV. Suspected immunodeficiency, workup pending. In setting of recent MMR and varicella vaccinations, critical illness, and suspected immunodeficiency, workup for disseminated vaccine strain measles sent at CDC. Positive for vaccine-strain measles from nasopharynx and urine. Patient initially presented with an otitis media on 1/30 and then re-presented with stridor and rapid respiratory failure. Evidence of epiglottic inflammation with "white dots" noted during intubation and cervical & retropharyngeal lymphadenitis. He had a respiratory PCR positive for adenovirus and RSV and serum positive for adenovirus, though not remarkably high level. EBV PCR in serum also low-level positive but serology from OSH suggestive of past infection. I&D of L neck lymphadenitis performed; cultures from lymph node I&D are negative. CT with evidence of developing retropharyngeal phlegmon. Subsequently developed knee lesion which was positive for HSV, HSV PCR from serum shows disseminated HSV at high viral levels. EBV and CMV positive at low levels, also HHV6 positive, likely represent reactivation in setting of severe illness. Based on multiple viral infections, immunology team involved and on DDX are immunodeficiencies such as TLR defects. HLH/MAS was considered and he met some criteria for this; was on anakinra and received intermittent steroid dosing. BAL cytology from 2/14 showed multinucleated giant cells. ETT quantitative RSV level pending. When measles results from NP/urine returned on 2/21, started on oral ribavirin (while pursuing IV ribavirin), high dose vitamin A, and redosed IVIG. HSV level continuing to fall. Unclear of contribution of measles vaccine strain to respiratory presentation; felt to be unclear whether represented prolonged shedding versus true pneumonia/pneumonitis. Further testing at CDC pending including measles IgM and measles PCR on deep respiratory sample.
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