Should I Bronch or Should I Go: The Need for Bronchoscopy in an Immunosuppressed Child with COVID-19

Abstract

Introduction: Flexible bronchoscopy with bronchoalveolar lavage (FB+BAL) is routinely used for diagnostic evaluation in immunocompromised patients with pulmonary infiltrates. However, during the current COVID-19 pandemic, this procedure has usually been deferred in those with suspected or known diagnosis of COVID-19, given the risk of aerosolization and subsequent transmission of SARS-CoV-2 to healthcare personnel. We report the case of an immunosuppressed teenager with persistent fever and progressive respiratory symptoms after an initial diagnosis of COVID-19 in whom the need of FB+BAL represented a clinical dilemma. Description: A 14-year-old female on treatment for relapsed acute lymphoblastic leukemia was diagnosed with SARS-CoV-2 infection by polymerase chain reaction (PCR) in a nasal sample after having a positive household contact. Her symptoms were initially mild until she developed fever, cough, and dyspnea ∼2 weeks after diagnosis. Her laboratory evaluation was notable for lymphopenia and her chest CT revealed extensive lower lobe consolidations with scattered ground-glass opacities (Figure A), prompting hospitalization. Despite broad-spectrum antibiotics, her respiratory status worsened and she eventually required high-flow nasal cannula support. Pediatric pulmonology was consulted for consideration of FB+BAL to rule out opportunistic infections. Her repeat SARSCoV-2 PCR nasal test at that time, done ∼3 weeks after her initial diagnosis, was inconclusive. Because of this, as well as her tenuous respiratory status, it was decided not to proceed with FB+BAL. She then received steroids, remdesivir, and immunoglobulin, with gradual resolution of her hypoxemia. She was subsequently discharged home. Unfortunately, her fever and dyspnea returned ∼1 week after, prompting re-admission. Her repeat SARS-CoV-2 PCR nasal test was positive and her chest CT demonstrated shifting consolidative and ground-glass opacities, now more predominant in the upper and mid-lung fields (Figure B). We then proceeded with FB+BAL, which was unremarkable. Evaluations for a broad range of viral, bacterial, and fungal pathogens were negative, except for positive SARS-CoV-2 by PCR from BAL fluid. Her symptoms slowly improved with supportive treatment, so she was again discharged home. Her SARS-CoV-2 PCR nasal testing ∼2 months after initial diagnosis continued to be positive. Discussion: There is limited evidence regarding the safety and utility of FB+BAL in those with suspected or diagnosed COVID-19, particularly in the pediatric population. This case highlights an immunosuppressed child with prolonged viral shedding and emphasizes that in certain clinical situations FB+BAL may be required for further microbiologic data, especially when illness is protracted, the differential diagnosis is broad, and imaging findings are non-specific for COVID-19.