Breathlessness in a Child Exposed to COVID-19

A 4-year-old boy suffering from celiac disease on gluten free diet and in close contact with a COVID-19 patient for 2 weeks presented with fever 101 degree F, diarrhea and breathlessness with hypoxia. COVID-19 RT PCR and inflammatory markers were negative. There was pneumothorax on right side with lacy bullous pattern on chest x-ray. CT chest showed bilateral cystic lung disease. Lung biopsy showed moderately dense diffuse nodular infiltrates of oval to medium sized Langerhans cells. It also showed CD1a and S100 positivity on immunohistochemistry confirming Langerhans Cell Histiocytosis (LCH). There was no bone, skin, liver, or lymph node affected suggestive of isolated pulmonary LCH. Introduction Pulmonary Langerhans Cell Histiocytosis (PLCH) with few or more systemic involvement is common in adults with smoking as strong association whereas in children 1 to 10 per million is the estimated incidence of all Langerhans Cell Histiocytosis (LCH) cases under 15 years of age.1 It has slight male preponderance (1.2 to 1.4:1).1 Isolated pulmonary LCH is rare and exact incidence is not available. Breathlessness is a feature of both COVID-19 infection and PLCH. However, ground glass appearance is a feature of COVID-19 infection and cystic lung disease is a feature of PLCH.2 We present a confusing case of a 4-year-old boy with exposure to COVID-19 who developed breathlessness but was subsequently diagnosed to have PLCH. Case Report A 4 year old boy suffering from celiac disease on gluten free diet and in close contact with a COVID-19 patient for 2 weeks presented with fever 101 degree F, diarrhea and breathlessness with hypoxia for 5 days. On examination child was 13 kg and had respiratory rate of 45 with room air oxygen saturation of 88%, pulse rate of 110/min, axillary temperature of 1010F and decreased air entry on right side of chest. Rest of the systemic examination was normal. Nasopharyngeal swab for Covid-19 RT PCR done 10 days ago as well as on admission was negative. Hemoglobin was 10.2 gm%, white cell count was 16,370/cumm with platelet count of 725,000/cumm and ESR of 24 mm at end of 1 hour. Chest x-ray was suggestive of right sided pneumothorax with pushed effect on heart while electrocardiogram (ECG) was normal. Chest tube drainage was done for pneumothorax and patient was started on oxygen, intravenous (IV) fluids and IV antibiotics (amoxicillin-clavulanate and amikacin). After chest tube drainage, a repeat chest X-ray showed hyperinflated right lung with lacy bullous pattern (figure 1). Mantoux test and gastric aspirate for acid fast bacilli were negative. CT chest revealed diffuse numerous cysts of variable size, shape and wall thickness in both lung fields with few tiny solid nodules in right lower lobe with generalized ground glass haziness with mild right sided pneumothorax suggestive of PLCH or lymphangioleiomyomatosis. A lung biopsy showed Address for Correspondance: Dr Meghana Phadke, OPD no 2001, new OPD wing, Metro Heart and Super Specialty Institute, Sector 16A, Faridabad 121002, Haryana. India. Email: meghana.sp@gmail.com ©2021 Pediatric Oncall ARTICLE HISTORY Received 13 July 2021 Accepted 20 August 2021