|Year : 2020 | Volume
| Issue : 4 | Page : 157-159
Arterial thrombosis complicating respiratory syncytial virus infection
Vipul Chechani, Himanshu Tadvi, Umesh Bhimani
Department of PICU, SAACHI Children Hospital, Surat, Gujarat, India
|Date of Submission||01-Dec-2021|
|Date of Acceptance||03-Dec-2021|
|Date of Web Publication||22-Dec-2021|
B-203, Surya Palace, City Light, Surat - 395 007, Gujarat
Source of Support: None, Conflict of Interest: None
Respiratory syncytial virus (RSV) is the most important respiratory pathogen of early childhood. Here, we present the case of a 3-year-old child with RSV pneumonia who developed brachial artery thrombosis while on treatment. Child was admitted with pneumonia, confirmed as human RSV on real-time polymerase chain reaction panel that showed gradual improvement on symptomatic treatment. However, on day 9 of illness, he developed cyanosis of left upper limb fingers, with cold extremity distal to elbow. Doppler flow showed complete occlusion of the distal part of brachial artery with absent blood flow in the forearm and palm. Intravenous unfractionated heparin was started along with oral aspirin in the anticoagulant dose. It was continued for 48 h with 6 hourly activated partial thromboplastin time monitoring. Child responded well to conservative management after which he was shifted to low molecular weight heparin followed by oral acenocoumarol. After 6 weeks of anticoagulation therapy, now the vessel has almost fully recanalized.
Keywords: Anticoagulation therapy, peripheral arterial thrombosis case report, respiratory syncytial virus infection
|How to cite this article:|
Chechani V, Tadvi H, Bhimani U. Arterial thrombosis complicating respiratory syncytial virus infection. J Pediatr Assoc India 2020;9:157-9
|How to cite this URL:|
Chechani V, Tadvi H, Bhimani U. Arterial thrombosis complicating respiratory syncytial virus infection. J Pediatr Assoc India [serial online] 2020 [cited 2022 May 25];9:157-9. Available from: http://www.jpai.in//text.asp?2020/9/4/157/333370
| Introduction|| |
Respiratory syncytial virus (RSV) is a common pathogen that infects the respiratory system in children. Usual clinical features are coryza and pharyngitis often associated with fever. Peripheral arterial thrombosis secondary to an RSV infection has not yet been reported. Here, we present the case of a child who was admitted for viral pneumonia and went on to develop a brachial artery thrombosis.
| Case Report|| |
A 3-year-old boy was brought with a history of fever, cough, and cold for 5 days associated with a history of vomiting and decreased oral intake. On admission, child was febrile, heart rate 120/min, respiratory rate 30/min, no pallor, and sick looking. On auscultation, bilateral crepitations and wheezing were heard; rest systemic examination was normal. Chest X-ray showed diffuse haziness bilaterally.
Child was started on ceftriaxone, oseltamivir, and symptomatic treatment after sending a blood culture. Initial blood investigations - Hb 12.0 g/dL, white blood cell 2600, platelet 2.20 lacs, C-reactive protein 0.3 mg/L, and procalcitonin < 0.05 ng/ml. For microbiological diagnosis, seasonal Influenza A H1N1 testing and COVID real-time polymerase chain reaction (RT-PCR) were done-both negative. Respiratory tract infection multiplex RT-PCR panel was sent which detected human RSV. Child had persistent high-grade fever and was irritable but consolable, with increasing respiratory distress. Injection methylprednisolone low dose (2 mg/kg/dose BD) was started. Child showed gradual improvement in terms of decrease in distress and tachypnea.
On day 9 of illness, child developed cyanosis of left-hand fingers. His palm was cold to touch, blanching was present, capillary refill was prolonged. Brachial, radial, and ulnar pulses were not palpable. Hand movement and sensations were normal. SpO2 was not detectable on the standard pulse oximeter on that side. BP was not recordable on left forearm. Child was not dehydrated. No vein was punctured for blood sampling or drug administration, other than on the dorsum of the hand.
| Management and Outcome|| |
Doppler flow study showed complete thrombo-embolic occlusion of left distal one-third of brachial artery and no flow traceable beyond that point in the rest distal arterial system. Proximal left upper limb, right upper limb, and both common carotids had normal Doppler. For thrombus etiology workup, COVID IgG negative, D-dimer normal, international normalized ratio (INR) 1.1, and activated partial thromboplastin time (aPTT) 31. Sickling and antinuclear antibodies were negative, serum homocysteine level was normal. 2D-echocardiography done was also normal. Vascular surgeon was consulted and advised conservative management.
Started injection unfractionated heparin (UFH), loading dose – 80 units/kg f/b maintenance 18 units/kg/h. aPTT was monitored every 6 hourly. Target aPTT was 55–90 s. aPTT did not increase and child was given bolus dose of UFH 50 units/kg and infusion was increased to 20 unit/kg/h. Further heparin infusion adjusted according to aPTT values. Perfusion and pulses began improving and heparin infusion was continued for the next 48 h. After that heparin infusion was tapered and stopped and the child shifted to subcutaneous low molecular weight heparin (LMWH). Given 1 mg/kg s/c twice daily for 5 days f/b once daily dose for the next 10 days. Repeat Doppler flow showed improvement in blood flow in the distal forearm and palm. Child was discharged, and after 15 days of LMWH therapy, child was shifted to oral Acenocoumarol. It was continued for 6 weeks and ecosprin for 4 weeks after which arterial lumen has got almost completely recanalized.
| Discussion|| |
Lower respiratory tract infections are common in children younger than 2 years. In a study by Jain et al. in US among 2222 children with radiographic evidence of pneumonia and with specimens available for bacterial and viral testing, a viral or bacterial pathogen was detected in 1802 (81%), one or more viruses in 1472 (66%), bacteria in 175 (8%), and both bacterial and viral pathogens in 155 (7%). RSV was more common among children younger than 5 years of age than among older children (37% vs. 8%).
The common complications following RSV infection include otitis media, pneumonia, and conjunctivitis. A case of arterial thrombosis from RSV infection has not yet been reported. The clinical signs of peripheral artery occlusion are absent palpable pulses, difference in blood pressure of over 10 mmHg between legs, decreased skin temperature, cyanosis, and prolonged CRT.
Treatment options of acute arterial thrombosis include anticoagulation, thrombolysis, embolectomy, and reconstructive surgery. UFH is frequently used as initial therapy because 70% of TEs resolve without exposing a child to further therapies. Thrombolytic therapy is indicated when an arterial thrombus threatens organ function or limb viability.
Given the short half-life, the use of UFH is preferred for arterial thrombosis occurring in critically ill children with a high risk of bleeding. UFH is loaded at 75 U/kg IV dose given over 10 min, followed by the maintenance dose of 28 U/kg/h for <1 year, and 20 U/kg/h >1 year. Further dose is titrated according to aPTT values [Table 1].
|Table 1: Unfractionated heparin dose adjustment according to aPTT values|
Click here to view
The most important side effect from heparin use in children is bleeding. For minor bleeding, discontinuation of heparin infusion is sufficient. For severe bleeding, reversal of heparin effect by protamine sulfate or blood product may be needed.
As compared to UFH, LMWH have superior bioavailability, a longer half-life, and dose-independent clearance, which results in a more predictable anticoagulant response. LMWH can be administered subcutaneously with minimal laboratory monitoring.
Long-term anticoagulation is achieved by oral anticoagulant drugs. Among them, warfarin is the most widely used drug but newer anticoagulants like Acenocoumarol, Dabigatran, Apixaban, Rivaroxaban, Betrixaban, and Edoxaban are increasingly being used. Because of the long half-lives of the circulating pro-coagulants and pharmacokinetics of warfarin, it takes 5–7 days to reach a therapeutic anticoagulant. INR should be therapeutic before discontinuation of the initial anticoagulant.
For total duration of anticoagulation therapy, no clear guidelines are available but in general it is continued for a total of 6 weeks to 3 months.
| Conclusion|| |
How a virus reacts in a host and how the host responds to it may sometimes be unpredictable. In a case of peripheral arterial thrombosis, timely initiation of anticoagulation therapy with close monitoring decreases the need for invasive procedures such as thrombectomy and helps in preventing potentially limb-threatening sequelae.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Jain S, Williams DJ, Arnold SR, Ampofo K, Bramley AM, Reed C, et al.
Community-acquired pneumonia requiring hospitalization among U.S. children. N Engl J Med 2015;372:835-45.
Wrotek A, Kobiałka M, Grochowski B, Kamińska I, Pędziwiatr K, Skoczek-Wojciechowska A, et al
. (2020) Respiratory Complications in Children Hospitalized with Respiratory Syncytial Virus Infection. In: Pokorski M. (eds) Health and Medicine. Advances in Experimental Medicine and Biology, vol 1279. Springer, Cham. https://doi.org/10.1007/5584_2020_530x
. [Last accessed on 2021 Dec 15].
Ino T, Benson LN, Freedom RM, Barker GA, Aipursky A, Rowe RD. Thrombolytic therapy for femoral artery thrombosis after pediatric cardiac catheterization. Am Heart J 1988;115:633-9.
Law C, Raffini L. A guide to the use of anticoagulant drugs in children. Paediatr Drugs 2015;17:105-14.