10-month-old baby with suspected myocarditis after the earthquake in Haiti

A 10-month-old previously healthy baby boy was referred to our hospital with high fever and a convulsion. A second seizure occurred in the emergency-room (with generalized tonic-colonic convulsions, which ceased only after receiving intravenous (IV) Midazolam. A lumbar puncture was performed and cerebrospinal fluid (CSF) was sent for gram stain, smear for cells- both were negative, and culture (laboratory tests that could have been performed in the field hospital laboratory). He was given IV Ceftriaxone for treatment of possible bacterial meningitis. Briefly on he was awake and alert, and the only abnormal finding on physical examination was mild wheezing, for which he was treated with inhaled Salbutamol with a good response. He was hospitalized for continued inpatient care.

The following morning his respiratory symptoms worsened gradually. He became despneic with obvious expiratory wheezes. To treat possible viral induced wheezing or an atypical pneumonia Azithromycin was added to the antibiotic regimen, and he was treated with IV steroids on top of the inhaled drugs. Despite receiving this treatment his respiratory condition deteriorated rapidly with increased work of breathing and decreased oxygen saturation measured by pulse oximetry. He was given oxygen by face-mask, but his saturation fell to 90% with periods of saturation as low as 80%. Chest X-Ray (CXR) revealed bilateral hazy infiltrates, without enlargement of the heart silhouette. Complete Blood Count (CBC) was normal. Blood chemistry revealed a mildly elevated CPK. An ECG showed mild ST-T changes. The working diagnosis was of a viral illness causing myocarditis – alone, or in a combination with respiratory tract infection.

He obviously required intubation and ventilation. But if he was intubated what could have been done next? No referral facility with mechanical ventilation capabilities existed outside the hospital. Due to scarce oxygen supply our ability to ventilate others would be limited.