We report an unusual case of a 2-month-old Ugandan baby boy found to have isolated dextrocardia, who presented with a one-week history of fever (37.8 C), flu, and cough as well as 3 days of difficulty in breathing with pulse oximetry at 85% on room air.
The baby was seronegative for HIV and had no history of TB exposure. The infant was born by spontaneous vaginal delivery and immunization was up-to-date. There was no history of diabetes, cocaine use, or any other drug intake in his mother. This was the 4th born of 4 children all from the same non-consanguineous parents, and all siblings well and healthy.
On examination, the infant was critically ill. He had no pallor, no jaundice, some dehydration, no cyanosis, no edema. He had moderate respiratory distress (subcostal recession, chest indrawing, tachypnea, and grunting) and bilateral basal fine crepitations. Cardiovascular system examination showed tachycardia at 148 beats/minute, but a regular and full volume pulse. There was cardiac dullness on his right side, and heart sounds 1 and 2 were heard, best on the right hemithorax with the apex beat best located in the 5th right intercostal space, and neither a gallop rhythm nor murmur. Abdominal examination revealed no palpable organomegaly but had dullness on percussion in the right upper quadrant and tympanic note over the left hypochondrium.
The infant was COVID negative, malaria slide showed no plasmodium parasites, he had a normal white blood cell count, hemoglobin but raised platelet count of 727,000 cells/microliter. The abdominal scan revealed a normal situs solitus however the left renal fossa was empty with the left kidney noted to be in the lower abdomen at the pelvic space, but normal in size, shape, and echogenicity.
A chest X-ray confirmed a right-sided cardiac shadow and the cardiac apex pointing to the right, but no cardiac silhouette enlargement. The mediastinum was central, liver shadow on the right consistent with situs solitus, and right hemidiaphragm presenting at a higher level compared to the left. Heterogeneous opacities in the upper and middle left lung zones and clear pleural spaces (Figure 1).
Echocardiography showed D-loop ventricular morphology with a right cardiac axis and the ventricular apex to the right. Also, a tiny patent ductus arteriosus with a moderate left to right shunting, and a stenotic superior- and inferior-vena caval inflow was noted at the right atrial junction, though no interventricular or interatrial septal defect. However, he had a normal visceral situs, and concordant atrio-ventricular-arterial (AVA) connections (Figure 2).
The baby was managed on Oxygen therapy by low flow nasal prongs at 3 liters/minute, started on Intravenous (IV) Ceftriaxone-Sulbactam 384 mg once daily, IV Amikacin 36 mg once daily, IV furosemide 9 mg stat dose then 5 mg twice daily, Tablets Zinc 10 mg once daily, IV Hydrocortisone 30 mg thrice daily, and Nasogastric tube feeding.