A 5-year-old female child was transferred from a local hospital for further management after 5 weeks of inpatient treatment with oxygen, parenteral broad-spectrum antibiotics, and anti-tuberculous (TB) drugs for non-resolving pneumonia and suspected pulmonary tuberculosis. Her symptoms started acutely with high fever, cough, and difficulty of breathing 8 weeks before admission. After 4 weeks of treatment, the fever subsided but the respiratory distress and hypoxemia persisted for which treatment for pulmonary tuberculosis was initiated empirically without strong clinical or laboratory/imaging evidence. Finally, the child was referred for better workup and management after she failed to respond to the anti-TB.
Physical examination at presentation demonstrated an acutely sick and emaciated child who had significantly increased work of breathing (WOB) and was hypoxemic (SPO2 = <70% at room air and 90-94% on 6-7 L/min facemask). She had crackles and decreased aeration over the left lower posterior chest with significantly decreased air entry over the right hemithorax and the remaining part of the systemic exam was unremarkable except for presenting as a grossly emaciated child.
PA chest X-ray (CXR) revealed a significant right pneumothorax (Figure 1); other investigations including CBC, COVID-19 and HIV test were unremarkable except for a mildly elevated ESR (30 mm/hr) but negative C-reactive protein.
Her antibiotics and anti-TB treatment were continued, and a chest tube was inserted for pneumothorax. Within the first hour of drainage, she started to have worsening cough and increased WOB with worsening hypoxemia. A repeat CXR 4 hours after her clinical deterioration showed an expanding but opacified right lung and worsening opacity of the left lung suggestive of bilateral pulmonary edema (Figure 2).
The patient was then started on treatment for severe pulmonary edema with diuretics, and noninvasive ventilation (NIV) without success for >12 hours, subsequently requiring admission to the PICU. She was put on mechanical ventilation with PRVC mode and prior management was continued but she failed to respond and died after 16 hours of PICU stay from therapy-resistant and worsening pulmonary edema.
To the best of our knowledge, this is the first case of RPE reported from Ethiopia. This case report aims to alert clinicians to this rare but potentially fatal complication following drainage of significant pleural effusions and pneumothorax, both of which are fairly common for the practicing pediatrician, especially in low- and middle-income countries (LMICs).