The case is a 2 year old girl who was referred to our Emergency Paediatric Unit from a Secondary Health Care Centre with complaints of chest, neck and facial swellings 3days after she was managed and discharged for Measles from the referring hospital. She did not receive measles vaccination but had oral polio vaccine ( OPV) during the supplementary immunization exercise. She had contact with other children who had measles infection among members of her household. She was not exclusively breastfed, and her complementary diet was poor. Her current diet was mainly carbohydrate for which she poorly tolerates with the onset of the illness. The parents are of low socio-economic class that engage in subsistence farming.
On examination, she was acute on chronically ill-looking, wasted and restless, mildly pale with hypo-pigmented hair, angular stomatitis and desquamating skin lesions on the trunk and upper limbs. She had massive peri-orbital, neck and chest wall swelling with subcutaneous crepitus extending down to the abdominal wall (Fig. 1). She was afebrile with no significant lymphadenopathy. Her weight was 54% of the expected with a Z-score of <-4SD. Her Respiratory system examination shows a rate of 28cpm with resonant chest percussion and oxygen saturation (SPO2) of 99%.
A provisional diagnosis of convalescent measles complicated by subcutaneous emphysema on background severe acute malnutrition was made.
Complete blood count shows WBC of 10.2 103/l with relative leukocytosis, Haematocrit of 28%, and normal platelets counts. Retro-viral screening for HIV and reverse transcriptase PCR for COVID-19 were negative. Blood sample for Bact/Alert was positive and gram stain showed gram positive cocci. Sub-culture yielded moderate growth of streptococcus spp after 48 hours of incubation, sensitive to Erythromycin, Gentamicin and Linezolid acid but resistant to Vancomycin. Abdominal ultrasound scan revealed bilateral grade I renal parenchymal disease. Arterial blood gases show pH of 7.56, pCO2 of 51.1mmHg, pO2 of 28mmHg and HCO3 of 46.3mmol/l lactate of 2.02mml/l. E/U/Cr showed potassium of 2mmol/l and ionized calcium of 1mmol/l. Chest X-ray reveled extensive soft tissue swelling in the neck and axillary region with areas of translucency. The lung fields were clear except for the perihilar opacities (Fig. 2).
Patient was reviewed by the Ophthalmologist, Otorhinolaryngologist, Paediatric Surgeon and Plastic Surgeon. She was initially placed on I.V Cefuroxime but changed to I.V Ampicillin/Sulbactam and Gentamicin, following blood culture result. She also had tabs Zinc, Vitamin A and nutritional support with therapeutic milk (F75 and F100). She was transfused with packed cells when the PCV dropped to 20%. She Had corrections for both potassium and calcium derangements. Supplemental oxygen was also administered. Her condition initially improved within 48hrs after the change of antibiotic necessitating the consideration of gas producing organism as the cause of the emphysema. However, on the 16th day of admission her condition worsens. She had subcutaneous fenestrated 18G cannular insertion on the supraclavicular area, with the open end attached to a suction machine set at a pressure of 125mmHg to create a negative pressure. She improved initially for 5 days but the swelling reaccumulates afterwards. She had closed thoracostomy tube drainage inserted at the right triangle of safety and an underwater seal bottle with intermittent negative pressure drainage on the 28th day of admission with complete resolution of the subcutaneous emphysema within ten days. She had remarkable improvement with healed ulcers, acid - base and electrolyte corrected and gained weight. Over the forty-seven days on admission, most of the care was funded by the volunteered staff, social welfare unit and faith based Non-Governmental Organization since the parents are of low socioeconomic class. Figure 3 shows the time course for the patient while on admission.