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Commentary: “Murder on the Orient Express of pandemic: COVID was found guilty, but was it the murderer?”

Open ArchivePublished:June 26, 2020DOI:https://doi.org/10.1016/j.jtcvs.2020.06.050
      During the COVID-19 pandemic, patients with congenital heart disease may contract the virus. It is easy to accuse the virus, but common hospital complications must not be forgotten: a compelling case.
      See Article page e97.
      In Agatha Christie's novel Murder on the Orient Express, detective Hercule Poirot brilliantly resolves the murder of Mr Ratchett, a kidnapper, and proposes 2 possible solutions. The first is a plausible solution that fits with the scenario and saves the unfortunate group of murderers, who were looking for revenge. The second solution describes what happened but would have sent all of them to jail. The investigators adopted the first solution as the truth to save the entire family from prison.
      Bezerra and colleagues
      • Freire Bazerra R.
      • Meiken Franchi S.
      • Khader H.
      • Romero Liguori G.
      • da Fonseca da Silva L.
      • da Silva J.P.
      • et al.
      COVID-19 as a confounding factor in a child submitted to staged surgical palliation of hypoplastic left heart syndrome: one of the first reports of SARS-CoV-2 infection in patients with congenital heart disease.
      report one of the first Fontan completions in a patient with hypoplastic left heart syndrome who had contracted COVID-19 infection. This case report should be read because it describes all the challenges that our community of congenital cardiac surgeons had to face during this pandemic. The medical evidence so far is that COVID-19 seems to affect children less frequently than adults, although some subgroups may be vulnerable to the most severe form of infection.
      • Lu X.
      • Zhang L.
      • Du H.
      • Zhang J.
      • Li Y.Y.
      • Qu J.
      • et al.
      Chinese Pediatric Novel Coronavirus Study Team. SARS-CoV-2 infection in children.
      • Dong Y.
      • Mo X.
      • Hu Y.
      • Qi X.
      • Jiang F.
      • Jiang Z.
      • et al.
      Epidemiology of COVID-19 among children in China.
      • She J.
      • Liu L.
      • Liu W.
      COVID-19 epidemic: disease characteristics in children.
      In children, SARS-CoV-2 has a typical presentation with fever, cough associated with leukopenia, and lymphopenia.
      • Chang T.H.
      • Wu J.L.
      • Chang L.Y.
      Clinical characteristics and diagnostic challenges of pediatric COVID-19: a systematic review and meta-analysis.
      Multiple small patchy shadows, consolidations, and peripheral interstitial changes are typical radiographic findings.
      • Lu X.
      • Zhang L.
      • Du H.
      • Zhang J.
      • Li Y.Y.
      • Qu J.
      • et al.
      Chinese Pediatric Novel Coronavirus Study Team. SARS-CoV-2 infection in children.
      ,
      • Chang T.H.
      • Wu J.L.
      • Chang L.Y.
      Clinical characteristics and diagnostic challenges of pediatric COVID-19: a systematic review and meta-analysis.
      ,
      • Xia W.
      • Shao J.
      • Guo Y.
      • Peng X.
      • Li Z.
      • Hu D.
      Clinical and CT features in pediatric patients with COVID-19 infection: different points from adults.
      The most striking findings in this case report are the COVID-19 nasopharyngeal swab results and the lung involvement. The patient underwent fenestrated extracardiac Fontan completion and tricuspid valve plasty, and then required reoperation for pacemaker implantation secondary to complete atrioventricular block. Subsequently he developed profound desaturation that triggered an invasive cardiologic assessment and COVID-19 swab, based on a family history suggestive for such infection. Surely this is one of the first cases of a patient with COVID-19 who underwent surgery for congenital heart disease, and the explanation provided easily fits the scenario, but that may not be what actually happened. There may be another explanation, and like Hercule Poirot, we would like to take you through it. The initial chest radiograph showed pleural effusion, and radiography after reoperation revealed multiple pulmonary consolidations, most evident in the upper third of the right lung, which is more typical of bacterial pneumonia than of COVID-19. The elevated C-reactive protein level and leukocytosis with neutrophilia were more likely to be caused by bacterial pneumonia.
      • Cui X.
      • Zhang T.
      • Zheng J.
      • Zhang J.
      • Si P.
      • Xu Y.
      • et al.
      Children with coronavirus disease 2019: a review of demographic, clinical, laboratory and imaging features in 2597 pediatric patients.
      Furthermore, the patient responded to antibiotic therapy with substantial clinical improvement after 1 week. Despite the positive SARS-CoV-2 swab, a bacterial pneumonia may be responsible for the clinical course. Bacterial pneumonia is frequently seen in children with COVID-19, as reported by the Wuhan Children's Hospital.
      • Xia W.
      • Shao J.
      • Guo Y.
      • Peng X.
      • Li Z.
      • Hu D.
      Clinical and CT features in pediatric patients with COVID-19 infection: different points from adults.
      We leave the final interpretation to you, and invite you to enjoy the reading to learn the difficulties they encountered. For us, the learning points missed in this case are (1) the importance of preoperative COVID-19 screening, especially in children, who usually contract the infection from family clusters,
      • She J.
      • Liu L.
      • Liu W.
      COVID-19 epidemic: disease characteristics in children.
      ,
      American Society of Anesthesiologists and Anesthesia Patient Safety Foundation
      The ASA and APSF joint statement on perioperative testing for the COVID-19 virus. April 28, 2020.
      and (2) that in the presence of the COVID-19 pandemic, other possible causes of postoperative lung complications should not be neglected.

      References

        • Freire Bazerra R.
        • Meiken Franchi S.
        • Khader H.
        • Romero Liguori G.
        • da Fonseca da Silva L.
        • da Silva J.P.
        • et al.
        COVID-19 as a confounding factor in a child submitted to staged surgical palliation of hypoplastic left heart syndrome: one of the first reports of SARS-CoV-2 infection in patients with congenital heart disease.
        J Thorac Cardiovasc Surg. 2020;
        • Lu X.
        • Zhang L.
        • Du H.
        • Zhang J.
        • Li Y.Y.
        • Qu J.
        • et al.
        Chinese Pediatric Novel Coronavirus Study Team. SARS-CoV-2 infection in children.
        N Engl J Med. 2020; 382: 1663-1665
        • Dong Y.
        • Mo X.
        • Hu Y.
        • Qi X.
        • Jiang F.
        • Jiang Z.
        • et al.
        Epidemiology of COVID-19 among children in China.
        Pediatrics. 2020; 145: e20200702
        • She J.
        • Liu L.
        • Liu W.
        COVID-19 epidemic: disease characteristics in children.
        J Med Virol. 2020; 92: 747-754
        • Chang T.H.
        • Wu J.L.
        • Chang L.Y.
        Clinical characteristics and diagnostic challenges of pediatric COVID-19: a systematic review and meta-analysis.
        J Formos Med Assoc. 2020; 119: 982-989
        • Xia W.
        • Shao J.
        • Guo Y.
        • Peng X.
        • Li Z.
        • Hu D.
        Clinical and CT features in pediatric patients with COVID-19 infection: different points from adults.
        Pediatr Pulmonol. 2020; 55: 1169-1174
        • Cui X.
        • Zhang T.
        • Zheng J.
        • Zhang J.
        • Si P.
        • Xu Y.
        • et al.
        Children with coronavirus disease 2019: a review of demographic, clinical, laboratory and imaging features in 2597 pediatric patients.
        J Med Virol. 2021; 161: e97-e101
        • American Society of Anesthesiologists and Anesthesia Patient Safety Foundation
        The ASA and APSF joint statement on perioperative testing for the COVID-19 virus. April 28, 2020.
        (Available at:)

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