LAUSR

Introduction: Disseminated Enterovirus (EV) is rare, most commonly occurs in neonates, and can be accompanied by septic shock and Multiple Organ Dysfunction Syndrome (MODS). We present a case of disseminated neonatal EV septic shock with MODS requiring inhaled nitric oxide (iNO) for pulmonary hypertension (pHTN), complicated by methemoglobinemia (metHb) and continuous renal replacement therapy (CRRT) for acute kidney injury (AKI). Description: A 4-day-old term 3.5kg male was admitted for a fever of 38.1 C. On hospital day (HD) 1, he became persistently tachycardic, prompting transfer to the PICU. Initial labs were notable for EV presence in the CSF, with subsequent detection in the blood. On HD2, he acutely decompensated with systolic blood pressure < 40mmHg and loss of pulse oximetry, warranting initiation of an epinephrine infusion and emergent intubation. Echocardiogram was notable for moderately depressed left ventricular (LV) function prompting addition of a calcium chloride infusion for inotropy. Repeat echo on HD3 demonstrated improved LV function, but evidence of severe pHTN. iNO was initiated at 20ppm, however after five days of iNO he developed metHb so was transitioned to IV sildenafil with successful resolution of metHb. Concurrently, he had ongoing MODS with systemic fluid overload and worsening respiratory failure in the context of AKI. Due to his size, placing a 7F catheter percutaneously at bedside was impractical. To facilitate effective CRRT, general surgery placed a tunneled 6F central venous catheter in the right internal jugular vein on HD3. He required 16 days of CRRT due to persistent oliguria despite reaching dry weight by day 10. Discussion: The care of this 3.5kg patient presented key challenges. While the incidence of metHb secondary to iNO is low, it has been associated with high concentrations of iNO or prolonged use in neonates. This complication requires careful surveillance to allow prompt identification and management. Additionally, historically catheters smaller than 7F were not routinely used for prolonged CRRT due to difficulties achieving adequate flow rates and concern for limited circuit survival. Recently 4-5F catheters have been found to be effective when used with a proportionally small pump. Our patient maintained a 6F catheter throughout his run on CRRT.