Covid-19 in a Child with Epilepsy in the Intensive Care Unit: Case Report

Background: This is a good case example in terms of explaining the effect of covid-19 on children with chronic diseases neglected in the pandemic and the nursing practices in these patients. Case presentation: Case; 5.5-year-old girl diagnosed with epilepsy and Covid-19, the general condition of the patient is poor, as a symptom of the disease, fever, diarrhea, common rales, tachypnea, cough, burning in the throat, respiratory distress, low saturation, convusion, decreased speech, decreased vision, walking has been found to have suffered from weakness and weakness. The main diagnoses and interventions; Case Management: Oxygen was started to be given immediately by connecting to a high flow oxygen (HFNC) device. The patient was consulted with infection, neurology, and metabolism experts. Covid-19 treatment: 0.2 mg/kg Dekort 1x, 2gr / kg IVIG, favipiravir, Kaletra, and clean as well as for the treatment of infection: meropenem, vancomycin, amikacin, fluconazole, Cipro was started, antiepileptics continued as used at home. Case Outcome: The case had to receive treatment and care in the intensive care unit. Almost all symptoms of covid-19 were observed in our patient. Conclusion: In addition, an increase in syncope with epilepsy was observed and the patient's gait was disturbed. During the treatment and care process, the patient's isolation from her family, entering a complex environment such as intensive care, uncertainty about the treatment process, and fear of death caused the patient and the family to experience anxiety.


Introduction
The coronavirus  infection that emerged in Wuhan, China in December 2019 has affected the whole world. The spread of the disease by droplets caused it to spread rapidly. The rapid spread has caused the number of infected people to exceed expected. [10,20]. A short while later, in March, the coronavirus (Covid - 19) infection was declared as a pandemic epidemic by WHO [20].  belongs to the same group of viruses that cause Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) [11,21]. The virus causes severe acute respiratory infections and progresses asymptomatic, mild or severe symptomatic. [11,22]. The first case was reported on 11 March 2020 Turkey. As the number of cases increased, various measures began to be taken, and protective measures against the virus continue to be taken. As of October 17, 2020, the total number of reported deaths in the world is 1099586, case number, 39,023,292, and the total number of cases reported in Turkey is 2.12 Mn 19.371 deaths (Turkish Ministry of Health, 2020). Pandemics that remind people of the reality of death can affect people's psychological health quite negatively. Factors such as staying at home continuously in order to protect against the epidemic, the decrease in social relations, when the epidemic process will end or the factors affecting this process may be unknown [18].
In addition, children with additional chronic diseases are in danger not only in terms of Covid-19 infection but also with the disruption of the management of their chronic diseases. For this reason, the management of chronic diseases gains importance during the pandemic period. Although there are differences in the reasons for [14,15]. In general, the effects of SARS-CoV-2 on the CNS may be in the form of direct neurological involvement, worsening of the preexisting neurological picture, and increasing sensitivity to neurological involvement that will occur due to other reasons or immune-mediated. Since scientific evidence has been obtained that this infection may be responsible for neurological involvement and neurodegenerative conditions in children infected with Covid-19, these children should be closely monitored neurologically [7]. In addition, there is no clear information revealing the effect of Covid-19 on children with epilepsy. For this reason, we aim to share up-todate information that will constitute a source for the literature and to convey the nursing care process of this case with the case presentation we will present.

De-identified patient-specific information
The patient is 5.5 years old, female, mother and father are unrelated, lives in a nuclear family with 3 siblings. The family lives in a village.
The patient was diagnosed with epilepsy at the age of 2 and is using Keppra and depakine suspension.

Primary concerns and symptoms of the patient
The patient, who had no seizures for 1.5 years, started to have seizures at frequent intervals in the last week and applied to the emergency department with fever, weakness, difficulty in speaking, sore throat, inability to walk, decreased vision, cough, diarrhea, vomiting, and respiratory complaints.

Medical, family, and psycho-social history including relevant genetic information
In the emergency room, chest radiography was taken, when suspected, lung tomography was taken and the PRC swab was sent and the patient was taken to the isolation room. The patient was taken to the intensive care unit with the diagnosis of Covid-19 + Lung involvement and ARDS due to the ground glass image in the lung tomography ( Figure 1), tachypnea, diffuse rales in the lung, PCR-test positivity (Table 1), and low saturation value and blood gas values not within normal limits. Oxygen was started to be given immediately by connecting to a high flow oxygen (HFNC) device. The patient was consulted with infection, neurology, and metabolism experts.

2-Nutrition and Metabolic Status:
Height: 110cm, weight: 18kg, the percentile is around 25 % within normal values. There is no problem with growth and development. The child was fed with a nasogastric while in intensive care. She refused to eat the hospital's food when she was taken to the ward and the family started to bring themself the meals. There were wounds in her mouth due to a longterm lack of oral feeding and a high fever.

3-Excretion:
She stated that although the child had toilet training while in intensive care, she was troubled by the bonding of the diaper.
A urinary catheter is attached to monitor urine output. Since the patient has diarrhea, the diaper is followed up and there is deterioration in the fluid electrolyte values. In addition, they have frequent sweating due to high fever.

4-Activity Exercise:
Since the child is very active in intensive care, her hands are tied while receiving treatment with HFNC. When he was taken to the service, the patient was not physically exercised because he was active, but there were problems in his walking due to his last seizure. She is taking HFNC treatment because she has shortness of breath. There is shortness of breath, sweating, and cough increasing with effort. In addition, there are limitations in her movements due to muscle pain and shortness of breath. She does not exercise because she is constantly moving in the service.

5-Cognitive perception:
When the sick child came to intensive care, there was a loss of consciousness. He had syncope, serious lefthand trouble. After the treatment period, she started to recover and examine the environment. However, the brain tissues had hallucinations and amnesia due to oxygen loss. He was able to maintain his orientation when he was taken to the service. He communicated with his family and environment.
6-Sleep-rest: She stated that she was disturbed by the sound of the devices and the voices of other patients in the intensive care unit and could not sleep. She also stated that she is used to sleeping with her parents. She stated that she had a hard time crying because they were not. Children in this age range are expected to experience separationrelated anxiety, mourning, and longing for them. might faint, so she did not play in the park without her family or someone to accompany her.

2-Nutrition and Metabolic Status:
The child was fed with a nasogastric while in intensive care. The height and weight of the patient were followed up. whether the necessary nutrition was provided or not was checked. In order to protect the patient from infections, attention was paid to the cleaning of the feeding catheter.
probe changes were made in accordance with antiseptic rules. Before feeding, residue control was made, stomach content was monitored.
After the patient left the breathing apparatus, normal nutrition was started. the nutrition of the patient was supported. she could not feed herself yet. Electrolyte values of the patient remained normal.

6-Sleep-rest:
In order to increase the sleep quality of the patient, attention was paid today and night sleep. An environment that is as quiet and less light as possible is created during night shifts. Attempts that could cause pain in the patient were reduced. painful procedures were usually carried out during the day with the support of the family.

7-Self perception:
The patient was left behind due to the payoffs of his chronic illness compared to his peers. Therefore, the patient was supported in fulfilling the patient's eating and toilet habits. In addition, she was supported to perform age-specific behaviors on her own and the family was informed about this situation. The family was observed in terms of the perception of fragility. In order to prevent the occurrence of this sensitive situation in the family, the follow-up of the child was shared with the parents, the communication of the child was increased.

8-Role and relationship:
The patient could not fully understand the concepts such as separation from the family due to the age period, illness, and death. in this case, it caused him extreme anxiety.
Meetings with his family were supported. The family was taken in so that the patient could talk to the family on the phone whenever he wanted and the family was outside, even to calm down the child.

10-Coping:
The intensive care experience of the child, the concepts of being away from the family, illness, and death have been very difficult for him. The difficult situations he had lived through were explained in a language he could understand by remaining calm, and every question he asked was tried to be answered patiently and the child's concerns were tried to be relieved.

11-Beliefs and values:
The child has conceived of his situation as the punishment for him. He wanted his family to abandon him and God back them. In order to support the family, the patient was contacted with the family at any time, and other patients whose disease affected everyone was explained by giving examples.
Some problems experienced by the patient and her family during this period were identified, and nursing diagnoses were determined for these problems.

Follow-up and Outcomes
The patient's blood gas values, vital signs, and the ground glass appearance in the lungs returned to normal. covid -19 positivity in the patient ended. The patient was discharged after receiving the epilepsy treatment in the neurology service and after the necessary information was provided.

Discussion
Children of all age groups mostly had mild respiratory symptoms such as fever, dry cough, and fatigue or it was determined that the children were asymptomatic. In addition, bronchial thickening and groundglass opacities were the most common radiological findings, and these findings were also reported in asymptomatic patients.

Patient Perspective
The patient returned to his normal routine and was discharged. While the patient and his family were being discharged, he said goodbye and thanked his nurse and medical team. During the discharge, the patient was celebrated with applause for defeating covid-19. The smiling face of the patient encouraged the medical team in this war. the routine follow-up of the patient continues and continues to communicate with the healthcare team.

Informed Consent
Because a child is young for approval, we were made approval from her relatives. A case report was made by obtaining approval from the relatives of the patient who was positive for Covid-19. The data were collected through the statements of the family, the information given by the specialist doctor and nurses working in the intensive care unit about the treatment, care process, and observation.

Conflıct of Interest Statement:
The authors report no actual or potential conflicts of interest.