Coronavirus 229E with Rhinovirus co-infection causing severe acute respiratory distress syndrome with thrombotic microangiopathy and death during Covid-19 pandemic: lessons to be learnt

Abstract

We report on a 3-month old infant male who had a seven-days history of fever and rhinorrhea associated with wheezing prior to his death, during the Covid-19 pandemic. Viral testing for Covid-19 (SARS-CoV-2) was negative but was positive for Coronavirus 229E and RP Human Rhinovirus. The pulmonary histological examination showed diffuse alveolar damage along with thrombotic microangiopathy affecting alveolar capillaries. Also, thrombotic microangiopathy was evident in the heart, lungs, brain, kidneys and liver. Thrombotic microangiopathy is a major pathologic finding in Acute Respiratory Distress Syndrome and in the multiorgan failure. This is the first report that illustrates thrombotic microangiopathy occurring in lung, heart, liver, kidney and brain in Acute Respiratory Distress Syndrome with Coronavirus 229E with Rhinovirus co-infection. The clinical presentation and pathological findings in our case share common features with Covid-19.

Keywords: Coronavirus infections; Respiratory Distress Syndrome, Adult; Rhinovirus; SARS virus; Thrombotic Microangiopathies.

Figure 1. Gross view of the larynx, trachea, left and right lungs, the latter with consolidation. Note the absence of signs of aspiration.

Figure 2. Photomicrographs of the lung and myocardium. A – Lung showing diffuse alveolar damage with denudation of epithelial cells, and hyaline membrane formation (arrow); B – Lung with focal areas with moderate infiltrate of lymphocytes within the alveoli (arrow); C – Thrombotic microangiopathy present in alveolar capillaries (arrow) and smaller pulmonary vessels; D – Thrombotic microangiopathy present in the myocardium. Here arrow points to microthrombi within a small vessel of the myocardium.

Figure 3. Photomicrographs of the kidneys and liver. A – Kidney showing microthrombi within glomerular capillaries (arrow) (H&E X 400); B – Microthrombi within portal vessels (arrow) and sinusoids of the liver.