Severe neonatal COVID-19: Challenges in management and therapeutic approach

Abstract

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the etiological agent of coronavirus disease 2019 (COVID-19), may manifest as a life-threatening respiratory infection with systemic complications. Clinical manifestations among children are generally less severe than those seen in adults, but critical cases have increasingly been reported in infants less than 1 year of age. We report a severe case of neonatal COVID-19 requiring intensive care and mechanical ventilation, further complicated by a multidrug-resistant Enterobacter asburiae super-infection. Chest X-rays, lung ultrasound, and chest computed tomography revealed extensive interstitial pneumonia with multiple consolidations, associated with persistent increased work of breathing and feeding difficulties. SARS-CoV-2 RNA was detected in respiratory specimens and stools, but not in other biological samples, with a rapid clearance in stools. Serological tests demonstrated a specific SARS-CoV-2 antibody response mounted by the neonate and sustained over time. The therapeutic approach included the use of enoxaparin and steroids which may have contributed to the bacterial complication, underlying the challenges in managing neonatal COVID-19, where the balance between viral replication and immunomodulation maybe even more challenging than in older ages.

Keywords: COVID-19; interstitial pneumonia; neonatal sepsis; neonates; severe acute respiratory syndrome 2.

Figure 1

Chest X‐ray (CXR) on day of life (DOL) 12, DOL 16, and DOL 26. On DOL 12 bilateral lung opacities, particularly in the right field. On DOL 16 improving of the CXR, with increased interstitial markings and persistent opacities on the basal field of the right lung. On DOL 26 extensive bilateral lung opacities and consolidations with prevalent involvement of the paracentral fields

Figure 2

Lung ultrasound was performed scanning the lung in 14 different areas (three posteriors, two lateral, and two anterior). On day of life (DOL) 12 showing B lines and pleural irregularities, suggesting interstitial pneumonia; on DOL 26 showed a consolidation area that reached the pleura, appearing as inhomogeneous ipoechoic area, with irregular, blurred, and indistinct edges, and with lenticular echoes inside, representing air trapped.

Figure 3

Chest computed tomography (CT) scan on day of life (DOL) 45 showing extensive consolidations with ground glass appearance involving the medium and posterior fields of both lungs, without the involvement of the anterior fields

Figure 4

Summary of the clinical, diagnostic and therapeutic features of the present case. Inflammatory markers: C reactive protein (CRP) max value 31 mg/dL; interleukin‐6 (IL‐6) max value 418 pg/ml; ferritin max value 1275 ng/mL; D‐dimer max value >35 mg/L