DISCUSSION:
Vertical transmission of the virus may be rare due to low placental
expression of the canonical receptors necessary for viral entry12. However, placentas from infected mothers have
shown thrombotic and vascular changes, which suggests that SARS-CoV2 is
a highly procoagulant infection and even in the absence of fetal viral
infection, it can trigger an inflammatory response, leading to
multiorgan damage 13. There are multiple case reports
of neonates presenting majorly with cardiac manifestations of shock,
arrythmias, thrombosis, Persistent pulmonary hypertension, as well as
respiratory failure, neurological abnormalities and hematological
manifestations 5,6,7,8,9,14. All these neonates had
history of exposure to maternal COVID-19 infection during pregnancy,
positive SARS-CoV2 antibodies and elevated inflammatory and
prothrombotic laboratory markers. In a case series of 20 neonates with
MIS-N, reported by Pawar et al5, they used diagnostic
criteria modified from Centre of Disease Control criteria for MIS-C and
interim guidance from American Academy of Pediatrics to accommodate lack
of fever in neonates and source of primary infection (mother, instead of
the child). The neonate described by us fulfilled these modified
criteria. Coagulation abnormalities and thromboembolic phenomenon are
listed as one of potential complications of MIS-C15.
D-dimer levels have been stated to be the best test for evaluating
hemostatic variations associated with COVID-19 4. Such
thromboembolic phenomena are also reported among infants. In a
retrospective cohort study by Whitworth et al 15, out
of all children aged 0-<21 years admitted with SARS-CoV2
infection or MIS-C, 20 patients were identified with thromboembolism
with an incidence of 6.5% in MIS-C patients, out of which 3 patients
had pulmonary embolism. 1 patient was <1year of age and had
lower extremity deep vein thrombosis. Perveen et al16, reported a neonate born with an ischemic limb to a
COVID-19 positive mother. Although, COVID antibodies were found in the
newborn, the coagulation workup was normal. The thromboembolic event was
thought to be a vascular effect of the COVID infection16. In another case reported by Engert et al7, a moderate preterm infant had petechial bleeds,
intracranial haemorrhage and periventricular leukomalacia with elevated
D-dimer levels and low platelet counts. The authors hypothesised this to
be secondary to maternal hyperinflammatory response following SARS-CoV2
infection during 2nd trimester of pregnancy7. In the case series of 20 neonates, Pawar et al
described one neonate with a cardiac thrombus 5.
Mamishi et al 17 studied the CT findings in 24
children with SARS-CoV2 infection. Atypical findings were seen in 58%
of the patients which included nodular and cavitary lesions. They
suggested that atypical findings may be indicative of disease
progression caused due to cytokine storm 17. The HRCT
in our case showed nodular lesions with central cavitation. In spite of
an extensive investigative work up, we could not find a causal
relationship of the CT scan findings to any of the conditions that could
have caused it like bacterial or fungal sepsis, tuberculosis, congenital
lung anomalies or malignancy 18. Endothelial injury by
SARS-CoV-2 and the hypercoagulability caused by the intense inflammatory
response is capable of causing the PTE 4,11. The
presence of in-utero exposure to COVID 19 virus, raised inflammatory
markers and elevated D-dimer levels lead us to conclude that our case
could have had pulmonary thromboembolic phenomenon as a consequence of
MIS-N which resulted in the rare CT picture of nodular and cavitary lung
lesions. However, due to lack of adequate evidence regarding its use in
neonates with MIS-N, we did not give antithrombotic medications. The
neonate responded to IVIG and had complete recovery of his clinical
symptoms. Due to this favourable response, we chose to not give steroids
as is recommended in MIS-C.
Considering the potential possibility of the pulmonary lesions in our
case to be secondary to MIS-N, we suggest that, clinical and laboratory
evaluation to diagnose thromboembolic complications should be carried
out in all symptomatic neonates exposed to SARS-CoV2 infection. Also,
future research should be planned to study the use of antithrombotic
prophylaxis in neonates exposed to the virus.