Title of Case:

CASE REPORT: SEVERE ACUTE PULMONARY COVID-19 IN A TEENAGER POST AUTOLOGOUS HAEMATOPOIETIC STEM CELL TRANSPLANT

Background:

Pulmonary COVID-19 infection in children, including immunocompromised, is generally described mild. A small proportion of children will become critically ill due to (cardio)respiratory failure, and require intensive care treatment.

Case Presentation Summary:

We report a teenager with Hodgkin’s lymphoma who acquired SARS-CoV-2 (PCR positive) on the day of her autologous stem cell transplant and developed acquired respiratory distress syndrome (ARDS) on day+10. Initially she received remdesivir, dexamethasone, and toculizumab for COVID-19 with sepsis cover. Following further clinical pulmonary deterioration she was intubated and ventilated, put on venovenous ECMO, and received a tracheostomy. Given persistent low SARS-CoV-2 Ct-values she received two further courses of remdesivir/dexamethasone with nitazoxanide experimentally added, and baricitinib for inflammation control (Figure 1). She slowly improved and remdesivir/nitazoxanide were stopped after 2 weeks of PCR SARS-CoV-2 negativity (Day+72), dexamethasone weaned. ECMO was stopped after 39 days (Day+57), she was discharged from PICU after 132 days (Day+143), and discharged to local hospital for rehabilitation on Day+218. She is currently home with a reduced lung function, but able to go to school.

Neutrophil reconstitution was observed on day+12, lymphocyte reconstitution on day+120. Naïve T-lymphocytes appeared from day+140. Despite low CD4-lymphocyte counts (CD4/CD8-ration 0.29), and JAK-inhibitor exposure, we observed specific SARS-CoV-2 antigen responses. Compared to seropositive controls, she had a higher proportion of IL-2 producing CD-4 lymphocytes in response to S1 and S2 spike peptide pools, but poor interferon gamma and TNF alpha response.

Learning Points/Discussion:

We describe successful treatment in a paediatric patient with COVID-19 ARDS, acquired at time of stem cell transplant, with ECMO, antivirals and immunomoduclation. We demonstrate SARS-CoV-2 specific cellular and humoral response development, despite ongoing immunosuppression.