Lung ultrasound and neonatal COVID-19 pneumonia: A case report.

doi:10.21203/rs.3.rs-33182/v1

Purpose: Severe Novel Coronavirus Disease 2019 (COVID-19) infection in neonates is possible but reports are scarce. Lung ultrasound (LUS) has been reported useful for triaging, diagnosing, and monitoring of patients with COVID-19.

Material and methods: We describe SARS-CoV-2 confirmed infection on a term newborn that developed pneumonia and pulmonary hypertension requiring mechanical ventilation. Ultrasonographic follow up of COVID-19 pneumonia and pulmonary hypertension was carried out.

Results: A 3,140-g male infant born at 40.3 weeks’ gestation developed progressive respiratory distress requiring mechanical ventilation. Real time PCR respiratory tract swabs for SARS COV 2 sampled on day 3 were positive for the baby and both parents. Lung ultrasound showed an irregular pleural line (shred sign), multiple confluent B-lines and bilateral ≥ 0.5 cm subpleural consolidations. Improvement of the lung and cardiac conditions were documented by ultrasound.

Conclusion: Our case represents a severe presentation of COVID-19 pneumonia with pulmonary hypertension requiring mechanical ventilation. LUS showed to be useful for diagnosis and follow up.

Pediatrics

Infectious Diseases

COVID- 19

Newborn

Pneumonia

Lung ultrasound

COVID–19 is rapidly spreading all around the world. In Mexico at the time 93,435 cases with 10, 167 deaths have been reported (June 1, 2020). Variable clinical and radiographic characteristics of neonates have been described¹. LUS has been reported useful for triaging, diagnosing, and monitoring of patients with COVID–19². Currently one pediatric and one neonatal case series describing lung ultrasound of infected patients (8 children, 5 newborns) have been reported^3,4.

A 3,140-g male infant was born at 40.3 weeks’ gestation to a 20-year-old gravida woman with history of type 1 diabetes mellitus in control with insulin. The pregnancy had irregular follow up with normal second and third trimester fetal ultrasound. On the day of delivery during labor fetal heart rate late decelerations to 60 beats per min were noted so an emergent caesarean section was planned. During resuscitation no late cord clamping was performed and supplemental oxygen was needed. Apgar scores were 8–9 at 1 and 5 minutes. Oxygen was stopped at minute 16. Silverman Andersen score was one with discrete nasal flaring. No skin to skin contact was performed (mother with general anesthesia). After transition desaturation occurred so oxygen hood with 30% FiO₂ was applied. Respiratory distress progressed and required high flow nasal cannula on day 2, CPAP on day 3 and was intubated on day 4 secondary to CPAP failure (Silverman Andresen score of 4, FiO₂ ≥ 40%, hypoxemia and hypercapnia) with AC(VG) (5.8ml/kg), 30% FiO₂. Real time PCR (RT-PCR) respiratory tract swabs for SARS COV 2 (sampled on day 3) were positive for the baby and both parents (that reported themselves asymptomatic). On chest radiography important cardiomegaly and bilateral ground-glass opacities were noted. An echocardiogram by Pediatric cardiology was performed finding moderate to severe pulmonary hypertension with right ventricular dilatation. Mild tricuspid and mitral regurgitation were noted. A 6 mm bidirectional patent ductus arteriosus (PDA) was noted with a caution note to evaluate the aortic arch once the PDA closes. Normal head ultrasound was reported. The baby was transferred to a COVID–19 third level referral hospital. One asymptomatic hypoglycemia on admission was managed with an 8 mg/kg/min glucose infusion. Upon arrival (day 5) portable LUS (Konted™, Beijing China, Linear 10.0MHz) showed an irregular pleural line (shred sign), multiple confluent B-lines and bilateral ≥ 0.5 cm subpleural consolidations (Figure 1). Admission laboratory exams showed lymphocytic predominance with mild thrombocytopenia with normal coagulation times (Table 1). The infant was kept in an incubator, no antibiotics were used. Prone positioning and increased PEEP 7–8 allowed FiO₂ to be lowered from 45 to 28%. On day 9 the neonatal intensive care unit ultrasound equipment (Vivid™ E90, GE Medical Systems, Milwaukee, WI, USA) was prepared according to the Canadian Association of Emergency Physicians⁵ and Pediatric cardiology confirmed a normal aortic arch. Targeted Neonatal Echocardiography (TnE) reported mild to moderate pulmonary hypertension with a 2.3 mm restrictive left to right PDA, biventricular dilatation. Portable LUS without big consolidations detectable, still irregular pleural line and less confluent b lines. Mechanical ventilation occurred for 6 days, then 3 days of CPAP and 3 days of supplemental oxygen. Biventricular dilatation was managed with diuretics. The highest temperature recorded was 37.5 ˚C (axillar). RT PCR was negative at day 14. At day 20 TnE examination reported a 1.9 mm non hemodynamically significant restrictive PDA with improvement of biventricular dilatation and a normal LUS (Figure 2). Baby was discharged at day 26 to an uninfected family member younger than 60 years without co-morbidities. Interestingly parents remained asymptomatic and the mothers RT-PCR at day 14 remained positive.

Table 1.

Admission laboratory exams
WBC (×109/L)	11.3
L% (%)	51
PLT (×109/L)	105
Hb (g/L)	160
CRP (mg/L)	<0.5
ALT (U/L)	17
AST (U/L)	49
BUN (mg/dl)	1.42
sCr (μmol/L)	36
CK-MB (U/L)	80
PT (s)	12.1
APTT (s)	21

WBC, white blood cell; L%, percentage of Lymphocyte; PLT, Platelet count; Hb, hemoglobin; CRP, C-reactive protein; ALT, alanine aminotransferase; AST, aspartate aminotransferase; BUN, blood urea Nitrogen; sCr, serum creatinine; CK-MB, creatine kinase-MB; PT, prothrombin time;; APTT, activated partial thromboplastin time.

Case reports or comparative studies on SARS-CoV–2 neonatal infection are limited. Current guidelines represent expert consensus and need to be updated. In our case baby started with respiratory distress shortly after birth and RT PCR was positive on day 3 with both asymptomatic parents being positive as well. Zeng and colleagues reported the outcome of 33 neonates born to mothers with COVID–19 finding despite implementing strict infection control measures 3 neonates (9%) presented with early onset SARS-CoV–2 infection⁶. Transplacental transmission is feasible as virions invading syncytiotrophoblast in placental villi have been documented by electron microscopy⁷. Additionally, Vivanti and colleagues demonstrated a case of transplacental transmission of SARS-CoV–2 from a pregnant woman affected during late pregnancy with her offspring being positive and showing gliosis of the deep white periventricular and subcortical matter⁸. SARS-CoV–2 RNA have been found in milk samples^9,10.

No specific clinical finding has been described in newborns, but severe neonatal infections are possible. Variable body temperature, respiratory symptoms (cough, tachypnea, apnea, grunting, nasal flaring), tachycardia, lethargy, vomiting, diarrhea, and abdominal distention have been described. In our patient expected cardiac (major cardiac anomaly, obstructive septal hypertrophic obstructive cardiomyopathy) and pulmonary (surfactant consumption) complications associated with uncontrolled diabetes were not present. Our patient developed pneumonia that required mechanical ventilation with findings consistent with the reported literature: subpleural consolidations, interstitial pattern, and confluent B-lines; with an improvement after ventilatory management with consolidations disappearing and B-lines pattern progressive reduction. Treatment is symptomatic including respiratory support, fluid-electrolyte balance, maintaining hemodynamic stability and parenteral or enteral nutrition.

Our case represents a severe presentation of COVID–19 pneumonia with pulmonary hypertension requiring mechanical ventilation. LUS showed to be useful for diagnosis and follow up of the patient.

AUTHORS’ CONTRIBUTION

DIR performed lung ultrasound and echocardiographic studies and wrote the manuscript draft. AJMG performed echocardiographic studies and helped in data collection. EPVS helped in data collection and participated in the newborn’s management. DVG and HMG critically reviewed the manuscript for important intellectual content. All authors approved its final version.

COMPETING INTERESTS

Authors declare no competing interests.

ETHICS DECLARATION

Case report was approved for the study by our local investigation ethics committee. Written consent from the family for hospitalization and management was obtained. For publication, the need for consent was waived by the approving ethics committee.

DATA AVAILABILITY

Additional information from studies performed is available from the corresponding author on reasonable request.

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2. Soldati G, Smargiassi A, Inchingolo R, et al. Is There a Role for Lung Ultrasound During the COVID–19 Pandemic? J Ultrasound Med.2020; 2020;doi 10.1002/jum.15284. doi:10.1002/jum.15284

3. Feng XY, Tao XW, Zeng LK, Wang WQ, Li G. Zhonghua Er Ke Za Zhi. 2020;58(5):347‐50. doi:10.3760/cma.j.cn112140–20200228–00154

4. Denina M, Scolfaro C, Silvestro E, et al. Lung Ultrasound in Children With COVID–19. Pediatrics.2020;e20201157. doi:10.1542/peds.2020–1157

5. Kim DJ, Jelic T, Woo MY, et al. Just the Facts: Recommendations on point-of-care ultrasound use and machine infection control during the coronavirus disease 2019 pandemic, CJEM. 2020;1‐5. doi:10.1017/cem.2020.364

6. Zeng L, Xia S, Yuan W, et al. Neonatal Early-Onset Infection With SARS-CoV–2 in 33 Neonates Born to Mothers With COVID–19 in Wuhan, China. JAMA Pediatr. 2020;e200878. doi:10.1001/jamapediatrics.2020.0878

7. Algarroba GN, Rekawek P, Vahanian SA, et al. Visualization of SARS-CoV–2 virus invading the human placenta using electron microscopy, Am J Obstet Gynecol. 2020;10.1016/j.ajog.2020.05.023. doi:10.1016/j.ajog.2020.05.023

8. Vivanti A, Vauloup-Fellous C, Prevot S et al. Transplacental transmission of SARS-CoV–2 infection, 15 May 2020, PREPRINT (Version 1) available at Research Square [+https://doi.org/10.21203/rs.3.rs–28884/v1+]

9. Groß R, Conzelmann C, Müller JA, et al. Detection of SARS-CoV–2 in human breastmilk. Lancet. 2020; S0140–6736(20)31181–8. doi:10.1016/S0140.

10. Tam PCK, Ly KM, Kernich ML, et al. Detectable severe acute respiratory syndrome coronavirus 2 (SARS-CoV–2) in human breast milk of a mildly symptomatic patient with coronavirus disease 2019 (COVID–19). Clin Infect Dis,2020. doi:10.1093/cid/ciaa673.

Lung ultrasound and neonatal COVID-19 pneumonia: A case report.

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Abstract

Figures

Introduction

Case Report

Discussion

Conclusions

Declarations

References

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