A recently published report describes the case of a 12-year-old female who experienced respiratory failure and severe thrombocytopenia caused by coronavirus disease 2019 (COVID-19).
The patient, who had no significant past medical history, presented to the hospital complaining of 5 days of fever, a nonproductive cough, shortness of breath, 2 days of nonbloody emesis, and hematuria. The patient’s vital signs at presentation were reported to be: body temperature, 39.6°C; pulse: 129 beats per minute; respiratory rate: 26 breaths per minute; oxygen saturation, 89% on room air.
Physical examination revealed that the patient had dyspnea, diminished breathing sounds diffusely, and petechiae. Bilateral diffuse airspace opacities and small pleural effusion were shown on chest x-ray. Laboratory findings revealed severe thrombocytopenia as well as elevated markers of inflammation (C-reactive protein, procalcitonin, and ferritin). Tests for both rhinovirus as well as influenza came back negative.
After being admitted into the intensive care unit, the patient progressed to respiratory failure. Despite having no known exposure to the virus, the patient’s COVID-19 test came back positive on the fourth day of her hospital stay.
During her hospital stay, the patient was treated for severe thrombocytopenia, acute respiratory distress syndrome (ARDS), as well as COVID-19. After receiving intravenous immunoglobulin (IVIG) and steroids, the patient’s platelet levels promptly improved. Management of ARDS included mechanical ventilation, inhaled nitric oxide (iNO), followed by airway pressure release ventilation (APRV).
The patient also received both azithromycin as well as hydroxychloroquine, however, no clinical benefit was observed. She was then initiated on tocilizumab, an anti-interleukin-6 receptor antibody used to manage rheumatologic disease and cytokine release syndrome (CRS), as well as remdesivir, an investigational broad spectrum antiviral agent. Clinical improvement was observed soon after the initiation of these agents.
“While our patient was treated with multiple SARS-CoV-2 directed (hydroxychloroquine and remdesivir) as well as ARDS directed therapies (iNO and APRV), her sustained improvement after the administration of tocilizumab with normalization of inflammatory markers and extubation within 7 days is consistent with results of its use in CRS,” the authors stated. They added, “Our case illustrates that hyperinflammation may be important in the pathophysiology of COVID-19 SARS and that treatment with cytokine-directed agents such as tocilizumab could be considered in critically ill patients.”
Patel PA, Chandrakasan S, Mickells GE, Inci Y, Kao, CM, Bennett CM. Severe pediatric COVID-19 presenting with respiratory failure and severe thrombocytopenia [published online May 1, 2020]. Pediatrics. doi: 10.1542/peds.2020-1437.