Navigating a complex case of pediatric COVID-19 with immunomodulatory therapies

Navigating a complex case of pediatric COVID-19 with immunomodulatory therapies | Image Credit: © Photocreo Bednarek - © Photocreo Bednarek - stock.adobe.com.

SARS-CoV-2 infections in pediatric patients exhibit a broad range of severity, often complicated by bacterial and viral coinfections and immune dysregulation. The optimal approach to managing these cases, balancing antimicrobial and immunomodulatory therapies, is still under investigation.

A poster session titled “COVID-19 with Streptococcal Infection, Hemolytic Uremic Syndrome, Hemophagocytic Lymphohistiocytosis,” presented at the 2023 American Academy of Pediatrics National Conference & Exhibition, featured a complex pediatric case involving SARS-CoV-2, bacterial coinfection, multiorgan failure, thrombotic microangiopathy, and systemic hyperinflammation, highlighting the absence of a standardized treatment protocol.

The authors highlighted a healthy 2-year-old boy who was admitted with a week-long history of fever and respiratory failure. Imaging revealed severe lung involvement, with bilateral dense lower lobe consolidations and pleural effusion.

The patient was placed on bilevel positive airway pressure because of respiratory distress. He was given dexamethasone for COVID pneumonia, and for pulmonary infiltrates was given ceftriaxone.

The patient was not initiated on remdesivir therapy because of symptom duration prior to presentation. Blood culture drawn on admission grew pansensitive Streptococcus pneumoniae, and microangiopathic hemolytic anemia developed, with hemoglobin as low as 3.0 g/dL, thrombocytopenia, and acute kidney injury with a creatinine peak of 1.12 mg/dL, in line with a Streptococcus pneumoniae-associated hemolytic eremic syndrome (SP-HUS).

Eculizumab was added as hemolysis and thrombocytopenia worsened despite antibiotics. Persistent elevated fevers were observed, and the patient subsequently developed pancytopenia, hypertriglyceridemia, and hyperferritinemia (peak ferritin 7793 ng/mL), bringing concerns of secondary hemophagocytic lymphohistiocytosis (HLH).

In hopes of limiting continued immunosuppression in the setting of active infections, anakinra was selected as the HLH therapy. After, significant improvements were observed in the patient’s hemolysis, kidney injury, and ferritin.

Necrotizing pneumonia with bilateral pneumothraces that required multiple chest tubes caused further complications to his illness. The author’s stated, “our patient’s respiratory failure was managed exclusively with non-invasive ventilation and his renal injury with supportive care, fortunately never requiring intubation or dialysis.”

On hospital day 32, following improvements, the patient was discharged and sent home on nasal cannula oxygen therapy. SARS-CoV-2 and concurrent illness is difficult to treat because of attempting to treat active infection, while also balancing treatment of hyperinflammation and immune dysregulations, the authors noted.

In critically ill patients with severe infections that require immunomodulating therapies for life-threatening dysregulation, the study authors concluded that eculizumab and anakinra should be considered based on descriptions of their patient with COVID-19 pneumonia, SP-HUS, bacterial superinfection, in addition to standard of care antibiotics and steroids.

Reference:

Chung N, Cai R, Weingarten-Arams J, et al. P2A222: COVID-19 with Streptococcal Infection, Hemolytic Uremic Syndrome, Hemophagocytic Lymphohistiocytosis. Poster. Presented at: 2023 American Academy of Pediatrics National Conference & Exhibition.