key: cord-0720068-ngd2yy2m
authors: Hamza, Salih Boushra
title: Severe SARS-COV-2 infection in pediatric patient with atypical Hemolytic Uremic Syndrome: A case report
date: 2022-02-24
journal: Ann Med Surg (Lond)
DOI: 10.1016/j.amsu.2022.103400
sha: 11bb4f7fa5b0ee38e24f2ae9bb41750303551a84
doc_id: 720068
cord_uid: ngd2yy2m

INTRODUCTION AND IMPORTANT: There is a high incidence of acute kidney injury with COVID-19 infections. We report a child with atypical Hemolytic Uremic Syndrome (aHUS) admitted to Intensive care Unit (ICU) due to severe SARS-COV-2 infection. Children are recognised as at lower risk of severe COVID-19 compared with adults, but the impact of atypical Hemolytic Uremic Syndrome is yet to be determined. CASE PRESENTATION: An eleven years old male presented to Mohammed Alamin Hamid Pediatric Hospital with generalize body swelling, skin rash and red urine. Examination reveal hepatomegaly and hemic murmur. Investigations reveal anemia, normal platelets, and impaired renal function. Peripheral blood picture shows shistocytes, crenated RBCs, occasional poikilocytes and mild neutrophilia.During hospital stay the patient developed severe shortness of breath and fever, diagnosed as COVID-19 and required ICU admission 2 days later due to severe respiratory compromised. CLINICAL DISCUSSION: An atypical Hemolytic Uremic Syndrome with normal platelets is extremely rare condition. SARS-COV-2 infection in patients atypical Hemolytic Uremic Syndrome has not been reported in literature. CONCLUSION: Our study shown that severe SARS-COV-2 infection can be developed in pediatric patients patients with co-existing atypical Hemolytic Uremic Syndrome.

Since December 2019, an outbreak of severe acute respiratory infection (SARS-COV-2) had emerged in Wuhan City, the capital of Hubei Province, China, driving an atypical pneumonia (COVID-19)¹. A retrospective analysis showed that SARS can cause elevated serum creatinine and acute tubular necrosis, implying renal function damage in patients infected with SARS-CoV²'³.

The Hemolytic Uemic Syndrome in pediatrics is classified into two categories: typical hemolytic Uremic Syndrome with a diarrheal prodrome, and atypical Hemolytic Uremic Syndrome without diarrheal prodrome. Typical disease represent up to 90% of children with the Hemolytic Uremic Syndrome, commonly presenting before school age, with acute onset of bloody diarrhea precipitated by verotoxin-producing bacteria such as Escherichia coli O157:H7 4 . Although many affected children have severe acute kidney injury, the majority regain effective function 5 .

The classic triad of HUS is microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure. HUS presenting with normal platelet count is extremely rare 6, 7 . A normal platelet count in the setting of anemia and renal failure typically leads the clinician to alternative diagnoses.

This study highlights a rare case of atypical Hemolytic Uremic Syndrome that is commonly missed in real practice. To our knowledge no study highlighted the severity of SARS-COV-2 infection in pediatric patients with atypical Hemolytic Uremic Syndrome. This work has been reported in line with the SCARE 2020 criteria⁸.

We present eleven years old male presented to Mohammed Alamin Hamid Pediatric Hospital with generalize body swelling, skin rash and red urine. The condition started with sorethroat diagnosed initially as tonsillitis and received Amoxicillin-clavulanic acid. Then the patient received medical advice initially at primary health center and labelled to have allergic reaction manifested with papular skin rash with complete response to antihistamine. One week after that the patient developed generalize body swelling, red urine and decreased urine out-put. On examination patient was I'll, not distress, afebrile, BP was 100/70, pulse rate was 75, respiratory rate was 26, and oxygen saturation was 98%. The patient had hemic murmur and Hepatomegaly. Investigations reveal impair renal function, urine analysis show unaccountable red blood cells and granular cast ( Table 1 ). The eGFR was 13 mL/min/1.73m2. Pt received antibiotics, amilodepine, furosomide and pulse methyl prednisolone regimen without improvement. Due to late presentation the patient was on plasma transfusion and regular hemodialysis. During hospital stay the patient developed severe shortness of breath and fever.

PCR for SARS-COV-2 infection was positive. Patient received Paracetamol 500mg, Aspirin 100 mg, Vitamin D, Dexamethasone 6 mg according to protocol developed by Case Management Committee, Federal Ministry of Health, Sudan 1 . Patient's oxygen saturation maintained with high follow through face mask. Two days later the patient was admitted to ICU due to severe respiratory compromise. We describe a case of 11 years old with features of atypical Hemolytic uremic syndrome infected with COVID-19.

Atypical hemolytic-uremic syndrome occurs at any age, and the onset tends to be insidious, often with marked hypertension; relapses occur that lead ultimately to end-stage renal disease 5 . Unlike typical HUS there is no specific prodromal diarrheal illness, although atypical Hemolytic Uremic Syndrome may occur after or simultaneously with illness, and severe pneumococcal disease associated with 30 to 40% of pediatric cases ⁹. Absence of diarrheal prodrome is essential to differentiate between typical and atypical HUS. Some types of Streptococcus pneumoniae J o u r n a l P r e -p r o o f produce a neuraminidase that cleaves sialic acid residues from renal endothelial cells, thereby exposing the Thomsen-Friedenreich (T) antigen to an anti-T immunoglobulin commonly found in the plasma, leading to endothelial damage and thrombotic microangiopathy¹⁰.

COVID-19 is also associated with a pro-thrombotic state with increased risk of thrombosis and disseminated intravascular coagulation (DIC)¹¹'¹². Our search report a cases of COVID-19 in HUS patients in both adult and children. Ville et al. reported a case of atypical HUS relapse in a 28year-old woman who was positive for COVID-19¹³. Another study report a 16-month-old boy, presented with COVID-19, new onset DKA, hemolytic anemia, thrombo-cytopenia and kidney failure. He was given a trial of fresh frozen plasma, however there was no improvement¹⁴.

It has been reported in the past that trombotic micro-angiopathy/atypical HUS can relapse in the setting of viral illnesses like infuenza. Some authors have suggested adding COVID-19 as a triggering factor for aHUS relapse.

We presented a case severe SARS-COV-2 infection in a child with atypical Hemolytic Uremic Syndrome with normal platelets and absence of diarrheal prodrome.

The datasets referred to in this case report are available from the corresponding author on reasonable request.

ACKNOWLEDGEMENT Special thanks to doctor Sara Abdelsalam, Omer Aljak, Salma Khairy, Hala and Enas abdelbagi for their great help.

Provenance and peer review Not commissioned, externally peer reviewed. Written informed consent was obtained from the patient for publication of this case report and accompanying images. Patient's parents have given consent for possible publication of this case report .A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

author contribution

The corresponding author made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; took part in drafting the article or revising it critically for important intellectual content; agreed to submit to the current journal; gave final approval of the version to be published; and agree to be accountable for all aspects of the work. 

Comorbidity and its impact on 1590 patients with Covid-19 in China: a nationwide analysis

Acute renal failure in SARS patients: more than rhabdomyolysis

Renal complications and their prognosis in Korean patients with Middle East respiratory syndrome-coronavirus from the central MERS-CoV designated hospital

Non-shiga toxin-associated hemolytic uremic syndrome

Haemolytic uraemic syndrome: an overview

Hemolytic uremic syndrome

Thrombotic micro-angiopathy, hemolytic uremic syndrome, and thrombotic thrombo-cytopenic purpura

The SCARE 2020 Guideline: Updating Consensus Surgical CAse REport (SCARE) Guidelines

A clinico-pathologic study of crescentic glomerulonephritis in 50 children: a report of the Southwest Pediatric Nephrology Study Group

Thomsen-Friedenreich antigen in haemolytic-uraemic syndrome

COVID-19 and its implications for thrombosis and anticoagulation

High risk of thrombosis in patients with severe SARS-CoV-2 infection: a multicenter prospective cohort study

Successful treatment of a COVID-19 patient with throm-botic microangiopathy

Toddler with new onset diabetes and atypical hemolytic-uremic syndrome in the setting of COVID-19

J o u r n a l P r e -p r o o f Highlights:1. We present a rare case of SARS-COV-2 infection in pediatric patient with aHUS.2. A typical HUS with normal platelets is extremely rare. 3 . No apparent diarrheal prodrome in this case.

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