key: cord-0759091-sf5zp5wg
authors: Kohli, Utkarsh; Rosebush, Julia C.; Orlov, Nicola M.; Ghavam, Ahmeneh
title: COVID-19 pneumonia in an infant with a hemodynamically significant ventricular septal defect
date: 2020-10-12
journal: Cardiology in the young
DOI: 10.1017/s1047951120003303
sha: e042ed24895ce46a3e8ce55ddae4061fc79d3e00
doc_id: 759091
cord_uid: sf5zp5wg

Reports thus far suggest a mild course for acute COVID-19 infection in children; however, its effects in vulnerable paediatric populations, including children with haemodynamically significant congenital heart disease, have rarely been reported. We therefore report on a 4-month-old Hispanic male with a moderate sized conoventricular ventricular septal defect and pulmonary overcirculation who presented with COVID-19-associated pneumonia.

We are currently in the midst of a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mediated coronavirus disease 2019 pandemic. In addition to pneumonia and damage to several other organ systems, SARS-CoV-2 infection has been associated with deleterious effects on human myocardium. [1] [2] [3] [4] [5] [6] Acute COVID-19 infection has been reported to run a milder course in children; however, severe myocardial involvement in children with multisystem inflammatory syndrome-children, a post COVID-19 likely immune mediated entity, has been reported. [7] [8] [9] [10] [11] Adults with underlying cardiovascular disease, however, have been found to sustain cardiorespiratory damage leading to increased morbidity and mortality due to COVID-19 infection. 6 Children with haemodynamically significant congenital heart disease are at an increased risk of decompensation and hospitalisation when concomitantly infected with other respiratory viruses such as respiratory syncytial virus and influenza, [12] [13] [14] lending credence to the notion that COVID-19 could run a more severe course in these children. As the effects of COVID-19 have rarely been reported in this population, 15 we report on the clinical course of an infant with COVID-19 pneumonia and a moderate-sized haemodynamically significant conoventricular ventricular septal defect.

An otherwise healthy 4-month-old (6.8 kg, 27th percentile for weight) Hispanic boy with a moderate-sized conoventricular ventricular septal defect was transferred to a quaternary care centre from an outside emergency room where he had tested positive (polymerase chain reaction assay) for COVID-19. Both of his parents were also found to be COVID-19 positive and were self-isolating. He was being cared for by his grandmother who noted the patient to be fussy and febrile (102 F) a day prior to presentation. She also reported decreased oral intake and several episodes of non-bilious emesis.

Upon admission to the paediatric intensive care unit, the patient's heart rate was 163 bpm, blood pressure 83/55 mmHg, respiratory rate 40-52 breaths/minute with increased work of breathing, and oxygen saturation of 99% on supplemental oxygen was noted. Cardiorespiratory examination was remarkable for a grade 3/6 holosystolic murmur best heard at the left lower sternal border and diffuse ronchi heard over bilateral lung fields. His liver was palpable 2 cm below the costal margin, and his chest radiograph demonstrated cardiomegaly, increased pulmonary vascularity, and a leftsided retrocardiac opacity suggestive of pneumonia (Fig 1) . An electrocardiogram was performed and only showed sinus tachycardia. The patient was also continuously monitored on telemetry and no arrhythmias, heart block, or ectopy were noted. A trivial patent foramen ovale, a moderate-sized conoventricular ventricular septal defect, moderate left atrial and left ventricular enlargement, and increased flow velocity across pulmonary and mitral valves (suggesting pulmonary overcirculation) were noted on transthoracic echocardiogram (Fig 2) . Biventricular function appeared normal and unchanged from the past. The patient was started on high flow nasal cannula (5 L per minute with 60% FiO 2 ) and continued on his home dose of furosemide (6 mg every 12 hours). Serum aspartate aminotransferase (44 U/L; normal: 8-37 U/L) and D-dimer a, b, and c) . The moderate-sized conoventricular ventricular septal defect is profiled in apical 4-chamber, parasternal long, and parasternal short axis views (red arrows, Panels b, c, and d). Interrogation with Colour Doppler reveals the shunt across the ventricular septal defect to be left-to-right. Continuous wave Doppler interrogation of the pulmonary valve (Panel e) reveals an increase in flow velocity (peak velocity 3.2 m/second, peak gradient 41 mmHg) across a normal-sized pulmonary valve annulus (1.0 cm, Z score = 0.29). An increase in flow velocity (Peak E wave velocity = 1.54 m/second, mean gradient = 3.3 mmHg) is also noted across a normal-sized mitral valve annulus (1.9 cm, Z score = 1.7) upon continuous wave Doppler interrogation suggesting functional mitral stenosis (Panel f).

U. Kohli et al.

(7.18 μg/ml; normal < 0.40 μg/ml) concentrations were elevated while his platelet count was mildly decreased (143,000/μl; normal: 150,000-450,000/μL). The rest of his laboratory parameters including ferritin and C-reactive protein were within the normal range. A nasopharyngeal swab was obtained for the SARS-CoV-2 RNA polymerase chain reaction assay (Roche cobas SARS-CoV-2 assay on the cobas 6800, Roche labs, Geneva, Switzerland) and was positive. A nasopharyngeal swab was obtained for other common respiratory pathogens and was found to be negative. Due to resolution of fever, rapid symptomatic improvement, and normalisation of laboratory abnormalities, he was able to be weaned from high flow nasal cannula to room air within 48 hours of admission and discharged home a day later with close follow-up with his primary care physician and cardiologist.

We report on the case of a 4-month-old boy with a moderate-sized conoventricular ventricular septal defect and left-sided volume overload secondary to pulmonary overcirculation, who developed COVID-19 pneumonia. The patient exhibited mild respiratory symptoms without signs of cardiac decompensation during his hospitalisation. These findings are of interest as COVID-19 pneumonia has not been previously reported in a child with unrepaired, haemodynamically significant congenital heart disease, though there are reports in children with repaired congenital heart disease and an adult with unrepaired congenital heart disease. [16] [17] [18] Although we are unable to draw any significant conclusions based on the clinical course of a single patient, the rapid improvement of this patient following admission does raise the possibility that COVID-19 infection may not necessarily be associated with marked decompensation in children with haemodynamically significant congenital heart disease, particularly left-toright shunts. Given the probable paucity of these patients at any single paediatric centre, there is a dire need for collaborative research efforts on a global scale to characterise the clinical features and outcomes of COVID-19 in children with haemodynamically significant congenital heart disease as well as other vulnerable paediatric populations.

Characteristics and outcomes of 21 critically ill patients with COVID-19 in Washington state

Acute heart failure in multisystem inflammatory syndrome in children (MIS-C) in the context of global SARS-CoV-2 pandemic

Risk factors for hospitalized respiratory syncytial virus disease and its severe outcomes

SARS-CoV-2: a potential novel etiology of fulminant myocarditis

Multisystem inflammatory syndrome in children in New York state

Risk factors for influenza virus related severe lower respiratory tract infection in children

Multisystem inflammatory syndrome in U.S. children and adolescents

Respiratory tract infection and risk of hospitalization in children with congenital heart defects during season and off-season: a Swedish National Study

SARS-CoV-2 infection in children

First reported case of unrepaired tetralogy of Fallot complicated with Coronavirus Disease-19 (COVID-19)

Characteristics and outcomes of children with coronavirus disease 2019 (COVID-19) infection admitted to US and Canadian Pediatric Intensive Care Units

The cardiovascular burden of coronavirus disease 2019 (COVID-19) with a focus on congenital heart disease

Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China

Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention

Clinical and CT features in pediatric patients with COVID-19 infection: different points from adults

Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study

Epidemiologic features and clinical course of patients infected with SARS-CoV-2 in Singapore

Clinical characteristics of children with coronavirus disease

Financial support. This research received no specific grant from any funding agency, or from commercial or not-for-profit sectors.

Ethical standards. Informed consent was obtained from all individual participants included in the report. This report does not include any human or animal experimentation.