key: cord-0826519-ghxbfec6 authors: Climent, Francisco José; Calvo, Cristina; García-Guereta, Luis; Rodríguez-Álvarez, Diego; Buitrago, Nelson Mauricio; Pérez-Martínez, Antonio title: Fatal outcome of COVID-19 disease in a 5-month infant with comorbidities date: 2020-04-27 journal: Rev Esp Cardiol (Engl Ed) DOI: 10.1016/j.rec.2020.04.011 sha: 5ffcff3a2dc81e708c23c951f4e3e959da7a08a6 doc_id: 826519 cord_uid: ghxbfec6 nan J o u r n a l P r e -p r o o f To the Editor, SARS-CoV-2 infection in children has been described in around 1% of cases in China. 1 Although data are still limited, most series report mostly mild cases, even in infants. Critically-ill patients represent 0.6% of children and 50% of them are younger than 1 year old. 2 There have been very few reports of deaths. In a Wuhan series, a 10-month-old infant with intussusception developed multiorgan failure and died, while 3 patients had underlying diseases, representing 1.7% of children. 3 Spain is currently in a situation of intense community transmission with more than 100 000 reported cases. Between 11 and 18 March 2020, 12 children with confirmed SARS-CoV-2 infection were admitted to a large university hospital, 5 (41.6%) of whom had underlying disease (1 liver transplant, 1 vasculitis with hemodialysis, 2 congenital heart disease, and 1 Hurler syndrome with associated dilated cardiomyopathy). One of the 12 children was a 5-month-old boy who had been diagnosed with heart failure and mucopolysaccharidosis type I-Hurler syndrome at age 1 month. He had moderate dilatation was performed to rule out coronary artery lesions. The possibility of heart transplant listing was excluded. After intense heart failure therapy, iv drips were discontinued and the patient was switched to oral therapy with captopril, diuretics, carvedilol and digoxin with a mild improvement, which allowed discharge after 8 weeks. ERT was continued to allow bone marrow transplant if cardiac function improved. When the patient was 5 months old, he was hospitalized after a 24-hour course of irritability, low-grade fever (below 38 C), cough, runny nose, and vomiting. He showed pallor, slight respiratory distress, and bibasal pulmonary subcrackles. Chest X-ray showed cardiomegaly COVID-19 disease was suspected and SARS-CoV-2 polymerase chain reaction was positive. Captopril was withdrawn in the emergency room prior to confirmation of the diagnosis. At 24 hours after admission, the patient was stable without oxygen therapy. After 48 hours, there was an increase in bilateral pulmonary crackles and palpebral edema. He had low-grade fever without analytical impairment, so it was interpreted as worsening heart failure with good response to diuretic treatment. However, 72 hours after admission, he had high fever (39.6 C) and respiratory distress, and chest X-ray revealed extensive symmetric parahilar consolidations Current treatment includes ERT and bone marrow transplant. 5 Severe cardiomyopathy in early infancy may complicate the clinical situation and affect survival but ERT has been reported to improve cardiac function. 5 SARS-CoV-2 infection is proposed to evolve in 3 phases, causing mortality in the third phase after about 2 weeks or more. 6 In the early phase, SARS-CoV-2 multiplies in the host, primarily focusing on the respiratory system with mild symptoms. SARS-CoV-2 binds to its target using the angiotensin-converting enzyme 2 receptor on human cells, abundantly present in the human lung. During the second phase, lung involvement is established, and lymphopenia appears. A minority of patients will reach the third phase of systemic hyperinflammation with an increase in inflammatory cytokines, interleukins, C-reactive protein, ferritin, D-dimer, and others. Troponin and N-terminal pro B-type natriuretic peptide can also be elevated. The clinical course of our patient was very short, reaching the hyperinflammation phase in just 3 to 4 days from the onset of symptoms. The situation of previous heart failure could Page 4 of 9 J o u r n a l P r e -p r o o f undoubtedly contribute to a low reserve that led to cardiac arrest. The role of previous treatment with an angiotensin-converting enzyme inhibitor may have contributed to his rapid deterioration but the role of angiotensin-converting enzyme inhibitors remains to be elucidated. There is scarce information about SARS-CoV-2 infection in children with underlying disease. It is noteworthy that in the first week of the pandemic in our center, 5 of the 12 admitted children had significant comorbidities. Patients with heart failure due to cardiomyopathies or congenital heart disease may constitute a group of special concern. Characteristics of and important lessons from the coronavirus disease Epidemiological Characteristics of 2143 Pediatric Patients With COVID-19 With Post-Chemotherapy Agranulocytosis in Childhood Acute Leukemia: A Case Report Association of Cardiac Injury With Mortality in Hospitalized Patients With COVID-19 in Wuhan Management of mucopolysaccharidosis type IH (Hurler's syndrome) presenting in infancy with severe dilated cardiomyopathy: a single institution's experience COVID-19 Illness in Native and Immunosuppressed States: A Clinical We wish to thank Dr Samuel Ignacio Pascual for his advice (Pediatric Neurology Department).