key: cord-0941322-pfc7kkds
authors: Goussard, Pierre; Schubert, Pawel; Parker, Noor; Myburgh, Chantelle; Rabie, Helena; van der Zalm, Marieke M.; Van Zyl, Gert U.; Preiser, Wolfgang; Maponga, Tongai G.; Verster, Janette; Gie, Andre G.; Andronikou, Savvas
title: Fatal SARS‐CoV‐2 Omicron variant in a young infant: Autopsy findings
date: 2022-03-11
journal: Pediatr Pulmonol
DOI: 10.1002/ppul.25881
sha: 50ead1ce5c13422a49087283525294f9bcf1dc1f
doc_id: 941322
cord_uid: pfc7kkds

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SARS-CoV-2 has spread rapidly worldwide since December 2019, but fewer children are diagnosed with SARS-CoV-2 and mortality remains relatively low compared to adults. 1 Even fewer neonates and infants are testing SARS-CoV-2 positive and data from the United States showed that children <1 years only represented 0.27% of all cases. 2 The majority of infants and children present with mild symptoms.

The first case of the SARS-CoV-2 Omicron variant was reported in November 2021 in South Africa and has since become the dominant strain globally. 3 A 7-week-old male infant (weight 2.05 kg) was admitted to the Paediatric Intensive Care Unit (PICU) after intubation for apnea and respiratory failure. He was a premature baby at 29 weeks with a birth weight of 1455 g who required continuous positive airway pressure after birth, but not surfactant replacement therapy. The baby was unexposed and had a negative HIV test.

Tracheal aspirate confirmed polymerase chain reaction (PCR) SARS-CoV-2 positive, with no other concomitant viruses or bacteria identified.

The blood results included white cell count 2.85 × 10 9 /L, neutrophil count 1.60 × 10 9 /L, lymphocyte count 0.70 × 10 9 /L, and C-reactive protein 6 mg/L. During the course of the disease, Candida albicans was identified on tracheal aspirate on Day 5. Klebsiella pneumonia was isolated from blood cultures on Day 10. Intermittent positive-pressure ventilation was changed to High-frequency Oscillatory Ventilation due to increasing Oxygenation index (OI) and air leak syndromes which included pneumothorax and pulmonary interstitial emphysema (PIE).

The chest X-rays showed progression of changes from Day 1 ( Figure 1A) when there was a diffuse ground-glass appearance to both lungs, to A limited autopsy restricted to the chest cavity was performed.

The lungs appeared consolidated, firm, and mottled with the right being more affected than the left.

On histological examination, both lungs showed similar pathology; however, the right lung was more diffusely affected. At low magnification, the lungs appeared solid (Figure 2A ) with the alveolar spaces obliterated by fibrinous balls with organization, (organizing pneumonia) with additional alveolar macrophages, lymphocytes ( Figure 2B) , and multinucleated giant cells ( Figure 2C ). Mainly a chronic inflammatory cell infiltrate is seen expanding the interstitial septae. Some alveoli still showed hyaline membranes while adjacent alveoli showed a more pronounced organizing pneumonia pattern ( Figure 2D ). Small foci of ongoing neutrophilic pneumonia and foci of squamous metaplasia were also noted.

Focal areas of subpleural hemorrhagic lung infarction ( Figure 2E ,F), as well as focal thrombosis in the pulmonary arteries, were noted ( Figure 2G ).

There were multiple areas of dilated lymphatic vessels in the subpleural parenchyma ( Figure 2H ), forming microcystic areas with compression of surrounding parenchyma, while in other regions these dilated lymphatic channels were seen surrounding the bronchovascular bundles which are seen "hanging" within clear spaces ( Figure 2I ). These dilated lymphatics are most likely indicative of air dissection into the lymphatic vessels (interstitial emphysema) with resultant breakthrough into the pleural cavities with pneumothorax as complications.

Additionally, a thrombus was found in the right ventricle of the heart, attached to the endocardial wall ( Figure 2J ). Antenatal vaccination has been shown to induce a maternal humoral response that effectively transfers to the fetus, supporting the role of vaccination during pregnancy and in future prevention of cases of severe SARS-CoV-2 pneumonia in young infants.

We report a case of severe pneumonia due to SARS-CoV-2 infection with the newly discovered Omicron variant. The histological findings showed thrombotic infarctions which suggest careful assessment in infants and children presenting with severe SARS-CoV-2 pneumonia and warrant further investigations.

Clinical experience with severe acute respiratory syndrome Coronavirus 2-related illness in children: hospital experience in Cape Town, South Africa

CDC COVID-19 Response Team. Coronavirus Disease 2019 in Children -United States

Rapid epidemic expansion of the SARS-CoV-2 Omicron variant in southern Africa

Simplified point-of-care full SARS-CoV-2 genome sequencing using nanopore technology. Microorganisms

Postmortem examination of COVID-19 patients reveals diffuse alveolar damage with severe capillary congestion and variegated findings in lungs and other organs suggesting vascular dysfunction