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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 10  |  Issue : 4  |  Page : 248-250

An unusual case of multisystem inflammatory syndrome in children in newborn due to covid-19 – presenting with stage 11 b necrotizing enterocolitis


1 Department of Pediatrics, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Pediatrics, Chandan Hospital, Lucknow, Uttar Pradesh, India

Date of Submission15-Jun-2021
Date of Decision09-Aug-2021
Date of Acceptance13-Aug-2021
Date of Web Publication24-Sep-2021

Correspondence Address:
Neha Thakur
Department of Pediatrics, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcn.jcn_78_21

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  Abstract 


Neonatal enterocolitis is the most common gastrointestinal emergency reported in preterm babies. The most common infective organism involved in the pathogenesis includes bacteria such as Escherichia coli and Klebsiella. Until now, severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) as a causative agent of necrotizing enterocolitis (NEC) has not been reported. We report a unique case of multisystem inflammatory syndrome in children (MIS-C) and adolescents in newborn who presented with NEC. A 34-week-old male baby born to COVID-19-positive mother by normal vaginal delivery was admitted since birth in the special care newborn unit due to respiratory distress. Baby was COVID positive within 24 h of birth. He developed NEC at day 8 of life. He developed signs and symptoms of MIS-C. He responded to intravenous immunoglobulin and was discharged on day 16 of life. This is the first case report of MIS-C in newborn in India. Baby had NEC due to SARS-CoV2 which has not been reported until now. This case highlights the possibility of surge in newborn MIS-C postsecond wave of COVID-19 pandemic in India.

Keywords: COVID-19, necrotizing enterocolitis, newborn, pandemic


How to cite this article:
Thakur N, Rai N. An unusual case of multisystem inflammatory syndrome in children in newborn due to covid-19 – presenting with stage 11 b necrotizing enterocolitis. J Clin Neonatol 2021;10:248-50

How to cite this URL:
Thakur N, Rai N. An unusual case of multisystem inflammatory syndrome in children in newborn due to covid-19 – presenting with stage 11 b necrotizing enterocolitis. J Clin Neonatol [serial online] 2021 [cited 2021 Dec 2];10:248-50. Available from: https://www.jcnonweb.com/text.asp?2021/10/4/248/326617




  Introduction Top


Necrotizing enterocolitis (NEC) is a gastrointestinal inflammatory disorder, primarily affecting preterm and low-birth-weight infants, which establishes itself amplified and severe in a milieu of intestinal immaturity, thereby increasing the risk of pathogenic bacterial invasion.[1] It is the most common surgical complication seen in preterm and low-birth-weight babies with high morbidity and mortality.[2] The pathogenesis of NEC is multifactorial, main factors being gut colonization with bacteria, formula feeding, and prematurity.[3] The important clinical manifestations of NEC include feed intolerance, abdominal distension, and blood in stools.[2] The pathognomic radiographic signs of NEC include pneumatosis intestinalis and portal venous gas. The most common causative organisms of NEC include bacteria such as Klebsiella, Clostridium, and Escherichia coli.[4] Coronavirus too is also associated in the pathogenesis of NEC.[5] In the current pandemic due to severe acute respiratory syndrome coronavirus-2 (SARS-Co V2), COVID-19 adults were found to be predominantly affected while children were relatively spared. Newborns born to COVID positive were mostly found to be asymptomatic. With evolving alpha, beta, and delta mutant strains of SARS-CoV2, children are now becoming more and more symptomatic.[6],[7],[8] This prompted WHO to develop a preliminary case definition of severe form of COVID in children and named it as multisystem inflammatory syndrome in children (MIS-C) and adolescents.[9] With India just crossing the peak of second wave cases of MIS-C are now being reported in infants and older children. To the best of my knowledge, this is the first case report of MIS-C in a COVID-19-positive neonate who had NEC as a presenting symptom.


  Case Report Top


A late preterm (34 weeks) male baby weighing 2.2 kg was born by normal vaginal delivery to COVID-positive primigravida mother. Baby cried immediately after birth with APGAR score of 8 and 9 at 1 and 5 min, respectively. Mother had no antenatal risk factors. Her serology for venereal disease research laboratory, HIV, Hepatitis Bs ag, and TORCH were negative. Baby had respiratory distress since birth, hence was admitted in special care new-born unit of district hospital. He was managed with oxygen, antibiotics (ampicillin and gentamicin), and intravenous (iv) fluid. The baby developed feed intolerance on day 6 of life and abdominal distention on day 7 of life; hence on day 8 of life, he was referred to our hospital which is a tertiary care center. On admission, baby was afebrile (temperature of 98.6 F) dehydrated (weighing 2.07 kg) tachypneic with respiratory rate of 76/min, in shock with delayed CRT of >3 s and heart rate of 126 beats/min and maintaining Spo2 of 92% at room air. Baby was lethargic; random blood sugar by the glucometer was 43 mg/dl; abdomen was distended and tense; anterior fontanelle was at level. The chest and cardiovascular examination was normal. There was bilious discharge in the nasogastric tube and abdominal girth was 33 cm. Laboratory results revealed a mild metabolic acidosis (base deficit of − 8) and hyponatremia (129 mEq/L). He had neutropenia with absolute neutrophil count 1404 with total leukocyte count of 3900/cu. mm. and platelet count of 35,000. Blood urea was 74.5 mg/dl serum creatinine was 1.91 mg/dl, serum albumin was 2.6 g/dl (3.8–5.4 g/dl is normal). His liver function test was within the normal limits. Serial abdominal X-ray's showed distended bowel loops dilated bowel loops (often asymmetrical in distribution) with loss of polygonal gas shape [Figure 1]. Ultrasound abdomen showed distended bowel loops with thickened bowel and bowel wall edema. Serum C-reactive protein (CRP) was 49.26 mg/dl (<10 mg/dl normal). Serum procalcitonin (PCT) was 3.6 ng/ml (<0.1 ng/ml is normal). Prothrombin time international normalized ratio was deranged. Stool occult blood was positive. Urine analysis showed protein +1, pus cells 1–2/hpf, and red blood cell was absent. Blood and urine cultures were sterile. Chest X-ray was normal. COVID reverse transcription polymerase chain reaction was positive (Gene E computed tomography [CT] value 27 and Rd Rp + N gene CT value 27). COVID antigen test was positive. Child was put nil per orally, started on total parental nutrition along with iv antibiotics (cefotaxime and amikacin). As there was no improvement on day 5 of admission, antibiotics were upgraded to meropenem and IV immuneglobulin (IVIG) was given. Post-IVIG child improved dramatically abdominal distention decreased and feed (mothers milk) was gradually reintroduced on day 8 of admission (day 16 of life). Baby was then discharged after 15 days of neonatal intensive care unit (NICU) stay. He remained COVID positive even on discharge. His inflammatory markers decreased after IVIG but remained high until discharge. Serum CRP was 12.39 mg/dl (<10 mg/dl normal) and serum PCT was 0.34 ng/ml (<0.1 ng/ml is normal) on discharge.
Figure 1: Gross dilatation of small bowel loops with thin lucency outlining the circumferential margin seen

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  Discussion Top


COVID-19 caused by the novel coronavirus SARS-CoV-2 is the most important health calamity of the century and the greatest challenge that humankind faced since the Second World War. India reported its first case of COVID-19 in January 30, 2020. During the first wave of pandemic, clinical manifestations of COVID-19 were found to be milder in children as compared to adults. With ever evolving mutant strains, the second wave was found to be more severe. In this second wave, children too were found to be symptomatic and case reports of MISC started to be appear.[10] There were occasional case reports of MISC in COVID-positive newborns from countries such as Mexico[11] and China.[12] However, to the best of our knowledge, our case is the first case report of MISC in newborn to be reported from India. Moreover, this is also the first case report where a COVID-positive newborn had presented with Stage 111A necrotizing enterocolitis (NEC). Staging of NEC was proposed by Dr. Martin Bell.[13] He had outlined the three stages to enhance the recognition and diagnosis of NEC. Based on this staging, our case developed Stage 1 NEC at day 6 of life when he had developed feed intolerance and abdominal distension. He was later admitted in our hospital at day 8 of life and rapidly progressed through Stage 11 b within a week. He became lethargic, abdomen became tense; there was bilious discharge and blood in stools. His laboratory parameters revealed mild metabolic acidosis, coagulopathy hyponatremia, and thrombocytopenia. There was no obvious microbial cause of inflammation, including bacterial sepsis, staphylococcal, or streptococcal shock syndromes. He was COVID positive had Stage 11b NEC with elevated markers of inflammation (both CRP and PCT), without any features suggestive of bacterial sepsis. Hence, he fitted into the diagnosis of MIS-C coined by the WHO.[9] Baby was COVID positive within 24 h of birth and was symptomatic since birth requiring NICU care. This suggests the vertical transmission of COVID-19 from mother. Very few case reports suggesting vertical transmission are available in literature.[12],[14],[15] Besides vertical transmission, baby developed NEC Stage 1 within a week of delivery and rapidly progressed to Stage 11 b in another 5 days responding only after IVIG was introduced to treatment.


  Conclusion Top


To the best of our knowledge, this is the first reported case of a newborn with MIS-C with Stage 11b NEC. This case could be considered both as NEC or part of MIS-C. With evolving mutations, COVID-19 is becoming more and more precarious for children, particularly new-borns. Hence, we need to have to prepare our neonatal setups for the possible increases in cases of symptomatic new-borns with COVID-19.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest



 
  References Top

1.
Chu A, Hageman JR, Caplan MS. Necrotizing enterocolitis: Predictive markers and preventive strategies. N Rev 2013;14:113-20.  Back to cited text no. 1
    
2.
Neu J, Walker AW. Necrotizing enterocolitis. N Engl J Med 2011;364:255-64.  Back to cited text no. 2
    
3.
Lin PW, Nasr TR, Stoll BJ. Necrotizing enterocolitis: Recent scientific advances in pathophysiology and prevention. Semin Perinatol 2008;32:70-82.  Back to cited text no. 3
    
4.
Smith B, Bodé S, Petersen BL, Jensen TK, Pipper C, Kloppenborg J, et al. Community analysis of bacteria colonizing intestinal tissue of neonates with necrotizing enterocolitis. BMC Microbiol 2011;11:73.  Back to cited text no. 4
    
5.
Chany C, Moscovici O, Lebon P, Rousset S. Association of coronavirus infection with neonatal necrotizing enterocolitis. Pediatrics 1982;69:209-14.  Back to cited text no. 5
    
6.
Shekerdemian LS, Mahmood NR, Wolfe KK, Riggs BJ, Ross CE, McKiernan CA, et al. Characteristics and outcomes of children with coronavirus disease 2019 (COVID-19) infection admitted to US and Canadian pediatric intensive care units. JAMA Pediatr 2020;174:868-73.  Back to cited text no. 6
    
7.
Qiu L, Jiao R, Zhang A, Chen X, Ning Q, Fang F, et al. A case of critically Ill infant of coronavirus disease 2019 with persistent reduction of T lymphocytes. Pediatr Infect Dis J 2020;39:e87-90.  Back to cited text no. 7
    
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Kamali Aghdam M, Jafari N, Eftekhari K. Novel coronavirus in a 15-day-old neonate with clinical signs of sepsis, a case report. Infect Dis (Lond) 2020;52:427-9.  Back to cited text no. 8
    
9.
World Health Organization. Multisystem Inflammatory Syndrome in Children and Adolescents with COVID-19. Available from: https://www.who.int/teams/health-care- readiness-clinical-unit/covid-19/data- platform/. [Last accessed on 2021 Jun 06].  Back to cited text no. 9
    
10.
Jain S, Sen S, Lakshmivenkateshiah S, Bobhate P, Venkatesh S, Udani S, et al. Multisystem inflammatory syndrome in children with COVID-19 in Mumbai, India. Indian Pediatr 2020;57:1015-9.  Back to cited text no. 10
    
11.
Hinojosa-Velasco A, de Oca PV, García-Sosa LE, Mendoza-Durán JG, Pérez-Méndez MJ, Dávila-González E, et al. A case report of newborn infant with severe COVID-19 in Mexico: Detection of SARS-CoV-2 in human breast milk and stool. Int J Infect Dis 2020;100:21-4.  Back to cited text no. 11
    
12.
Wang S, Guo L, Chen L, Liu W, Cao Y, Zhang J, et al. A case report of neonatal 2019 coronavirus disease in China. Clin Infect Dis 2020;71:853-7.  Back to cited text no. 12
    
13.
Bell MJ, Ternberg JL, Feigin RD, Keating JP, Marshall R, Barton L, et al. Neonatal necrotizing enterocolitis. Therapeutic decisions based upon clinical staging. Ann Surg 1978;187:1-7.  Back to cited text no. 13
    
14.
Alzamora MC, Paredes T, Caceres D, Webb CM, Valdez LM, La Rosa M. Severe COVID-19 during pregnancy and possible vertical transmission. Am J Perinatol 2020;37:861-5.  Back to cited text no. 14
    
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Lowe B, Bopp B. COVID-19 vaginal delivery – A case report. Aust N Z J Obstet Gynaecol 2020;60:465-6.  Back to cited text no. 15
    


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