Discussion
Severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) is the third virus of the twenty-first century to become a global concern2. The clinical picture of COVID 19 infection in the pediatric population seems more indistinct and less severe than in adults, with the most common symptoms being fever, cough, dyspnea, and malaise3. These symptoms are extremely common among children with a variety of respiratory diseases, which they are highly susceptible to due to their developing immune systems. This is thought to be a contributing factor to the delayed presence of published pediatric cases with COVID-19 infection and their particular ways of disease presentation4. Children are susceptible to infection with COVID 19 virus as it is mainly transmitted via respiratory droplets5. The incubation period in children is similar to adults and is about 1 to 14 days, up to 24 days. Children, generally, have immature immunity, and some exhibit a long incubation period after SARS‐CoV‐2 infection6.
Newborns can also be infected with SARS-CoV-2 due to the immaturity of their immune systems; however, uncommon presentations have been associated with this age group2. In the few published cases of COVID-19 in neonates, the presentation was that of late neonatal sepsis; interestingly, the lung involvement was not as common as in the older children and adults7.
Our patient presented in her neonatal period with pulmonary hemorrhage, which has been reported in adults, but rarely in children with COVID 19 infection8. It is such a diagnostic challenge because it can be caused by multiple alternative diagnoses, such as chest infections and ANCA vasculitis. However, history, examination, and workup can give a clue to whether the pulmonary hemorrhage is caused by diseases other than COVID-19 infection. For example, a key distinguishing feature between ANCA-positive vasculitis and COVID-19 infection in adults and children who can cough is the presence of hemoptysis. The literature suggests that hemoptysis is uncommon in COVID-19 and has a symptom prevalence of 2%9.
Regarding the etiology of pulmonary hemorrhage in patients with COVID 19, some case reports in adults suggested that patients with COVID infection had increased inflammatory states that led to developing vasculitis and consequently pulmonary hemorrhage10. Autopsies performed on deceased adult patients revealed that pulmonary hemorrhage was interestingly associated with the inappropriate formation of thrombi. Furthermore, they showed signs of diffuse alveolar damage with a rich infiltrate of inflammatory cells, which could contribute to damage to small alveolar vessels1. Due to the rarity of cases of pulmonary hemorrhage in pediatrics, data about presumed etiology is limited and mostly adopted from adults. COVID 19 virus keeps showing itself in many unfamiliar ways, which leaves physicians in a challenging situation. The acuity of the cases often makes extensive investigations hard to achieve. However, it is necessary to rule out causes such as other viral infections, bacterial diseases, and states of coagulopathy before we can assume hemorrhage is caused primarily by the COVID 19 virus. The patient in our case underwent screening for infections and coagulation disorder and came out negative. Her young age and acute presentation make rheumatological diseases extremely unlikely. Up to our knowledge, this is the youngest age at which a patient with COVID-19 infection developed pulmonary hemorrhage with no other underlying cause of it.
Early bronchoalveolar lavage (BAL) is the diagnostic test needed to confirm diffuse alveolar hemorrhage. The gold standard is the sequential rise in red blood cells or haemosiderin-laden macrophages on repeat BAL9. This invasive procedure was not done in our case for two main reasons; First, she was clinically unstable to perform bronchoscopy. Secondly, the procedure is highly aerosol-generating that should only be performed in the most necessary of cases, to minimize the potential risk of COVID-19 transmission11.