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.