Discussion
We report for the first time to our knowledge a case of COVID-19 acute respiratory distress syndrome (ARDS) causing severe hypoxemia leading to bradycardic cardiac arrest and seizures in an ex-premature infant with comorbidity of bronchopulmonary dysplasia.
After the first detection of novel coronavirus 2019 (SARS-CoV-2) in China in early December 2019 initial studies showed most children were asymptomatic or had mild and moderate symptoms. (1) The percentage of severe and critical cases in the pediatric patients with COVID-19 was 5.9% compared to 18.5% in adult patients. Admission rates to PICU range from 9.7% among infected children to 20% of the hospitalized patients. (2,3) ARDS has been reported in 3-5.8% of all COVID19 patients and in about 60% of patients requiring ICU care in adults and children. Our patient met the Berlin criteria for severe ARDS with PaO2/FiO2 ratio < 100. Our patient had worsening hypoxemia and increased inflammatory markers of CRP and procalcitonin, low platelets and initial acute kidney injury similar to that seen by Chao and colleagues. (4) The severe transaminitis noted in our patient has not been reported in the pediatric studies published thus far. Our patient had several risk factors for impaired alveolarization and normal lung growth after birth secondary to the prolonged need for oxygen, non-invasive positive pressure ventilation and post-natal infection with human metapneumovirus. (5) The abnormal lung development in our patient put him at high risk for ARDS from COVID-19 that led to hypoxemic acute respiratory failure, bradycardic cardiac arrest and seizures. In conclusion, the various manifestations of COVID-19 in children are still not entirely known. Pediatricians and pediatric critical care physicians should be cognizant of the development of ARDS from SARS-CoV-2 infections in patients with comorbidity of prematurity and associated chronic lung disease as the various factors that interfere with their post natal lung development continue to be studied.