Necrotizing Enterocolitis-like Pneumatosis Intestinalis in an Infant With COVID-19

Neonatal necrotizing enterocolitis due to a COVID-19. A case report

Digestive symptoms have been reported in an important proportion of children with COVID-19, and the clinical expression of critical patients with COVID-19 is thought to result from progressive increase of inflammation and an unusual trend of hypercoagulation. We report a newborn received with abdominal distension, green vomiting and imaging suggestive for enterocolitis. He had a close contact with COVID-19 and the PCR for SARS-CoV-2 came back positive. Despite the supportive measures, his condition deteriorated and a surgery was decided. The surgical exploration found an ischemic bowel. The therapeutic measures were ineffective as the child passed away a few hours after surgery despite the resuscitation treatment performed. The confirmed enterocolitis happening within the period of acute infection by SARS-CoV-2, the NEC was likely a manifestation of COVID-19.

Gastrointestinal tract lesion in children with COVID-19: from pathogenesis to clinical manifestations

Since the beginning of the pandemic, the new coronavirus infection has been regarded primarily as a respiratory disease. By now, it has become obvious that COVID-19 is a systemic infectious process with multiple organ damage. Having affinity for ACE-2 receptors, the virus can infect the cells of the respiratory tract, as well as the cells of the cardiovascular and nervous systems and smooth muscle structures of various organs. Expression of ACE-2 by enterocytes of the small intestine makes the gastrointestinal tract vulnerable in COVID-19 disease and leads to the manifestation of symptoms of gastrointestinal damage, which is often observed in clinical practice. Gastrointestinal symptoms usually include anorexia, nausea, vomiting, diarrhea, and abdominal pain, which can occur both at the onset and during the disease. Several mechanisms are described to explain these changes in COVID-19. 

SARS CoV-2 detected in neonatal stool remote from maternal COVID-19 during pregnancy

BACKGROUND

In utero transmission of SARS coronavirus 2 (SARS-CoV-2) has not been fully investigated. We investigated whether newborns of mothers with COVID-19 during pregnancy might harbor SARS-CoV-2 in the gastrointestinal tract.

METHODS

This cohort study investigated stool from 14 newborns born at 25-41 weeks admitted at delivery to our urban academic hospital whose mothers had COVID-19 during pregnancy. Eleven mothers had COVID-19 resolved more than 10 weeks before delivery. Newborn stool was evaluated for SARS-CoV-2 RNA, Spike protein, and induction of inflammatory cytokines interleukin-6 (IL-6) and interferon-γ (IFN-γ) in macrophages.

RESULTS

Despite negative SARS CoV-2 nasal PCRs from all newborns, viral RNAs and Spike protein were detected in the stool of 11 out of 14 newborns as early as the first day of life and increased over time in 6. Stool homogenates from all 14 newborns elicited elevated inflammatory IL-6 and IFN-γ from macrophages. Most newborns were clinically well except for one death from gestational autoimmune liver disease and another who developed necrotizing enterocolitis.

CONCLUSIONS

These findings suggest in utero transmission of SARS-CoV-2 and possible persistent intestinal viral reservoirs in the newborns. Further investigation is required to understand the mechanisms and their clinical implications.

IMPACT

SARS-CoV-2 RNAs or Spike protein was detected in the stool of 11 out of 14 preterm newborns born to mothers with resolved COVID-19 weeks prior to delivery despite negative newborn nasal PCR swabs. These novel findings suggest risk of in utero SARS-CoV-2 transmission to the fetal intestine during gestation. The presence of SARS-CoV-2 RNAs and Spike protein in the intestines of newborns may potentially impact the development of the gut microbiome and the immune system; the long-term health impact on the preterm infants should be further investigated.

Coagulation Abnormalities and Clinical Complications in Children With SARS-CoV-2: A Systematic Review of 48,322 Patients

Given the limited information on the coagulation abnormalities of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in pediatric patients, we designed a systematic review to evaluate this topic. A comprehensive literature search was conducted for "SARS-CoV-2," "coagulopathy," and "pediatrics." Two authors independently screened the articles that the search returned for bleeding, thrombosis, anticoagulant and/or antiplatelet usage, and abnormal laboratory markers in pediatric patients with SARS-CoV-2, and the authors then extracted the relevant data. One hundred twenty-six publications were included. Thirty-four (27%) studies reported thrombotic complications in 504 patients. Thirty-one (25%) studies reported bleeding complications in 410 patients. Ninety-eight (78%) studies reported abnormal laboratory values in 6580 patients. Finally, 56 (44%) studies reported anticoagulant and/or antiplatelet usage in 3124 patients. The variety of laboratory abnormalities and coagulation complications associated with SARS-CoV-2 presented in this review highlights the complexity and variability of the disease presentation in infants and children.

Premature twin neonates with a Coronavirus-19 positive mother present with an unusual pattern of intestinal ischemia

COVID-19 infection during pregnancy is associated with premature rupture of membranes, preterm delivery, and low birth weight. It has also been associated with hypercoagulability and vasculitis in certain patients. This article reports two premature twins born from a COVID-19 mother who presented with an unusual pattern of ileal ischemia and perforation within 24 hours of each other. We suggest that maternal infection with the novel coronavirus might lead to this atypical distribution of intestinal pathology.

Severe acute respiratory syndrome coronavirus 2 pandemic related morbidity and mortality in patients with pediatric surgical diseases: A concerning challenge

The global spread of the novel severe acute respiratory syndrome coronavirus 2 has had serious consequences in terms of patient morbidity and mortality and overburdened health care systems as well as the socioeconomic implications. In the absence of effective therapies and vaccinations during the viral outbreak, the major and most concise means to control viral spread is spread prevention. Although information concerning the impact of severe acute respiratory syndrome coronavirus 2 on pediatric surgical patients has greatly expanded, relevant comprehensive studies are scarce. However, pandemic related morbidity has increased, while under normal circumstances mortality could have been minimized.

Necrotizing Enterocolitis in a 34-Week Premature Infant with COVID-19

Coronavirus disease 2019 (COVID-19) is a viral respiratory infection caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). While SARS-CoV-2 is a leading cause of morbidity and mortality in older adults, COVID-19 also affects newborn infants in nurseries and the Neonatal Intensive Care Units (NICUs). The majority of infected neonates are believed to acquire SARS-CoV-2 by horizontal transmission, and most of them have asymptomatic or mild symptomatic infections. In rare cases, infants with COVID-19 may have severe complications resulting in death. We report a case of COVID-19 in a premature neonate born at 34 weeks gestational age who presented with hypothermia and respiratory distress and subsequently developed clinical and radiological signs of necrotizing enterocolitis (NEC). The neonate received medical management, including antibiotics, suspension of gastric feeds, and intensive NICU support. The neonate's clinical condition improved without surgical intervention, and after 10 days of antibiotics and gradual reestablishment of gastric feeds, patient health condition returned to normal, and weeks later, he was discharged home. COVID-19 in infants is frequently asymptomatic or associated with mild disease, and in rare cases, it may be associated with severe gastrointestinal complications including NEC.

A Systematic Review of Abdominal Imaging Findings in COVID-19 Patients

OBJECTIVE

The objective of this systematic review was to evaluate key imaging manifestations of COVID-19 on abdominal imaging by utilizing a comprehensive review of the published literature.

METHOD

A systematic literature search from PubMed, Google Scholar, and Scopus was performed for studies mentioning abdominal imaging findings in COVID-19 patients. Studies published from inception to 15 March 2021 were included.

RESULTS

A total of 116 studies comprising 1,198 patients were included. Abdominal pain was the most common indication for abdominal imaging in 50.2% of the patients. No abnormality was seen in 48.1% of abdominopelvic computed tomography scans. Segmental bowel wall thickening (14.7%) was the most common imaging abnormality, followed by bowel ischemia (7.1%), solid organ infarction (6.7%), vessel thrombosis (6.7%), and fluid-filled colon (6.2%). Other relevant findings were dilated air-filled bowel, pancreatitis, pneumatosis/portal venous gas, bowel perforation, and appendicitis. Other than abdominal findings, COVID-19-related basal lung changes were incidentally detected in many studies. Moreover, the presence of bowel imaging findings was positively correlated with the clinical severity of COVID-19 infection.

CONCLUSION

This review describes the abdominal imaging findings in COVID-19 patients. This is pertinent for the early diagnosis of COVID-19 in patients presenting solely with abdominal symptoms as well as in identifying abdominal complications in a known case of COVID-19.

Comparison of Necrotizing Enterocolitis in Pre-mature Infants vs. Term-Born Infants With Congenital Heart Disease

Purpose: Necrotizing enterocolitis (NEC) is a serious illness that occurs among premature infants and term-born infants with congenital heart disease (CHD). Prior studies have suggested these two groups may experience different disease entities. We sought to evaluate if there are differences in disease characteristics between these two populations. Materials and Methods: A retrospective chart review of infants treated for Bells stage 2-3 NEC from 2011 to 2020 was performed. Demographic information, CHD diagnoses and clinical data were recorded. Prior to data analysis, patients were divided into two groups: term-born patients with CHD (TC) and premature patients without CHD (PT). Results: 99 patients were analyzed-23 TC patients and 76 PT patients. Platelet counts (222.7 ± 176.1 vs. 310.2 ± 174.5 cells/uL, P = 0.03) and C-reactive protein (CRP) levels (53.6 ± 81.7 vs. 117.6 ± 90.4 mg/L, P < 0.001) were significantly higher among the PT group. In addition, PT patients were more likely to develop pneumatosis (30.4 vs. 68.4%, P = 0.002) than TC patients. NEC-specific mortality was similar between both groups of patients. Conclusions: When compared to TC patients, PT patients had higher CRP levels, higher platelet counts and more commonly developed pneumatosis. These factors may point toward a difference in disease pathophysiology regarding NEC development in premature patients vs. term-born patients with CHD.