Giant intracardiac thrombosis in an infant with leukaemia and prolonged COVID-19 viral RNA shedding: a case report

Children with SARS-CoV-2 infection during the novel coronaviral disease (COVID-19) outbreak in Iran: an alarming concern for severity and mortality of the disease

BACKGROUND

The rapid worldwide spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections led to public health crises globally and the number of pediatric patients with Coronavirus Disease 2019 (COVID-19) is still rising. The aim of this study was to describe the epidemiological, clinical, laboratory, and imaging features of hospitalized patients with COVID-19 at an Iranian referral pediatrics hospital and to compare these parameters between hospitalized patients with and without severe disease, multisystem inflammatory syndrome in children (MIS-C) and children with acute COVID-19, as well as deceased and discharged cases.

METHODS

This study included hospitalized children and adolescents (≤ 18 years) with suspected COVID-19 who had positive results for SARS-CoV-2.

RESULTS

Among the 262 patients with suspected COVID-19, 142 confirmed COVID-19 cases were included in the study. A total of 11 children were diagnosed as MIS-C. The majority of the cases with MIS-C were male, (n = 9, 82%) which is significantly higher than children (n = 61, 47%) with acute COVID-19 (P = 0.03). Fifty patients (35%) were shown to have a more severe form of COVID-19. Ninety percent of the cases (n = 45) with severe COVID-19 had comorbidities that was significantly higher than cases with non-severe or mild disease (n = 41, 45%; P < 0.0001). A mortality rate of 10% was reported (n = 14). Ninety-three percent of the deceased cases (n = 13) had comorbidities that were significantly higher than discharged patients (n = 73, 57%; P = 0.009).

CONCLUSION

The increasing number of children with severe COVID-19 is cause for great concern. Underlying diseases, mainly cardiovascular diseases, cancer, and malignancies, are associated with greater risk of development of severe COVID-19 and even death in children. On the other hand, pediatric patients with MIS-C usually develop a milder form of the disease. However, evaluation specific immunological responses in children to explore the delayed inflammatory syndrome are highly recommended.

Thromboembolic complications in children with COVID-19 and MIS-C: A narrative review

COVID-19 and multisystem inflammatory syndrome in children (MIS-C) have been associated with a higher incidence of hypercoagulability and thromboembolic events (TEs), even in children, leading to relevant morbidity, and mortality. However, our understanding of such complications in childhood is limited. To better understand the incidence, clinical manifestations, risk factors, and management of COVID-19 and MIS-C-related TEs in children, a review of the current literature and a brief update on pathophysiology are given. Sixty-two studies, describing 138 patients with TEs associated with COVID-19 or MIS-C, were included. The overall number of TEs was 157, as 16 patients developed multiple TEs: venous TEs represented the majority (54%), followed by arterial thrombosis (38%, mainly represented by arterial ischemic stroke-AIS), and intracardiac thrombosis (ICT) (8%). Within the venous TEs group, pulmonary embolism (PE) was the most frequent, followed by deep venous thrombosis, central venous sinus thrombosis, and splanchnic venous thrombosis. Notably, 10 patients had multiple types of venous TEs, and four had both venous and arterial thrombosis including a newborn. Most of them (79 cases,57%) had at least one predisposing condition, being obesity the most frequent (21%), especially in patients with PE, followed by malignancy (9%). In 35% of cases, no data about the outcome were available About one-third of cases recovered, 12% improved at discharge or follow-up, and 6% had persistent neurological sequelae. The mortality rate was 12%, with death due to comorbidities in most cases. Most fatalities occurred in patients with arterial thrombosis. Pediatricians should be aware of this life-threatening possibility facing children with SARS-CoV-2 infection or its multisystemic inflammatory complication, who abruptly develop neurological or respiratory impairment. A prompt intensive care is essential to avoid severe sequelae or even exitus.

Incidental diagnosis of a large cardiac thrombus swinging through an interatrial communication in a COVID-19 patient: Case report and literature review

Introduction

The hypercoagulability state induced by COVID-19 has been well established and various forms of subsequent thromboembolic events have been reported throughout literature including multiple cases of intracardiac thrombi, four of which in our center alone, this case being the fifth.

Case report

We report the case of a 38-year-old male with no prior cardiovascular history who -subsequently to a COVID-19 infection-developped a right atrial thrombosis associated to a pulmonary embolism, and in whom cardiography revealed an interatrial communication. Management relied upon curative doses of low molecular weight heparin (LMWH) with favourable outcome.

Discussion

In our discussion, we lay out the various physiopathological mechanisms incriminated throughout literature in the genesis of a hypercoagulability state distinctive of COVID-19, before highlighting the incidence of an interatrial communication (whether a Potent Foramen Ovale or Atrial Septal Defect) discovered in patients with COVID-19, and the potential paradoxical embolization risks they imply as well as reported cases. A mention of hemostatic parameters monitored was also warranted. Finally we discuss the guidelines in terms of prophylactic and therapeutic anticoagulation in hospitalized patients before discussing cardiac thrombosis's therapeutic options.

Conclusion

Our case highlights various key points which could change the prognosis of COVID-19 patients, whether related to the underdiagnosis of interatrial abnormalities or with regards to the diagnosis to thromboembolic events, but also the indisputable place of anticoagulation in COVID-19 management.

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Thromboembolic events complicating COVID-19 have been well described and are attributed to a hypercoagulability state distinctive of COVID-19.

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A pre-existing Potent Foramen Ovale (PFO) or Atrial septal Defect (ASD) in COVID-19 patients is unknown as only a handful of studies covered the subject.

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The association of a cardiac thrombosis with a pulmonary embolism and interatrial communication exposes patients to risks of paradoxical embolization and subsequent arterial thrombotic events.

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Prophylactic and curatrive anticoagulation is unrefutably a key pillar in the management of COVID-19.