Convalescent Plasma Therapy in Four Critically Ill Pediatric Patients With Coronavirus Disease 2019: A Case Series

Abstract

Background: Coronavirus disease 2019 is a pandemic with no specific therapeutic agents or vaccination. Small published case series on critically ill adults suggest improvements in clinical status with minimal adverse events when patients receive coronavirus disease 2019 convalescent plasma, but data on critically ill pediatric patients are lacking. We report a series of four critically ill pediatric patients with acute respiratory failure who received coronavirus disease 2019 convalescent plasma as a treatment strategy for severe disease. Case Summary: Patients ranged in age from 5 to 16 years old. All patients received coronavirus disease 2019 convalescent plasma within the first 26 hours of hospitalization. Additional disease modifying agents were also used. All patients made a full recovery and were discharged home off of oxygen support. No adverse events occurred from the coronavirus disease 2019 convalescent plasma transfusions. Conclusion: Coronavirus disease 2019 convalescent plasma is a feasible therapy for critically ill pediatric patients infected with severe acute respiratory syndrome coronavirus 2. Well-designed clinical trials are necessary to determine overall safety and efficacy of coronavirus disease 2019 convalescent plasma and additional treatment modalities in pediatric patients.

The use of convalescent plasma for pediatric patients with SARS-CoV-2: A systematic literature review

“…Table 1 presents the characteristics of the studies included in the final review. Three case reports included patients (n = 9) without comorbidity [ [17] , [18] , [19] ]; 5 reported on patients (n = 5) with a comorbid condition: one each with agammaglobulinemia [ 20 ], aplastic anemia and severe pancytopenia [ 21 ], acute lymphoblastic leukemia [ 22 ], trisomy 21 with congenital heart disease [ 23 ], and juvenile myelomonocytic leukemia [ 24 ].

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“…Clinical conditions at admission before treatment were severe, including pneumonia [ 20 , 22 , 24 ], respiratory failure [ 17 , 18 ], and (multi)organ failure [ 21 , 23 , 19 ]. Among the additional drug treatments administered during hospital stay, the most frequent was remdesivir (n = 5) [ 20 , 22 , 17 , 23 , 19 ]. Five case reports described the use of CP antibodies against SARS-CoV-2 IgG [ 21 , 17 , 23 , 18 , 24 ], whereas 3 did not [ 20 , 22 , 19 ].…”

“…Among the additional drug treatments administered during hospital stay, the most frequent was remdesivir (n = 5) [ 20 , 22 , 17 , 23 , 19 ]. Five case reports described the use of CP antibodies against SARS-CoV-2 IgG [ 21 , 17 , 23 , 18 , 24 ], whereas 3 did not [ 20 , 22 , 19 ]. No CPT-related adverse events were reported in 5 studies [ 21 , 17 , 18 , 24 , 22 ], and 3 studies made no mention of adverse events [ 20 , 23 , 19 ].…”

“…Five case reports described the use of CP antibodies against SARS-CoV-2 IgG [ 21 , 17 , 23 , 18 , 24 ], whereas 3 did not [ 20 , 22 , 19 ]. No CPT-related adverse events were reported in 5 studies [ 21 , 17 , 18 , 24 , 22 ], and 3 studies made no mention of adverse events [ 20 , 23 , 19 ]. Patient outcomes were reported as recovery and/or discharge from hospital (n = 6) [ 20 , 22 , 17 , 23 , 19 , 24 ] or as amelioration of markers of SARS-CoV-2 infection [ 21 , 18 ].…”

“… At 5 wks: CP* with antibodies against IgG titer 1:700 once in a 200 mL/dose Poor effect of treatment: IVIG, lopinavir-ritonavir + steroid Negative SARS-CoV-2 RNA in nasopharyngeal swabs (3 wks); hematologic parameters (pancytopenia) did not improve; no adverse events In patients with pancytopenia, transfusion of CP* could be an option Shankar AU, et al (2020) [ 22 ] Case report India 4-year-old girl Acute lymphoblastic leukemia Chest X-ray: bilateral fluffy opacities; hypoxia with increasing oxygen requirement to 7 L/min with face mask RT-PCR*** for SARS-COV-2 RNA from nasopharyngeal swab CP* 15 mL/kg on day 8 and 9. Lopinavir-ritonavir and remdesivir dexamethasone (0.2 mg/kg) and IVIG (1 g/kg) Children with cancer (high-risk population); severe COVID-19 associated pneumonia Remarkable improvement with reduction in respiratory rate, work of breathing and oxygen requirement (10 dys) No transfusion reaction Positive outcome following use of IVIG, steroids and CP* alone Schwartz SP, et al (Oct 2020) [ 17 ] Case report (n = 4) USA 1) 15-year-old obese Hispanic male; 2) 16-year-old obese Asian male; 3) 5-year-old Hispanic female; 4) 12-year-old obese Hispanic female None Acute respiratory failure requiring high-flow nasal cannula (HFNC) at admission Anti-SARS-CoV-2 antibodies targeted to RBD** of SARS-CoV-2 spike protein CP* units transfused: Case 1) no. 2 (RBD** binding titer 1:160; same donor); Remdesivir.…”