SARS-CoV-2 and Respiratory Syncytial Virus Coinfection in Hospitalized Pediatric Patients

Abstract

was gradually tapered over 2 weeks then stopped; Sildenafil and Furosemide were stopped before discharge on day 34. At discharge, the baby was exclusively breast-feeding, neurologically stable, and had normal echocardiographic findings. He was well at followup after 7 days and at age 2 months; his declining antibody titers (Table 1) suggested transplacental transfer.In view of the positive anti-SARS-CoV-2 IgG antibodies in both baby and mother, transplacental transfer of maternal antibodies was considered to have potentially contributed to the hyperinflammatory response with cytokine storm seen in the neonate. A potentially MIS-C syndrome-like presentation was thought likely with multisystem involvement including lungs, skin, gut, and heart, with raised inflammatory markers (Table 1). The initial PPHN observed may have been part of the inflammatory cascade, thus accounting for the initial presentation in the absence of significant birth asphyxia, meconium aspiration, and minimal need for resuscitation at birth. DISCUSSIONThe diagnosis of MIS-C is based on 6 criteria: pediatric age, persistence of fever, presence of laboratory markers of inflammation, manifestation of signs or symptoms of organ dysfunction, lack of an alternative diagnosis, and a temporal relation to COVID-19 infection or exposure. 6 MIS-C typically presents around 3-4 weeks after acute SARS-CoV-2 infection; many affected children have positive antibodies to SARS-CoV-2, but negative PCR at the time of evaluation for MIS-C. 6 The presentation in the infant described may be a case of MIS-C in a neonate without direct evidence of SARS-CoV-2 infection but whose mother had evidence of SARS-CoV-2 infection about 3 weeks before delivery and subsequent transplacental transfer of maternal SARS-CoV-2 IgG antibodies. The pyrexial response in neonates is usually poorly developed, and the criteria suggested for diagnosing MIS-C in children may not be entirely applicable to the neonates.Transplacental transfer of specific SARS-CoV-2 IgG antibodies when measured in infants were similar to that of the mother and is thought to confer the neonate with passive immunity. [2][3][4][5] Analysis of EBM from 14 mothers following recovery from SARS-CoV-2 infection detected both IgM and IgG antibodies to SARS-CoV-2, confirming passive transfer of antibodies. 7 Although harm has not been demonstrated due to the transfer of maternal IgG antibodies to SARS-CoV-2 infection, [3][4][5]7 from anecdotal experience in older children, antibody dependent enhancement responses have been implicated in induced immune injury where low-titer neutralizing antibodies may accentuate viral triggered immune responses causing the cascade of inflammatory cytokines. [8][9][10] In our case, the transfer of maternal antibodies transplacentally and through EBM may have led to a hyperinflammatory state with cytokine storm and may have been responsible for the MIS-C like presentation. CONCLUSIONSWe believe this case to be first in the literature to report MIS-C in a neonate and highlights the imp...

Sequential infections with rhinovirus and influenza modulate the replicative capacity of SARS-CoV-2 in the upper respiratory tract

“…Several studies have recently reported the co-detection of SARS-CoV-2 with additional respiratory viruses in co-infected children and adults [ 3–5 ]. However, conflicting results were found in terms of clinical relevance [ 6 , 7 ]. Questions remain regarding the impact of co-infections on virus replication and disease severity and the mechanisms involved.…”

Prevalence and Clinical Impact of Coinfection in Patients with Coronavirus Disease 2019 in Korea

“…Concordant with the results of previous studies [14,18,21], RSV, HRV, and influenza were commonly detected in this study. Coinfection with RSV is associated with a longer length of stay [22]. HRV with a long period of viral shedding and environmental resistance [23] has been associated with higher morbidity rather than mortality, causing an economic burden [24].…”

SARS-CoV-2 and rhinovirus infections: are there differences in clinical presentation, laboratory abnormalities, and outcomes in the pediatric population?

“…Alvares 11 compared children with solely SARS-CoV-2 infection versus SARS-CoV-2/RSV coinfection and demonstrated longer hospitalizations in the coinfection group. Here, coinfection rates of SARS-CoV-2 were low, as reported in other studies 2 , 9 , 12 .…”