What Kept Back on the Mirror of COVID-19-Related Acute Transverse Myelitis? A Genetic Background!

COVID-19-associated acute transverse myelitis (ATM) cases have been reported worldwide. Nevertheless, Iran, Italy, and the USA are the most affected countries, witnessing the possibility that genetic factors might be associated with this susceptibility. The genetic variants of the coronavirus-2 entry mechanisms and host innate immune response-related genes like interferons, interleukins, Toll-like receptors, human leukocyte antigens, blood groups, and some risk loci may be accountable. This study describes the compatibility of the geographical distribution between ATM and the Neanderthal core haplotype that confers risk for severe COVID-19 and some possible culprit genes.

Multisystem inflammatory syndrome in a newborn (MIS-N): clinical evidence and neurodevelopmental outcome.

BACKGROUND: Although coronavirus disease-2019 (COVID-19) seems to be milder in children than in adults, children may exhibit severe multisystemic involvement, supported by growing evidence of this incidence in neonates. This case report aimed to demonstrate an inflammatory response syndrome in a full-term neonate born from a 35-year-old woman infected with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) . CASE PRESENTATION: A full-term neonate girl with uneventful perinatal history was admitted with mild tachypnea at the first hour of birth and getting worse gradually, resulting in subsequent ventilator support on the second day. The nasal SARS-CoV-2 real-time polymerase chain reaction (RT-PCR) test was positive in several cessations from the time of admission until the tenth day. She revealed cardiomegaly, a diffuse opacification of lungs in the chest radiograph, both side ventricular hypertrophy, valvular regurgitation, and severe pulmonary hypertension on echocardiography. She underwent treatment with surfactant, antibiotics, paracetamol, inotropes, and sildenafil, with beneficial effects. In the lack of a positive fluid culture, she developed necrotizing enterocolitis, transaminitis, and a generalized rash on day six. Furthermore, her mild brain edema that occurred on the second day developed into hydrocephaly. The patient was considered MIS-N and successfully treated with methylprednisolone pulse and intravenous immunoglobulin. She was discharged after 29-days and followed for eight months with persistent mild hydrocephalous and possible evidence of cerebral palsy. CONCLUSIONS: We conclude that maternal exposure to COVID-19 may potentially be associated with multisystem inflammation in the early neonatal period. However, this condition is relatively rare. Immunomodulatory agents may be beneficial in this condition.

Finding positive SARS-CoV-2 RT-PCR in cerebrospinal fluid of two pediatric patients with severe COVID-19: a brief case report.

BACKGROUND: There is growing evidence of nervous system involvement and related complaints in children with coronavirus disease 2019 (COVID-19). However, it seems that attempts to track of the virus in the nervous system have so far been unsuccessful. CASE PRESENTATION: Here we describe two pediatric cases of severe COVID-19 who had positive cerebrospinal fluid (CSF) and nasopharyngeal polymerase chain reaction (PCR) tests for severe acute respiratory syndrome coronavirus disease 2019 (SARS-CoV-2). A 36-month-old girl who presented with fever, diarrhea, mild left ventricular dysfunction and bizarre movements, and a five-month-old boy who presented with fever, watery diarrhea, severe dehydration, mottling, and two episodes of seizure. Their CSF analyses and cultures were normal. They admitted in intensive care unit (ICU) for near four days and discharged after ten days without any complaint. CONCLUSION: This is one of the first reports of the presence of coronavirus in the central nervous system in COVID-19 pediatric patients, emphasizing the neurotropism and neuroinvasion characteristics of the virus.

Sigmoid colon perforation in a SARS-CoV-2 positive neonate: a uniqueness report and a brief review.

BACKGROUND: Despite the relative prevalence of small bowel and proximal colon perforation in the neonatal period, recto-sigmoid perforation is extremely rare. Full-term neonates experience intestinal perforation less frequently than premature infants. Here we report a neonate with sigmoid perforation and simultaneous Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection. CASE PRESENTATION: A 2550 g female neonate born at 38-weeks' gestation from a coronavirus disease-2019 (COVID-19) infected mother by cesarean section. Despite a good Apgar score in the first and fifth minutes, she was admitted to the neonatal intensive care unit with grunting and mild respiratory distress. She underwent antibiotics and oxygen by head box resulting in an Oxygen Saturation rate of 94%. The patients' respiratory distress decreased during the second day, resulting once breastfeeding without tolerance. While she passed meconium in the first 2 days, she developed abdominal distention on day 3. The nasopharyngeal SARS-CoV-2 real-time polymerase chain reaction (RT-PCR) was performed with positive results. Surgical consultation was requested and a thoraco-abdominal X-Ray was performed at this stage, which suspected to be a gastrointestinal perforation. Due to clinical deterioration and persistent abdominal distention, a contrast study was performed with water-soluble contrast, which confirmed intestinal perforation. However, the surgical exploration revealed perforation of the sigmoid colon at the posterior segment. The patient underwent antibiotic therapy, abdominal lavage, and colostomy, immediately. She was discharged in good condition approximately 14-days later. CONCLUSION: To our knowledge, this is the first report of sigmoid colon perforation in a term neonate following COVID-19.

Post SARS-CoV-2 infection reactive arthritis: a brief report of two pediatric cases.

BACKGROUND: Although, preliminary reports of Severe Acute Respiratory Syndrome (SARS)-CoV-2 infection suggest that the infection causes a less severe illness in children, there is now growing evidence of other rare or even serious complications of disease. CASE PRESENTATION: During the recent COVID-19 pandemic in Kerman, Iran, two children (an 8 year-old boy and a 6 year-old girl) were referred to outpatient Clinic of Pediatric Rheumatology with complaints of limping. Both children had experienced fever and mild respiratory tract infection. At the beginning of the second week of infection, they developed joint effusion. They both tested positive for coronavirus infection and were therefore diagnosed with post Coronavirus reactive arthritis. Both children were treated successfully with rest and Non-Steroidal Anti-Inflammatory Drugs (NSAID). They did not have any medical problems in the two months fallow up. CONCLUSIONS: These two cases suggest that COVID-19 may be rheumatogenic. Highlighting the need for awareness of physicians, especially pediatricians, regarding the pathogenesis margins of this virus, as late presentations are of great importance.

Acute transverse myelitis of childhood due to novel coronavirus disease 2019: The first pediatric case report and review of literature.

The global coronavirus disease 2019 (COVID-19) pandemic appears to have some streaks of severity in pediatrics. These streaks include variable signs of respiratory distress, a new entity called multi-system inflammatory syndrome, and some evidences of neurological symptoms involving both central and peripheral nervous systems. Here, we described the first pediatric patient with COVID-19 who presented with acute transverse myelitis. An 11-year-old otherwise healthy girl presented to our clinic with acute onset of lower limbs paresis, urinary and fecal retention, alongside epigastric pain, and fever for 3 days. A neurological examination revealed a severe flaccid paraplegia in her lower limbs associated with a sensory level at T5. She was evaluated systematically for all probable causes of her symptoms, and finally, due to having a positive nasopharyngeal PCR test, she was considered to suffer from post-COVID-19 transverse myelitis. She underwent intravenous-immunoglobulin, methylprednisolone pulse, and other supportive cares without obvious results. Therefore, she underwent seven sessions of plasma exchange with little effects on muscle strength. The focal inflammation and injury of the spinal cord, otherwise known as transverse myelitis, have a wide array of potential etiologies. Transverse myelitis has been well documented to be the result of viral and bacterial infections. We believe our patient was not involved in a cytokine storm status due to good CRP, IL-6 and Ferritin levels. Albeit, we cannot certainly consider the patient to have a direct viral impactor involved in a late immunity process. To our knowledge, this is the first report of TM in the field of pediatrics occurred after COVID-19. Thus, this is critical to note that children can present with some severe types of COVID-19.

Why COVID-19 is less frequent and severe in children: a narrative review.

BACKGROUND: Despite the streaks of severity, severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection is, in general, less frequent and severe in children than in adults. We searched for causal evidence of this mystery. DATA SOURCES: An extensive search strategy was designed to identify papers on coronavirus disease 2019 (COVID-19). We searched Ovid MEDLINE, PubMed, EMBASE databases, and Cochrane library and carried out a review on the causes of this dilemma. RESULTS: Our searches produced 81 relevant articles. The review showed that children accounted for a lower percentage of reported cases, and they also experienced less severe illness courses. Some potential explanations, including the tendency to engage the upper airway, the different expression in both receptors of angiotensin-converting enzyme and renin-angiotensin system, a less vigorous immune response, the lower levels of interleukin (IL)-6, IL-10, myeloperoxidase, and P-selectin and a higher intracellular adhesion molecule-1, a potential protective role of lymphocytes, and also lung infiltrations might have protective roles in the immune system-respiratory tract interactions. Finally, what have shed light on this under representation comes from two studies that revealed high-titer immunoglobulin-G antibodies against respiratory syncytial virus and mycoplasma pneumonia, may carry out cross-protection against SARS-CoV-2 infection, just like what suggested about the vaccines. CONCLUSIONS: These results require an in-depth look. Properties of the immune system including a less vigorous adaptive system beside a preliminary potent innate response and a trained immunity alongside a healthier respiratory system, and their interactions, might protect children against SARS-CoV-2 infection. However, further studies are needed to explore other possible causes of this enigma.