ABSTRACT
Background: Infections represent a significant cause of morbidity and mortality in pediatric patients undergoing treatment for hematologic malignancies. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has led to a worldwide pandemic of coronavirus disease 2019 (COVID-19) and pediatric patients with cancer appear to be at higher risk of severe disease than reported in the general pediatric population. Data are limited on the optimal management of children infected with SARS-CoV-2 and a new diagnosis of leukemia. The objective of this study was to describe our experience of six children who presented with a new diagnosis of acute leukemia and concurrent COVID-19.
ABSTRACT
Objective: SARS-CoV-2 infection has led to a worldwide pandemic of COVID-19 (coronavirus disease 2019), placing individuals with pre-existing medical conditions at a higher risk for morbidity and mortality. Limited data inpediatric patients with malignancies suggest that severe COVID-19 illness is rare. The objective of this study was todescribe our experience of two adolescents who presented with new diagnoses of acute myeloid leukemia (AML)and concurrent COVID-19. Methods: The clinical presentation, treatment, and serology of two patients who presented with AML andconcurrent SARS-CoV-2 infection were abstracted. Residual blood was tested for serial quantitative IgG by ELISA tothe SARS-CoV-2 spike protein receptor binding domain, which has high sensitivity and specificity to SARS-CoV-2.The study was approved by Children's Healthcare of Atlanta and Emory University IRBs. Results: Patient 1 was a 16-year-old Caucasian male with previously treated classical Hodgkin's lymphoma whopresented with fever, cough, hyperleukocytosis, and pulmonary infiltrates and was diagnosed with therapy-relatedAML (TR-AML). SARS-CoV-2 was detected by nasopharyngeal (NP) RT-PCR testing on admission. He receivedremdesivir for treatment of COVID-19 and modified induction therapy with cytarabine alone starting on hospital day(HD) 3. He demonstrated high SARS-CoV-2 IgG titer (1:1327.3) on HD 4 and cleared SARS-CoV-2 with a negativeNP RT-PCR on HD 14. He went on to receive additional myelosuppressive AML therapy on HD 26 with azacitidineand gemtuzamab ozogamicin. On HD 34, his IgG titer remains elevated (1:5621.4) and he is currently awaitingcount recovery. Patient 2 was a 19-year-old Hispanic, previously healthy male who presented with fever, cough, dyspnea, and hyperleukocytosis and was diagnosed with de novo AML (D-AML). He also tested positive for SARS-CoV-2 via NP RT-PCR on admission. He began standard induction therapy with cytarabine, etoposide, anddaunorubicin on HD 2. He developed hypoxemic respiratory failure on HD 4 and received COVID-19 directedtherapies of convalescent plasma, remdesivir, and tocilizumab. His serologic testing showed low SARS-CoV-2 IgGtiter (1:619.3) on HD 4 despite administration of convalescent plasma. His titers waned over the subsequent twoweeks and he continued to test positive for SARS-CoV-2 via NP RT-PCR on HD 21. He remains critically ill inmultiorgan failure with signs of neutrophil recovery on HD 25. Conclusion: COVID-19 can be severe in children with AML and make treatment decisions challenging. Clinicalpresentation, curative modalities (hematopoietic stem cell transplantation for TR-AML versus potentiallychemotherapy alone for D-AML), and concurrent COVID-19 were considered in determining induction therapy. Whiledifficult to draw definite conclusions from two patients, the differential serologic response in these patients seems tocorrelate with the intensity of therapy they received and may have contributed to the overall severity of their COVID-19.