Placental Thrombosis Resulting in Hypoxic Ischemic Encephalopathy in an Infant of a Mother with Covid-19

Case Report: Since the beginning of the Coronavirus Disease 2019 (COVID-19) pandemic, there has been much work to understand the negative effects of SARS-CoV-2 on tissues expressing the Angiotensin Converting Enzyme-2 (ACE2) receptor, including the placenta. However, there is limited information regarding placental pathology findings in mothers with COVID-19 and the effects of SARS-CoV-2 on the placenta. The available research reports effects on the fetus ranging from minimal to intrauterine fetal demise. Case Description: A 4680g baby boy was born at 38+1 weeks of gestation to 36y old G4P1021 female via repeat cesarian section. The pregnancy was complicated by advanced maternal age, chronic hypertension with superimposed pre-eclampsia with severe features, BMI of 80, and SARS-CoV-2 infection. The mother had mild COVID-19 symptoms and did not require hospitalization or oxygen support. Prenatal ultrasounds were limited due to body habitus. At the time of delivery, there was clear amniotic fluid. Upon delivery the infant was cyanotic and limp and was brought to the warmer immediately. Non-invasive positive pressure ventilation was initiated at 5 minutes of life with improvement in infant color and oxygen saturation. He was then admitted to the Neonatal Intensive Care Unit (NICU). APGARs were 2, 3, 5, and 7 at 1, 5, 10, and 15 minutes respectively. Cord gases showed severe metabolic acidosis. The patient was diagnosed with hypoxic-ischemic encephalopathy (HIE) and therapeutic hypothermia was initiated. Both the NICU and obstetric teams were unable to identify a clear perinatal cause of HIE in this patient. Later, the placenta pathology report revealed a large placenta for estimated gestational age corresponding to the 75th percentile, villous parenchyma with focal chorangiosis and thrombi, with unremarkable fetal membrane and three vessel umbilical cord. The cause of HIE was then thought to be due to the placental thrombi likely caused by SARS-CoV-2 infection. Discussion(s): Fetal vascular malperfusion and fetal vascular thrombus have been noted as a common finding in the placentas of pregnant women who test positive for SARS-CoV-2. There are various causes of HIE, from maternal, placental and fetal factors. This patient had no clinically evident hypoxic event, but information was limited due to the lack of monitoring of the fetus in utero. Given the mother's SARS-CoV-2 infection and the placental pathology findings, it is likely that the cause of this patient's HIE was related to the effects on the placenta from SARS-CoV-2. Conclusion(s): As more information comes to light about the effects of SARS-CoV-2 on the placenta, it is important to consider a maternal SARS-CoV-2 infection during pregnancy as a cause of HIE in a newborn.

Limping in a Pandemic

Introduction: Transient synovitis is a common cause of hip pain in children. Patients present with acute limp, hip pain or referred pain to the knee. The mainstay of treatment consists of antiinflammatory medications and activity limitations. While the exact etiology of transient synovitis is unknown, there has been a noted relationship with an antecedent viral illness. We present one of the first reported cases of transient synovitis caused by COVID-19. Case Description: A 10-year-old male presented with concerns for left knee pain and limp. Five days prior, the patient developed general URI symptoms and was diagnosed with COVID-19, via rapid testing. His maximum temperature was 38.5°C at home and his respiratory symptoms resolved. Two days prior to presentation, he complained of left knee pain, which progressed to limp, and refusal to bear weight. He denied known injuries, trauma, visible bruising, swelling, redness, or warmth. He was afebrile and non-weight-bearing on his left leg, otherwise in no apparent distress. On physical exam, he exhibited full, painless range of motion of left knee, no bony tenderness, effusion, or cutaneous changes. There was refusal to bear weight on left leg, and significant pain with internal rotation of left hip. Lab work revealed there was no leukocytosis. C-reactive protein level and sedimentation rate were unremarkable. Radiographs of bilateral hip and pelvis, and left knee were obtained, which revealed no osseous abnormalities or significant effusion. Patient was given ibuprofen and on follow up exam he exhibited improved discomfort and willingness to bear weight. With a negative workup and clinical improvement, he was discharged with crutches, instructions for supportive care, and outpatient follow-up. Mother reported no complications during his recovery. He was able to wean from the crutches within a few days and returned to his usual gait within 3 weeks. Discussion: Transient synovitis can be clinically distinguished from septic arthritis with features of overall well appearance, lack of swelling or redness to the joint, and normal range of motion with mild pain. For our patient, Kocher criteria were helpful in distinguishing transient synovitis from septic arthritis, as well as the clinical improvement with NSAIDs. A clinical dilemma could occur if elevated inflammatory markers were present, as one might expect with acute COVID-19. Though transient synovitis is thought to be related to a viral etiology, there does not appear to be an increase in cases amidst the pandemic described in published literature. Conclusion: This case illustrates a patient who had COVID-19 with transient synovitis, a previously unreported sequela. When evaluating similar patients, providers should consider the possibility of COVID-19 and ensure appropriate testing and isolation.

How Important Are in-Person Clinic Visits during Maintenance Therapy for Pediatric Acute Lymphoblastic Leukemia?

[Formula presented] Background Acute Lymphoblastic Leukemia (ALL) is the most common cancer seen in the pediatric age group. The treatment consists of an initial intensive phase of chemotherapy followed by a prolonged period of maintenance chemotherapy intended to reduce the risk of relapse. Children are commonly seen in clinic every 4-6 weeks for bloodwork and physical examination during the maintenance phase. The COVID-19 pandemic has prompted consideration of alternative means of providing medical care. The objective of this study was to determine the proportion of in-person clinic visits during ALL maintenance therapy for which the outcome of the physical examination resulted in a change of patient management. Methods A retrospective chart review of children diagnosed with precursor-B ALL between January 2017 and December 2018, and who were in maintenance therapy between September 2019 and February 2020, was conducted. All routine maintenance visits were reviewed to identify new physical examination findings and patient outcomes and classified as either “could be managed virtually” or “essential in-person visit”. For the latter, a second classification was conducted to distinguish between visits necessitating a change of management versus not. Results Eighty-five children were diagnosed with precursor B ALL and continued to maintenance treatment during the study period. 10 children were excluded as not meeting the inclusion criteria or not evaluable. Of the remaining 75 children, 54 were male (72%) and 21 female (28%). The median age at diagnosis was 4.83 years (0.73 - 14.8 years). 39 patients (52%) had standard risk ALL, 35 patients (46.7%) had high risk ALL and one patient had Infant ALL (1.3%) A total of 240 routine maintenance visits were included in the final analysis. An abnormal physical exam finding was noted in 20 visits (8.3%) and of these, new findings were noted in 14 (5.8%). 6 visits were classified as essential in-person visits (2 for new bruising, 1 for new limp, 1 for new lymphadenopathy, 1 for acute otitis media, and 1 for new wheezing). Among the 14 visits with new exam findings, only 5 had an impact on patient management and of these, only 2 (0.8%) were classified as obligate in-person visit for requiring immediate management (acute otitis media and wheezing). Conclusion Our results demonstrate that most in-person visits can be provided as virtual visits without affecting patient outcomes. The results of this study provide the foundation for a prospective study that will evaluate the benefits, risks and families' preferences associated with virtual visits and delineate the optimal frequency and timing of in-person clinic visits during ALL maintenance therapy. [Formula presented] Disclosures: No relevant conflicts of interest to declare.