Acute upper gastrointestinal hemorrhage in a coronavirus disease of 2019 positive pediatric patient with sickle cell disease

ABSTRACT

Background: SARS CoV-2, the virus that causes Coronavirus Disease of 2019 (COVID-19), most commonly presents as a febrile respiratory illness. Atypical symptoms are being increasingly recognized including myalgias, anosmia, vomiting, and diarrhea. Pediatric COVID-19 infections are usually mild, self-limiting, and rarely require hospitalization. We describe a case of severe upper gastrointestinal bleeding as the only initial symptom of COVID-19 infection in a child with sickle cell disease (SCD). Case A 12-year-old male with SCD, HbSS subtype, with a history of splenectomy presented to our Emergency Department (ED) with acute onset progressively worsening hematemesis for the past 24 hours. He denied fever, cough, melena, peptic ulcer disease, family history of excessive bleeding, or regular nonsteroidal anti-inflammatory drug use. Upon arrival, the patient had tachycardia, hypotension (HR 150, BP 86/40), and cool extremities with delayed capillary refill. His temperature was 100.0F with an oxygen saturation of 100% on room air. His initial laboratory results were significant for hemoglobin of 4.1 g/dL, (baseline 7-8 g/dL), reticulocytes 13.7%, venous blood gas pH of 7.17, lactate of 7.3, white blood cell count of 21.7 K/uL, and prothrombin time (PT) of 19.9 seconds / INR of 1.7. His hepatic and renal function tests were within normal limits. In the ED, the patient received a normal saline bolus, two units of packed red blood cells, pantoprazole, famotidine, ondansetron, tranexamic acid, and ceftriaxone. His chest X-ray was unremarkable. A nasopharyngeal COVID-19 swab was sent. Pediatric gastroenterology and hematology were consulted, and he was admitted to the pediatric intensive care unit. The following day he underwent esophagogastroduodenoscopy which showed diffuse hemorrhagic gastropathy with superficial mucosal bleeding and without frank ulcers (Figure 1). An abdominal ultrasound revealed a normal gallbladder, no portal hypertension, and known absent spleen. His nasopharyngeal swab was positive for COVID-19. Helicobacter pylori testing was sent and reported negative. He received Vitamin K and two units of fresh frozen plasma for his coagulopathy resulting in normalization in his PT/INR. He did not have any further hematemesis but developed melena which improved, and he was discharged with a hemoglobin of 9.3 g/dL. Discussion: To date, we have not seen reports of either upper gastrointestinal bleeding as the only initial presenting symptom of COVID-19 or endoscopic visualization of gastric lumen during acute infection. The petechial hemorrhaging located at the body of the greater curvature and fundus of the stomach is an unusual site and indicated the underlying coagulopathy as the cause for bleeding. Our patient's mild coagulopathy is consistent with other reports of critically ill COVID-19 patients. This case highlights the importance of maintaining a high index of suspicion for COVID-19 infection in an immunocompromised pediatric patient with severe bleeding or new coagulopathy within our current medical climate.