Case:
We present a 4-year-old male with a history of moderate HS and sickle cell trait without prior splenectomy who presented with two days of worsening cough, congestion, and subjective fevers. At presentation, he had mild decrease in oral intake and mother had noted some slight yellow discoloration of his eyes. The patient’s mother was sick with similar upper respiratory symptoms, but there were no known COVID-19 exposures.
He reported to the emergency room and was found to be febrile and tachycardic, but otherwise hemodynamically stable.  His exam was notable for a palpable spleen tip just below the rib margin and scleral icterus without other significant findings. Additionally, a chest x-ray was within normal limits.
Lab work-up was notable for a hemoglobin of 6.5 GM/dL, an absolute reticulocyte count of 333 k/cumm, and a total bilirubin of 6 mg/dL, suggestive of an acute hemolytic process. Other cell lines were within normal limits with a reassuring differential, and his remaining metabolic profile was also within normal limits. Due to the fever, cough, and congestion, a COVID-19 nasopharyngeal polymerase chain reaction was performed in accordance with our institution’s guidelines.  He was admitted and given an infusion of 10ml/kg of packed red blood cells (pRBCs). The transfusion was complicated by a fever, and he only received 6ML/kg of red blood cells.
On hospital day 1, labs continued to indicate a hemolytic process and hemoglobin was relatively unchanged at 6.5 gm/dL (Table 1). His COVID-19 sample returned positive and COVID-19 specific labs showed a white blood cell count of 6.9 k/cumm, a lymphocyte percentage of 52%, a C-reactive protein of <0.5 mg/dL, and Aspartate aminotransferase (AST) and alanine transaminase (ALT) of 37 and 11 Units/L respectively. It is believed that his fever during the transfusion was due to COVID-19 and was not a transfusion reaction. With the persistently low hemoglobin, he received a second transfusion of red blood cells without complications.  His hemoglobin improved to 10.7 gm/dL, and his hemolysis markers were trending to normal. Hemoglobin obtained 6 hours later was found to be stable at 10.7 gm/dL, indicating no further hemolysis. He was at his baseline behavior and resolution of scleral icterus without any respiratory distress. He was discharged home with instructions to quarantine for at least 14 days in accordance with published guidelines.  At time of phone follow up 48 hours after discharge, he continued to do well with no appreciable evidence of jaundice or worsening respiratory status.