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.