DISCUSSION:
Vertical transmission of the virus may be rare due to low placental expression of the canonical receptors necessary for viral entry12. However, placentas from infected mothers have shown thrombotic and vascular changes, which suggests that SARS-CoV2 is a highly procoagulant infection and even in the absence of fetal viral infection, it can trigger an inflammatory response, leading to multiorgan damage 13. There are multiple case reports of neonates presenting majorly with cardiac manifestations of shock, arrythmias, thrombosis, Persistent pulmonary hypertension, as well as respiratory failure, neurological abnormalities and hematological manifestations 5,6,7,8,9,14. All these neonates had history of exposure to maternal COVID-19 infection during pregnancy, positive SARS-CoV2 antibodies and elevated inflammatory and prothrombotic laboratory markers. In a case series of 20 neonates with MIS-N, reported by Pawar et al5, they used diagnostic criteria modified from Centre of Disease Control criteria for MIS-C and interim guidance from American Academy of Pediatrics to accommodate lack of fever in neonates and source of primary infection (mother, instead of the child). The neonate described by us fulfilled these modified criteria. Coagulation abnormalities and thromboembolic phenomenon are listed as one of potential complications of MIS-C15. D-dimer levels have been stated to be the best test for evaluating hemostatic variations associated with COVID-19 4. Such thromboembolic phenomena are also reported among infants. In a retrospective cohort study by Whitworth et al 15, out of all children aged 0-<21 years admitted with SARS-CoV2 infection or MIS-C, 20 patients were identified with thromboembolism with an incidence of 6.5% in MIS-C patients, out of which 3 patients had pulmonary embolism. 1 patient was <1year of age and had lower extremity deep vein thrombosis. Perveen et al16, reported a neonate born with an ischemic limb to a COVID-19 positive mother. Although, COVID antibodies were found in the newborn, the coagulation workup was normal. The thromboembolic event was thought to be a vascular effect of the COVID infection16. In another case reported by Engert et al7, a moderate preterm infant had petechial bleeds, intracranial haemorrhage and periventricular leukomalacia with elevated D-dimer levels and low platelet counts. The authors hypothesised this to be secondary to maternal hyperinflammatory response following SARS-CoV2 infection during 2nd trimester of pregnancy7. In the case series of 20 neonates, Pawar et al described one neonate with a cardiac thrombus 5. Mamishi et al 17 studied the CT findings in 24 children with SARS-CoV2 infection. Atypical findings were seen in 58% of the patients which included nodular and cavitary lesions. They suggested that atypical findings may be indicative of disease progression caused due to cytokine storm 17. The HRCT in our case showed nodular lesions with central cavitation. In spite of an extensive investigative work up, we could not find a causal relationship of the CT scan findings to any of the conditions that could have caused it like bacterial or fungal sepsis, tuberculosis, congenital lung anomalies or malignancy 18. Endothelial injury by SARS-CoV-2 and the hypercoagulability caused by the intense inflammatory response is capable of causing the PTE 4,11. The presence of in-utero exposure to COVID 19 virus, raised inflammatory markers and elevated D-dimer levels lead us to conclude that our case could have had pulmonary thromboembolic phenomenon as a consequence of MIS-N which resulted in the rare CT picture of nodular and cavitary lung lesions. However, due to lack of adequate evidence regarding its use in neonates with MIS-N, we did not give antithrombotic medications. The neonate responded to IVIG and had complete recovery of his clinical symptoms. Due to this favourable response, we chose to not give steroids as is recommended in MIS-C.
Considering the potential possibility of the pulmonary lesions in our case to be secondary to MIS-N, we suggest that, clinical and laboratory evaluation to diagnose thromboembolic complications should be carried out in all symptomatic neonates exposed to SARS-CoV2 infection. Also, future research should be planned to study the use of antithrombotic prophylaxis in neonates exposed to the virus.