Autoimmune Hemolytic Anemia in a Pediatric Patient With Severe Acute Respiratory Syndrome Coronavirus 2 Infection.

Abstract

To the Editors: Multiple clinical manifestations have been described in relation with coronavirus disease 2019 (COVID-19). However, no previously reported cases of autoimmune hemolytic anemia (AIHA) associated to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been described in children so far. We report a case of severe AIHA in a 13-year-old female with SARS CoV-2 infection. The patient was admitted to our hospital because of a 7-day period of fever (37.5°C), asthenia, headache, and a syncope episode without loss of consciousness. She denied respiratory or gastrointestinal symptoms. At admission, she had tachycardia with hemodynamic stability and mucocutaneous pallor. No other abnormalities were found in physical examination. Personal history revealed a previous diagnosis of Psoriasis. Results of blood tests showed decreased hemoglobin (6.3 g/dL), hematocrit (17.8%), mean corpuscular volume (90.4 fI), mean corpuscular hemoglobin (32 pg), and haptoglobin (<7.38 μmol/L) associating reticulocytosis (301,600 mm3). Increased lactate dehydrogenase (458 U/L) and hyperbilirubinemia (1.9 mg/dL) with indirect predominance (1.25 mg/dL) were found. Platelets and leukocytes count, serum ions, and transaminases were normal. Coagulation and D-dimer did not alter; C-reactive protein (2 mg/L) and ferritin (148.6 ng/mL) were normal. Direct Coombs test was performed with a positive result (positive immunoglobulin G4 [IgG4] and negative C3d). Normal level of glucose-6-phosphate dehydrogenase was found.#8232; Due to the pandemic situation, the reverse transcription-polymerase chain reaction test was performed with a positive result, with negative virus-specific immunoglobulin M and negative virus-specific IgG. Six days later, a new reverse transcription-polymerase chain reaction test was performed, with the negative result but positive virus-specific IgG. Other viral infections were ruled out. Antinuclear, antiextractable nuclear antigens, and anticitrullinated protein antibodies were negative. Chest radiograph showed no alterations. AIHA was diagnosed and treatment with methylprednisolone pulses (250 mg/daily) was given for the first 72 hours. Afterward, the maintenance dose with prednisolone 1 mg/kg daily was administered. Hemolysis reduced and 14 days later, the hemoglobin value increased to 10.6 g/dL and without the need for blood transfusions. Recently, 2 studies reported some cases of AIHA associated with COVID-19 in adults.1,2 The median age of adult cases reported by Lazarian et al2 was 62 years and all of them presented risk factors for developing a severe form of COVID-19. All cases started after the beginning of symptoms of SARS CoV-2 infection. In contrast, our patient did not have any known risk factor for severe SARS CoV-2 infection, did not suffer any respiratory symptoms and anemia was the only clinical manifestation associated with SARS CoV-2 infection. The etiology of AIHA in pediatric population is mostly associated with viral and bacterial infections.3 However, in teenagers and young adults, there is an increased association with underlying systemic illness, most commonly immunodeficiencies and autoimmune disorders. Our results, after ruling out immunodeficiency, autoimmune disorder, or other viral infection, suggest that SARS CoV-2 could have triggered AIHA, being the first pediatric case reported so far. In conclusion, this case suggests that SARS CoV-2 can trigger AIHA in predisposed children. In the current epidemiologic situation, upon the finding of severe hemolytic anemia without any apparent cause in a previously healthy child, SARS CoV-2 infection should be ruled out. Pilar Vega Hernández, MDYaiskybele Borges Rivas, MDEstefanía Ortega Sánchez, MDAraceli Marqués Cabrero, MDLaura Remedios Mateo, MDPatricia Silvera Roig, MDAranzazu Infante Quintanar, MDRafael Díaz-Delgado Peñas, MDVerónica Sánchez Escudero, MDMaría Luz García-García, PhDPediatrics DepartmentSevero Ochoa University HospitalLeganés, Madrid, Spain