P0444 - A case of successful ECMO run in an immunocompromised pediatric patient with severe COVID-19

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) epidemic, while known for severe lung disease of several types and multisystem failure (called COVID-19), usually has a mild or asymptomatic course in children and youth. There is a paucity of data defining the risk factors for severe disease in pediatric patients and how they interact with SARS-CoV-2 infection.

A 15-year-old female, with MyD88 immunodeficiency and a suspected COVID-19 exposure, presented to the emergency department with fever, and subsequently tested positive for SARS-CoV-2. Her immune defect, known for a predisposition to severe, invasive, and frequently fatal bacterial infections without warning signs of inflammation, results from failed toll-like receptor signaling. Her immune control of viral disease is predicted to be normal. At presentation, in addition to identifying SARS-CoV-2 infection, this patient had a lobar pneumonia, presumed to be a bacterial infection, and treated with prompt administration of broad-spectrum antibiotics. Her clinical course was remarkable for rapid deterioration and escalation of respiratory support from non-invasive ventilation to invasive mechanical ventilation 3 days after presentation. The evolving clinical picture was characterized by concomitant acute kidney injury, ventricular arrhythmia, and vasoactive-resistant shock requiring steroid administration. Treatment targeting COVID-19 disease included Hydroxychloroquine, Tociluzimab and Remdesivir. This patient, failing conventional therapy, and after discussion and consent from the family, was provided veno-venous extracorporeal membrane oxygenation (VV-ECMO) 5 days after initial presentation. The choice to cannulate and support this patient with VV-ECMO occurred prior to complete decompensation and cardiac arrest. Careful planning and preparation for all team members of the cannulation procedure following strict rules for personal protective equipment (PPE) then proceeded in a thoughtful, careful manner. Following an uneventful 7 days of VV-ECMO support with continued pulmonary and circulatory improvement, the patient was decannulated and eventually extubated 2 days after decannulation.

Critical illness in children or adolescents is infrequent with COVID-19. We identify one such risk factor and a potential mechanism for this patient’s severe disease. This immune defect seemed to create an opportunity for a concurrent bacterial pneumonia immediately on presentation which then promoted more SARS-CoV-2 invasion and infection, producing progressive, severe COVID-19 disease. Additionally, there is very limited experience supporting pediatric COVID-19 patients with ECMO. The need to plan cannulation logistics and prepare staff with PPE emphasizes the utility of “early ECMO” as the preferred modality for COVID-19 disease. This case will add to scant literature that suggests early initiation of ECMO in pediatric patients with COVID-19 can be beneficial.