Suspected Neonatal COVID-19 Infection in an Extremely Premature Infant

Introduction: The COVID-19 pandemic has been widely described, however, there is limited data regarding neonatal infection. We present an extremely premature neonate with suspected COVID-19 pneumonia treated with Remdesivir.

Case Description: Our patient is an infant born via emergency cesarean section for chorioamnionitis at 24 weeks gestational age with extremely low birth weight (ELBW). Mother is a 23-year-old primigravid female whose pregnancy was complicated by asymptomatic COVID-19 infection diagnosed by nasopharyngeal PCR ten days prior to delivery. Antenatal steroids were given for imminent premature delivery. Infant was intubated during initial resuscitation then extubated to non-invasive positive pressure ventilation (NIPPV) on day three of life. On day seven of life, she developed increasing apneic spells and feeding intolerance. Empiric antibiotics were initiated while awaiting blood and cerebrospinal fluid cultures. Blood culture grew Serratia marcescens and antibiotic coverage was tailored to cefepime monotherapy. Our patient remained stable on non-invasive respiratory support seven days into her sepsis event. Around this time, histopathological analysis of the placenta revealed acute villitis and intervillositis highly suggestive of COVID-19 placentitis. A positive nasopharyngeal COVID-19 PCR was noted on day ten of life. Our patient remained stable on non-invasive respiratory support until day fourteen of life, when she suddenly developed refractory hypoxemia requiring intubation. This coincided with acute changes in her chest x-ray (Fig 1). The negative bacterial respiratory culture, timing of clinical deterioration, and placental findings increased our suspicion for symptomatic co-infection with COVID-19.

Patient continued to have refractory hypoxia and poor ventilation despite maximum settings and inhaled nitric oxide. After an extensive multidisciplinary discussion, patient received Remdesivir as a compassionate measure. Neonatal dosage was well tolerated with no adverse effects at 5 mg/kg loading dose followed by four days of maintenance dosing at 2.5 mg/kg. Significant clinical improvement was noted after the second day by decreasing FiO2 requirements. COVID-19 PCR remained positive ten days after Remdesivir treatment was completed. Patient was extubated to NIPPV on day thirty-six of life and is currently requiring no respiratory support at 37 weeks corrected age.

Discussion: We present an ELBW neonate with placental findings typical of COVID-19 infection and refractory hypoxemia likely due to COVID-19 pneumonia. To date, the mechanism for this infant’s infection is unclear. Based on the Acharya et al. Classification for Maternal-Fetal-Neonatal SARS-CoV-2 infection, our patient fits into probable neonatal infection acquired post-partum category. We have strong evidence of infection but lack of absolute proof to confirm congenital disease as no testing was done at birth. We acknowledge that part of the clinical course was complicated by sepsis, however, the peak of illness correlates with the typical clinical course for COVID-19 infection.

Conclusion: To our knowledge, this may be the youngest patient documented to have COVID-19 pneumonia and received Remdesivir treatment.