P3C207: A Novel Presentation of covid-19-related Multisystem Inflammatory Syndrome in a Neonate (MIS-N)

Introduction: Maternal infection with COVID-19, a novel coronavirus causing a global pandemic, during pregnancy may lead to adverse pregnancy outcomes including preterm delivery or maternal mortality, though previous reports have shown limited vertical transmission of COVID-19. In April 2020, a novel post-infectious hyperinflammatory syndrome in children (MIS-C) was identified. To date, there are few published reports of MIS-C in the neonatal population (MIS-N). A systematic review of MIS-N found noted challenges in diagnosis given overlap with neonatal morbidities and timing of original infection. Since the COVID-19 emergence, an increased rate of persistent pulmonary hypertension of neonates (PPHN) has also been identified.
Reported here is a potential case of MIS-N in a neonate initially presenting with features of PPHN at birth, requiring extracorporeal membrane oxygenation (ECMO) due to respiratory failure and hypoxia.

Case Description: A male was born at 39&0weeks gestation to a G1P0 36-year-old female via vaginal delivery after induction of labor. APGAR scores were 2 (1 minute) and 7 (5 minutes) with hypoxemia noted. The infant required stimulation, oxygenation and CPAP, and developed bilateral pneumothoraces in the neonatal intensive care unit (NICU). Bilateral chest tubes were placed and Curosurf was administered, on Day 2 the patient remained significantly hypoxic, and was cannulated for VA ECMO.

Maternal history included self-reported migraines during pregnancy and prenatal vitamins. Approximately 8 weeks before delivery, she developed a mild respiratory illness with congestion lasting 4-5 days, but didn’t have confirmatory COVID-19 testing, although reported positive contacts. She did not receive COVID immunizations for >1 year prior to delivery.

On Day 5, the infant began developing an erythematous macular rash (Figure 1). Due to lack of a clear etiology for the PPHN coupled with rash, increasing heparin demand, and rising inflammatory markers, MIS-N via vertical transmission of anti-SARS-CoV-2 IgG antibodies was considered. SARS-CoV-2 IgG antibodies taken were elevated at 10,145.9 AU/ml, along with elevated Interleukin-6 (19 pg/mL), ferritin (786 ng/mL), C-reactive protein (21.2 mg/L), thrombocytopenia (platelets 111 K/uL). The patient had features consistent with MIS-N and was treated with methylprednisolone and intravenous immunoglobulin.

Discussion: MIS-C diagnosis is based on 6 criteria, and presentation has been reported to manifest 2-8 weeks after COVID-19 infection, with symptoms such as fever, mucocutaneous lesions, and cardiac dysfunction. This presentation is a novel case of MIS-N without direct evidence of maternal COVID-19 infection causing transfer of SARS-CoV-2 IgG antibodies in a neonate. Previously reported MIS-N cases have followed direct infections or confirmed vertical transmission of COVID-19.

Conclusion: This presentation highlights the importance of understanding the clinical manifestations of MIS-N. Criteria such as the pyrexial response in neonates is poorly developed, and all diagnostic criteria for MIS-C may not be applicable to the neonate. There is need for research and guidelines for diagnostic criteria for MIS-N.