Fetal Inflammatory Response Syndrome Associated With SARS-CoV-2 Exposure In Utero

During this covid-19 pandemic, a few cases of vertical transmission of severe acute respiratory syndrome coronavirus-2 from mothers to the fetus have been documented. Anti-SARS CoV-2 antibodies mediated multisystem inflammatory response syndrome (MIS-C) is known phenomenon in children. With this case report, we aim to demonstrate the evidence of fetal inflammatory response syndrome (FIRS) associated with anti-SARS CoV-2 antibodies in a premature neonate presenting with respiratory distress, seizures and shock in initial hours of life. The infant was RTPCR negative for covid-19, but positive for anti-SARS CoV-2 antibodies with raised inflammatory markers, suggestive of systemic inflammatory response syndrome. A comprehensive workup for other infectious pathogens also came up negative. Baby received IvIg and steroids and recovered completely. We believe that this systemic inflammation occurred due to antenatal exposure to the covid-19 virus and that more such instances will emerge in future. Introduction In current times, COVID-19, caused by SARS-CoV-2, has been a global public health crisis. The disease severity is less in neonates and young children for certain reasons .1 But recent reports of multisystem inflammatory syndrome in children, MIS-C, have been described by Kathleen M et al and Shreepal J et al.2,3 The specific mechanism is unknown, although it is thought to be related to immunological dysregulation caused by SARS CoV2 infection.4 The disease manifests as persistent high grade fever and multisystem involvement with raised inflammatory markers and requiring PICU management]2. The disease simulates Kawasaki disease and cytokine storm as in adults. Majority of the children are positive for anti SARS CoV2 antibodies while less number of kids are RTPCR positive.2 Unlike MIS-C, where SARSCoV-2 infection and multisystem inflammation occur in the same subject, a few case reports suggest neonatal multisystem inflammation occurs secondary to maternal SARS-CoV-2 infection.5,6 Here we report a case of a newborn with very high SARS CoV-2 antibodies titre and elevated inflammatory markers who presented as multi systemic inflammation also known as fetal inflammatory response syndrome within the first few hours of life. Case Report A 26 years old primigravida went into spontaneous labour at 32 weeks of gestation and a male neonate (birth weight 1474 grams) was delivered by vaginal delivery in a private nursing home at Pune, Maharashtra, India. Baby cried immediately at birth and did not require resuscitation (APGAR score 8 at 1 minute, 10 at 5 minutes) but within 30 minutes developed grunting and respiratory distress. Baby was then shifted urgently in a tertiary care NICU at Pune, Maharashtra, India, under standard transportation protocol in neonatal ambulance. Baby was initially placed on CPAP with a PEEP of 6 and a FiO2 of 30 percent, but due to her increasing work of breathing, baby was intubated and given positive pressure ventilation. Initial ABG was showing pH of 7.29, pCO2 46, pO2 97, HCO322.1, BE -4.5, lactate 1.5. As initial chest X-ray showed normal volume lungs and was not suggestive of respiratory distress syndrome hence surfactant was not given. Within 4 hours of life, the baby presented as poor perfusion (with prolonged CRT of 5 seconds, hypotension, tachycardia and cold extremities) and metabolic acidosis. Functional echocardiography showed mild LV dysfunction with LV ejection fraction of 40%. So baby was started on inotropic support after initial fluid resuscitation. Baby was lethargic and developed seizures within 6 hours of life, which were managed with phenobarbitone and levetiracetam. Neurosonography was done on second day of life which showed germinal matrix hemorrhage and parenchymal patchy haemorrhage. In view of deranged coagulation and drop in haemoglobin, baby received plasma and PCV transfusion. Sepsis screen and blood culture was sent and broad spectrum iv antibiotics were initiated as per unit protocol. CSF studies were normal. Both CSF and blood culture came negative so antibiotics were stopped after 48 hours of initiation. Baby’s perfusion improved gradually over 48 hours Address for Correspondance: Dr Mahesh Shinde Department of Pediatrics and Neonatology, Noble Hospital and Research Center, Hadapsar, Pune, Maharashtra 411013, India Email: maheshh248@gmail.com ©2021 Pediatric Oncall ARTICLE HISTORY Received 2 September 2021 Accepted 11 December 2021