Twenty-day-old female neonate presented in emergency department with complain of difficulty in breathing and poor feeding. The neonate was born by cesarean section at 38 weeks with birth weight of 3600 gram and had immediate cry after birth. She was exclusively breastfeed. The mother had no history of any specific disease during pregnancy and no history of hospitalization after birth. At first examination, she had central cyanosis (O2 saturation = 70%), tachycardia (HR = 285/min), tachypnea (RR = 90/min) and hypothermia (T = 35.7˚) with normal blood pressure (BP = 65/40 mmHg). Neonate was slightly irritable. Heart and lung auscultation were normal. Other system examinations were also normal.
The neonate had a history of contact with three SARS-CoV-2 positive persons whom one was her mother.
Initially, she was transferred under an incubator and the necessary measures were taken to make her normothermic.. Intravenous fluid and oxygen support was started immediately Sepsis Workup was performed. The result of laboratory tests were summarized in Table 1.
Table 1
Lab test | value | Lab test | value |
PH( ABG) | 7.36 | AST | 41U/L (10–40) |
PaCO2 | 26.5 | ALT | 56 U/L (10–50) |
PaO2 | 32.3 | ALP | 547 U/L (48–406) |
HCO3 | 14.6 mmol/L | LDH(1st day / 2nd day) | 446 U/L (160–450) 798U/L (160–450) |
BE | − 10.8 MMOL/L | CPK(1st day / 2nd day) | 82 U/L (< 400) 281 U/L (< 400) |
WBC | 11 ×〖10〗^3/µL (5000–15000) Neutrophil = 50% Lymphocyte = 43.8% Mixed = 6.2% | Bilirubin | Total = 6.4mg/dL Direct = 0.5mg/dL |
RBC | 4.99×〖10〗^6/µL (3.9–5.8) | D-Dimer | 3392 ng/dL (0-500) |
Hb | 12.8 /dL (12–18) | Troponin | 19.7 ng/L(< 18) |
HCT | 39.7%. (32–49) | ferritin | 1645 µg /L (200–600) |
MCV | 79.6 fl (95–105) | Urea | 40 mg/dL (15–45) |
MCH | 25.7 pg (27–32) | Creatinine | 0.6 mg/dL (0.44–0.66) |
MCHC | 32.2 (31–36) | Na | 137 mEq/L (135–145) |
PLT | 640 ×〖10〗^3/µL (150–450) | K | 3.5 mEq/L (3.5–5.4) |
Esr | 2 mm (1–10) | Ca | 9.8 mg/dL (9-10.5) |
Crp | C Reactive Protein = 1 mg/dL (0–6) | p | 5mg/dl |
Blood culture | Negative | Blood sugar | 81 mg/dL (60–110) |
Chest X-ray (CXR) was taken. RT-PCR test of COVID-19 virus was sent. An ECG was performed for the patient due to the tachycardia. An arrhythmia with supraventricular tachycardia (SVT) probability was observed on EKG. Intravenous adenosine 100 mg / kg and 200 mg / kg were administered twice, but the arrhythmia did not respond to adenosine. The re-ECG showed saw-tooth flutter waves, suggesting an atrial flutter (Fig. 1). The patient was given three CDs of cardioversion. 1 J / kg was given in the first round and 2 J / kg in the second round, but the arrhythmia did not respond to the above action. The neonate had refractory atrial flutter. Due to the lack of response to treatment, amiodarone was started for the patient at a dose of 7 / g / kg / min.
Simultaneously neonate became normothermic. There was persistence of atrial flutter after 12 hours of amiodarone infusion. Vital signs at this point of time were Pulse rate 250 / min, Respiratory rate 85 / min and mean blood pressure of 40 mmHg. Echocardiography performed showed Ejection fraction (EF) of 30% and there was severe TR and sever MR. The patient underwent re-CD cardioversion three times, the first time being1 J / kg and the second and third time J / kg 2, but the arrhythmia did not respond. Amiodarone was discontinued and oral flecainide 3 mg / kg every 12 hours and propranolol 1 mg / kg every 8 hours were started after discussion with pediatric cardiologist. Arrhythmia was resistant to both flecainide and propranolol.
As the patient had refractory AF with positive history of close contact with confirmed cases of COVID- 19 and laboratory investigation were suggestive of multisystem inflammatory syndrome in children (MISC), we considered the patient as a case of arrhythmia secondary to Covid myocarditis. Consultation with infectious department was done and IvIg was started for the patient (1gram/kg/day for 2 days). After starting the first dose of IvIg, a dramatic response to atrial flutter was observed and the heart rate became normal within 4 h after starting IvIg injection and after two days, the heart rate was 120 beats per minute. On repeat echocardiography, Ejection Fraction increased to 50% with Moderate to severe TR and Mild to Moderate MR., Ejection fraction reached 65% with Mild MR and Mild TR was seen in echocardiography done four days later. The patient was discharged with flecainide and propranolol. Propranolol was tapered and discontinued within 6 months. Flecainide was tapered to be discontinued after 9 months of starting treatment. The patient is in regular follow up and there was no episode of any arrhythmia in follow up.