Abstract PO-012: Clinical features and antibody response of two pediatric patients presenting with new-onset acute myeloid leukemia and concomitant severe COVID-19
Authors: Patel Pratik A. , Rostad Christina A. , Lapp Stacey A. , Stokes Claire L. , Pauly Melinda G. , Anderson Evan J. , Sabnis Himalee S. 
Published: December 2020

Abstract
Objective: SARS-CoV-2 infection has led to a worldwide pandemic of COVID-19 (coronavirus disease 2019), placing individuals with pre-existing medical conditions at a higher risk for morbidity and mortality. Limited data in pediatric patients with malignancies suggest that severe COVID-19 illness is rare. The objective of this study was to describe our experience of two adolescents who presented with new diagnoses of acute myeloid leukemia (AML) and concurrent COVID-19.
Methods: The clinical presentation, treatment, and serology of two patients who presented with AML and concurrent SARS-CoV-2 infection were abstracted. Residual blood was tested for serial quantitative IgG by ELISA to the SARS-CoV-2 spike protein receptor binding domain, which has high sensitivity and specificity to SARS-CoV-2. The study was approved by Children’s Healthcare of Atlanta and Emory University IRBs.
Results: Patient 1 was a 16-year-old Caucasian male with previously treated classical Hodgkin’s lymphoma who presented with fever, cough, hyperleukocytosis, and pulmonary infiltrates and was diagnosed with therapy-related AML (TR-AML). SARS-CoV-2 was detected by nasopharyngeal (NP) RT-PCR testing on admission. He received remdesivir for treatment of COVID-19 and modified induction therapy with cytarabine alone starting on hospital day (HD) 3. He demonstrated high SARS-CoV-2 IgG titer (1:1327.3) on HD 4 and cleared SARS-CoV-2 with a negative NP RT-PCR on HD 14. He went on to receive additional myelosuppressive AML therapy on HD 26 with azacitidine and gemtuzamab ozogamicin. On HD 34, his IgG titer remains elevated (1:5621.4) and he is currently awaiting count recovery. Patient 2 was a 19-year-old Hispanic, previously healthy male who presented with fever, cough, dyspnea, and hyperleukocytosis and was diagnosed with de novo AML (D-AML). He also tested positive for SARS-CoV-2 via NP RT-PCR on admission. He began standard induction therapy with cytarabine, etoposide, and daunorubicin on HD 2. He developed hypoxemic respiratory failure on HD 4 and received COVID-19 directed therapies of convalescent plasma, remdesivir, and tocilizumab. His serologic testing showed low SARS-CoV-2 IgG titer (1:619.3) on HD 4 despite administration of convalescent plasma. His titers waned over the subsequent two weeks and he continued to test positive for SARS-CoV-2 via NP RT-PCR on HD 21. He remains critically ill in multiorgan failure with signs of neutrophil recovery on HD 25.
Conclusion: COVID-19 can be severe in children with AML and make treatment decisions challenging. Clinical presentation, curative modalities (hematopoietic stem cell transplantation for TR-AML versus potentially chemotherapy alone for D-AML), and concurrent COVID-19 were considered in determining induction therapy. While difficult to draw definite conclusions from two patients, the differential serologic response in these patients seems to correlate with the intensity of therapy they received and may have contributed to the overall severity of their COVID-19.
Citation Format: Pratik A. Patel, Christina A. Rostad, Stacey A. Lapp, Claire L. Stokes, Melinda G. Pauly, Evan J. Anderson, Himalee S. Sabnis. Clinical features and antibody response of two pediatric patients presenting with new-onset acute myeloid leukemia and concomitant severe COVID-19 [abstract]. In: Proceedings of the AACR Virtual Meeting: COVID-19 and Cancer; 2020 Jul 20-22. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(18_Suppl):Abstract nr PO-012.