A respiratory viral panel and SARS-CoV-2 testing were both negative.
The next day, he had a fever and required aggressive fluid resuscitation after becoming hypotensive with antibiotic administration, and subsequently developed respiratory distress necessitating high-flow nasal cannula oxygen. Repeat SARS-CoV-2 testing the next day was again negative, and blood cultures grew both Acinetobacter junii and Pseudomonas aeruginosa. He clinically improved over the next few days and was off supplemental oxygen within 4 days without any further respiratory symptoms. SARS-CoV-2 testing was repeated in advance of a scheduled procedure and was positive. He continued to do well and was discharged 3 days later after completing antibiotics. Repeat testing 2 weeks later was negative.
Patient 2 is a 6-year-old male with recently relapsed T-cell acute lymphoblastic leukemia undergoing reinduction chemotherapy. He presented to the oncology clinic for chemotherapy with cough and rhinorrhea, but was afebrile and otherwise well. Over the next 2 weeks, he had gradual improvement in his respiratory symptoms. It was then discovered that he had been exposed to SARS-CoV-2, 5 days prior to symptom onset. He presented 2 weeks later for another cycle of chemotherapy, at which time he tested positive. He tested positive again on day 8, and then 2 days later was admitted with fever and neutropenia without worsening cough or rhinorrhea. He had an uncomplicated hospital course, but still tested positive for SARS-CoV-2 on the day of discharge and again 5 days later. Repeat testing after another 10 days, 6 weeks after symptom onset, was negative.
Although children have milder SARS-CoV-2 infections, there is a natural concern that children with cancer are at higher risk of severe illness from SARS-CoV-2 infection and that further immunosuppressive cancer-related treatment may increase this risk, as has been reported in adults with cancer. [1] [2] [3] We found that our cancer patients with SARS-CoV-2 infections had generally mild, self-limited courses without need for any respiratory support, similar to the presentation of SARS-CoV-2 infection in the general pediatric population. 6, 7 Two of the three patients requiring hospital admission were for reasons unrelated to SARS-CoV-2 infection and the respiratory symptoms of the third patient that required ICU-level care was in the setting of preexisting lung pathology from posttransplant complications, and seemed to be related to polymicrobial sepsis, given his rapid improvement with antibiotics and diuresis. Additionally, two of our patients (numbers 2 and 4 in Table 1 ) received further chemotherapy without clearance of SARS-CoV-2 infection. Although both experienced an increase in the level of SARS-CoV-2 RNA detected (based on decreasing Ct value), this was likely related to chemotherapy-induced lymphopenia and did not correlate with any worsening of symptoms.
Our series of pediatric oncology patients with relatively benign courses of SARS-CoV-2 infection is consistent with reports from both Italy and New York city, where five and 20 pediatric cancer patients, respectively, were identified as having mild or asymptomatic SARS-CoV-2 infection, 8, 9 and mirror the experience in some patients on biologics for immune-mediated inflammatory disease. 10 This patient had a prior negative test 20 days earlier after presenting with headache, cough, and fever 10 days after doxorubicin and cisplatin.