Epidermolysis in a newborn of a mother affected by covid-19 in the 3rd trimester of pregnancy

Summary

Covid-19, caused by severe respiratory syndrome coronavirus 2 (SARS-CoV-2), is currently a pandemic. Although this infection primarily presents with respiratory symptoms, the number of reported extrapulmonary manifestations, including dermatological, is also increasing. A group of pregnant women is particularly susceptible to respiratory diseases, but with regard to covid-19, there is still limited data on the course of infection in pregnancy in relation to the possibility of vertical transmission. We present the case of a 30-year-old unvaccinated patient with a history of overcoming covid-19 infections in the 7^th month of pregnancy, and with persistent skin lesions. The patient gave birth to a mature newborn with epidermolytic lesions on a bullous base. In the differential dia­gnostic process, Staphylococcal scalded skin syndrome and epidermolysis bullosa were ruled out in the newborn. Considering the clinical findings and epidemiological history of the mother, we assume a possible vertical transmission of covid-19 with skin manifestation of the disease in the newborn.

Keywords:

COVID-19 – pregnancy – skin graft – vertical transmission – skin manifestation

Introduction

Covid-19, the novel human coronavirus disease, happens to be considered as the 5^th documented pandemic due to its rapid worldwide spread. This highly contagious virus was named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by the International Committee on Taxonomy of Viruses based on phylogenetic analysis [1].

The new pathogen was isolated from samples of the lower respiratory tract of infected patients in Wuhan, China in December 2019, therefore the first cases of pneumonia were reported from this epi­center. Since then, it is well-know that the virus can affect different organ systems, probably also including the skin, apart from the respiratory system [2]. Cutaneous lesions associated with covid-19 are increasingly encountered, but their exact incidence has yet to be estimated. Some reports have suggested that they are present in up to 20.4% of patients with covid-19 [3]. Extreme polymorphically-expressed skin manifestation of infection has become common in many age groups including children who were thought to be asymptomatic to the infection, but the pathophysiological mechanism of these cutaneous lesions remains unknown [4,5]. There is no previous detailed classification or description of the cutaneous manifestations of covid-19. In the study of 429 cases from Spain, they were able to describe five cutaneous clinical patterns and several sub-patterns associated with covid-19 [2]. We would like to describe the case of cutaneous manifestation as the epidermolysis in a newborn of the mother infected by covid-19 in the 3^rd trimester of pregnancy.

Case report

A 30-year-old secundigravida, primipara was admitted at term pregnancy at 38+4 weeks with regular uterine contracting activity in the transitioning phase of the first stage of labor. She complained of feeling pressure in the minor pelvis and rectum. At this stage the amniotic membranes were intact without spontaneous amniotic fluid outflow. From the documentary, the result of the vaginal swab for Group B Streptococcus from the 36^th gestational week was negative. There was no exposure to possible teratogens. Serological tests for toxoplasmosis, rubella, cytomegalovirus, herpes simplex, HIV, hepatitis B surface antigen, and treponema pallidum hemagglutination were negative. The previous pregnancy was uneventful, but the first baby was born with toxic erythema. The father-in-law of the mother had psoriasis. Other past medical and family history was insignificant.

In the 7^th month of gestation, the mother overcame covid-19 with a mild course of illness, headache, lower back pain, joint pain and no fever. After infection, she had persistent non-healing angular cheilitis and skin lesions in the capillitium. She wasn’t vaccinated against covid-19.

Before admission to the delivery ward, the patient was tested. RT-PCR covid-19 test was performed with a negative result. Her body temperature was 36.6 °C. Laboratory findings of maternal blood included a white blood cell count of 16.4 × 10⁹/L and C-reactive protein of 9.4 mg/L. All other laboratory results were normal. After we provided the artificial rupture of the membranes, the green colored amniotic fluid was drained. We took the swab from the lower segment of the uterus and later from the membranes and placental surface after the delivery. Escherichia coli and Peptococcus species were later cultivated from amniotic fluid.

A eutrophic female newborn (birth weight 2,890 g, birth length 47 cm, Apgar score 9/10/10) was born after spontaneous uncomplicated delivery. Lesions with raised epidermis after ruptured bullae were present in the frontoparietal scalp measuring 1.5 × 1.5 cm, the temporal area with a size of 1.5 × 1.5 cm (Fig. 1), in the lumbosacral region the two defects measured 5 × 4 cm and 2 × 2 cm, in the right inguinal area measuring 3 × 1 cm extending up to the area of the right labia majora, and in the area of the little finger of the left hand a collapsed bulla was detected on the skin of the newborn at the first neonatal checkup (Fig. 2). The newborn was admitted to the intensive care unit with intensive monitoring of vital functions. It was tested for covid-19 infection via RT-PCR test from a nasopharyngeal swab and the results were negative. Initially the condition was evaluated as suspicious epidermolysis bullosa, and the lesions were sterilely treated. In initial laboratory parameters, leukocytosis was present; in bio­chemical parameters, there was nonspecifically elevated interleukin-6 and C-reactive protein was within normal limits. On the second day, a plastic surgeon performed necrectomy and the lesion surface area (100 cm²) was covered with sterile amniotic membranes, I.V. rehydration therapy was ordered, and intravenous analgesics and Ampicillin were ordered to prevent infection. Perioral intake was started on the first day with good tolerance, and from the third day the child was on full enteral intake. During the entire hospitalization, the infant was cardiopulmonary compensated without saturation drops. On the 3^rd day of life, the plastic surgeon designed a bandage in collaboration with a dermatologist, so the skin findings were significantly improved and the original areas started epithelializing (Fig. 3), but also a new lesion was present under the left axilla measuring up to 1 cm. A chamomile poultice was recommended for minor defects, and the healed areas were remasked with calcium ointment. Culture examination was done with Escherichia coli and Enterococcus species found on the skin, Escherichia coli and Peptococcus species came from amniotic fluid, and Escherichia coli and Staphyloccocus epidermidis came from the rectum with good sensitivity to the prescribed antibio­tics therapy which lasted 6 days. The infant’s clinical condition improved and was discharged with negative inflammatory markers. Two weeks after discharge, the follow-up examination was performed by a dermatologist, where the skin was healed, there were no eroded areas and scar remodeling was present, hence no further therapy was needed.

In the differential dia­gnosis we considered Staphylococcal scaled skin syndrome due to the improving clinical findings, but it did not correspond with the definitive culture findings. For possible epidermolysis bullosa, blood was drawn for DNA analysis with a negative result. All conceivable dia­gnoses were excluded. Due to the persistent mother’s skin lesions after overcoming covid-19 in the 7^th month of pregnancy, we assume that the newborn’s skin lesions could also have been caused by covid-19 after possible vertical transmission.

Discussion

There are a few urgent questions about the relationship between covid-19 and pregnancy. The first is whether pregnant women with covid-19 pneumonia will develop different symptoms from non-pregnant adults, the second one whether pregnant women who have confirmed covid-19 pneumonia are more likely to die from the infection or undergo preterm labor, and thirdly whether covid-19 could spread vertically and pose risks to the fetus and neonate [6]. Data from previous pandemics suggest that pregnant women may be at increased risk for infection-associated morbidity and mortality. Physiological changes in normal pregnancy and metabolic and vascular changes in high-risk pregnancies may affect the pathogenesis or exacerbate the clinical presentation of covid-19 [7]. Pregnant women are particularly susceptible to respiratory pathogens and severe pneumonia, because they are at an immunosuppressive state, and physiological adaptive changes during pregnancy (e. g., diaphragm elevation, increased oxygen consumption, and edema of the respi­ratory tract mucosa) can render them intolerant to hypoxia [6].

Covid-19 is highly infectious with multiple possible routes of transmission. Controversy exists regarding whether SARS-CoV-2 can be transmitted in utero from an infected mother to her infant before birth [8]. Potential mechanisms of maternal transfer of SARS CoV-2 to the infant include [2] in utero transmission either transplacentally or via ingestion by the fetus of viral particles in amniotic fluid [9], intrapartum through direct contamination of infected amniotic fluid or maternal secretions and [1] post-partum through direct contact [10]. The clinical characteristics and vertical transmission potential of covid-19 pneumonia in pregnant women is unknown [6]. Vertical transmission has been proven in only a couple of cases so far. Reported rates of vertical transmission are 2% [10].

Allgaroba et al. in their study identified virions of SARS-COV-2 invading the syncytiotrophoblasts in the placental villi, which contribute to the evidence of placental infection. However, in their study, there was no evidence of fetal infection [11]. Zamaniyan et al. reported evidence of potential intrauterine infection in a woman with covid-19. They found positive RT-PCR test results for covid-19 in the amniotic fluid and repeated neonatal nasal and throat swabs [12]. There was also a described case of a neonate with elevated IgM antibodies born to a mother with covid-19 infection. The elevated IgM antibody level suggests that the neonate was infected in utero. IgM antibodies are not transferred to the fetus via the placenta [8].

We suppose that the bullous and epidermolytic lesions of the fetus have persisted without healing since overcoming covid-19. A similar clinical picture is seen in fetuses with epidermolysis bullosa, which are born with extensive foci of skin peeling [13].

ORCID authors

E. Dosedla 0000-0001-8319-9008

P. Gašparová 0000-0002-6354-6911

Z. Ballová 0000-0002-0605-948X

K. Radaljová 0000-0002-6085-1953

P. Calda 0000-0002-2903-5026

Submitted/Doručené: 2. 10. 2022

Accepted/Prijaté: 9. 1. 2023

Assoc. Prof. Erik Dosedla, MD, PhD, MBA

Department of Gynecology and

Obstetrics Hospital Agel Košice-Šaca Inc.

Faculty of Medicine

P. J. Safarik University in Kosice

Lúčna 57

040 15 Košice-Šaca

Slovak Republic

erik.dosedla@nke.agel.sk