178: Upper Gastrointestinal Bleeding in a Pediatric Patient With Sickle Cell Disease and COVID-19

INTRODUCTION: Gastrointestinal (GI) symptoms can be the first presenting finding in children infected with the severe acute respiratory syndrome coronavirus-2 (SARSCoV- 2) The novel coronavirus disease 2019 (COVID-19) has a higher rate of mortality and critical illness in adults, however, severe presentations in children are increasingly reported Patients with chronic illness are at a higher risk of complications from the infection, but there is no data in patients sickle cell disease (SCD) METHODS: A 12-year-old African American boy with SCD, subtype HbSS, presented with acute worsening hematemesis, 2 days of non-bloody diarrhea, and back pain that responded a dose of ibuprofen He had a history of splenectomy and multiple episodes of acute chest syndrome (ACS) and vaso-occlusive crises On presentation, he was febrile, tachycardic, and hypotensive, without signs of respiratory distress His hemoglobin had dropped to 4 1 g/ dL His nasopharyngeal swab was positive for SARS-CoV-2 He required multiple blood transfusions and other supportive measures to treat his shock state Esophagoduodenoscopy (EGD) showed diffuse hemorrhagic gastropathy without ulcerations, but no biopsy was taken RESULTS: The patient's presenting symptoms of diarrhea and fever were consistent with published data on children with COVID-19 He also had leukocytosis, elevated inflammatory markers, and an abnormal coagulation profile These are seen in more severe cases and are currently described under the multisystem inflammatory syndrome of children His respiratory status remained stable despite having multiple ACS episodes in the past Upper GI bleeding is not yet described in pediatric COVID-19 Most cases of upper GI bleeding in children are attributed to NSAIDs exposure, but it's unlikely that one dose of ibuprofen causes such severe bleeding Histopathologic samples from COVID-19 patients show evidence of lymphocytic infiltrate and interstitial edema in the gastric mucosa, with detection of SARS-CoV-2 nucleocapsid protein in gastric epithelial cells We hypothesize that the severe hemorrhagic gastritis resulted from SARS-CoV-2-induced coagulopathy and viral invasion This was further compounded by the acute insult from an NSAID and the underlying mucosal infarction and vascular congestion from sickling