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The Coronavirus Disease 2019 (COVID-19) pandemic has become the worst pandemic in modern history. The lack of prior immunity to the virus has resulted in a high mortality rate, though children have fared better than adults, overall. We present a case of a child who developed B-cell acute lymphoblastic leukemia 1 week following a symptomatic COVID-19 infection. It is possible that this viral infection provided the “second hit” posited to occur in pediatric leukemogenesis as proposed by Dr Greaves, with his initial viral exposure occurring several weeks earlier.

Avian metapneumovirus (aMPV) is a respiratory virus that infects a range of avian hosts, including chickens and turkeys. Migratory and local wild birds are implicated in aMPV spread among farms, countries, and seasonal outbreaks of the disease. A subtype B aMPV isolate from commercial chicken flocks suffering from respiratory disease was experimentally inoculated oculonasally into 7-week old chickens, young pigeons, and sparrows. Chickens showed minimal tracheal rales, whereas pigeons and sparrows were asymptomatic. Shedding of aMPV was detected by reverse transcription polymerase chain reaction on homogenates from nasal turbinates. At 5 days postinfection, 5 of 5 chickens, 2 of 5 pigeons, and 1 of 5 sparrows were positive; at 10 or 15 days, none were positive. At 2 and 5 days, aMPV antigens were localized at the ciliated boarder of respiratory epithelium in nasal cavity and trachea of chickens, as well as to the conjunctival epithelium. Pigeons had detectable viral antigens in only the trachea at 2 and 5 days; sparrow tissues did not show any positive staining. At the end of the experiment, at 21 days postinfection, 14 of 15 inoculated chickens seroconverted against aMPV, but none of the inoculated pigeons or sparrows did. The authors believe that pigeons and sparrows have the ability to transmit the virus between chicken farms, although they do not consider pigeons and sparrows as natural hosts for aMPV, given that they failed to seroconvert. In conclusion, pigeons and sparrows are partially susceptible to aMPV infection, probably acting more as mechanical vectors because infection is only temporary and short-lived.

Background The standard first line therapy for iron deficiency anemia (IDA) is oral iron. Yet, many patients fail to respond to oral iron due to poor adherence and/or adverse effects. Intravenous (IV) iron is an effective means of treating IDA in patients with malabsorption of iron or who are non-adherent and/or experience adverse effects with oral iron. Some IV iron preparations carry an FDA-mandated black box warning and/or require a test dose or prolonged infusion. Ferric carboxymaltose (FCM, Injectafer®) is a relatively new IV iron preparation with demonstrated safety and efficacy in adults with IDA. The manufacturer recommended dosing is 15 mg/kg/dose (maximum 750 mg) x2 doses administered at least 7 days apart, and each individual infusion can be administered over 10 to 15 minutes, without the need for a test dose. Limited data exist on its use in children. Our objective was to assess the hematologic response and adverse effects of IV FCM in a diverse population of infants, children and adolescents with IDA who failed oral iron therapy. Method All children with IDA who received FCM at Children's Health from June 1, 2014 through June 10, 2015 were included. Subjects were identified via search of pharmacy records. All patients received at least one dose of FCM 15 mg/kg (maximum 750 mg) administered as a 15-minute IV infusion (without test dose or pre-medications). Patient characteristics, adverse effects and hematologic response were retrospectively collected from the electronic medical record. Results During the study frame, one hundred twenty-five infusions of FCM were administered to 87 patients (71% female) with a median age of 14 years (range 9 months to 20.8 years). The most common racial/ethnic group was Caucasian/White (Latino) at 45% followed by African American/Black and Caucasian/White (Non-Latino), each at 22%. The primary etiologies were heavy menstrual bleeding (38%), nutritional (24%), and GI bleeding and/or malabsorption (20%) with the remaining 18% representing other/mixed causes of IDA (e.g., inflammatory). The median dose administered during a single infusion was 750 mg (range 132 to 750 mg). No adverse effects were noted during or following the infusion in 77 subjects. Two patients had transient tingling, nausea and/or mild abdominal pain. Five others developed generalized pruritis and/or urticaria and received diphenhydramine and/or hydrocortisone, with prompt resolution. Two adolescents had more clinically significant reactions, 1 with nausea/vomiting post-infusion (likely psychogenic) requiring admission, and 1 with dyspnea 2 minutes into the infusion, requiring its immediate termination and administration of diphenhydramine, hydrocortisone and normal saline with prompt symptom resolution. One patient experienced asymptomatic extravasation during the second infusion which resulted in localized iron-staining of the skin. Median pre-infusion hemoglobin concentration for all patients was 9.1 g/dL (range 3.9 to 13.3 g/dL) (Table). A follow-up measurement was available for 76 patients at a median time of 6 weeks (range 1 to 30 weeks) post-initial infusion with a median hemoglobin increase of 3.3 g/dL (range -1.5 to 9.5 g/dL). Conclusion Intravenous FCM, administered in an outpatient infusion setting as one or two short IV infusions and without need for a test dose, was safe and effective in most children and adolescents with IDA refractory to oral iron therapy. Further clinical data are necessary to more fully characterize the extent of adverse effects in young patients. Prospective studies of IV FCM in children are indicated to assess clinical efficacy, including outcomes such as health related quality of life and fatigue. Table. *Hematologic Response to FCM Pre-Infusion **Post-Infusion Hemoglobin concentration (g/dL) All Etiologies, Pre (n=87), Post (n=76) Heavy menstrual bleeding, Pre (n=33), Post (n=26) Nutritional, Pre (n=21), Post (n=20) - 9.1 (3.9 to 13.3) 9.3 (4.2 to 13.3) 8.8 (4.9 to 12.2) - 12.2 (7.1 to 16) 12.7 (8.8 to 16) 12.2 (10.5 to 13.7) Mean corpuscular volume (fl), Pre (n=87), Post (n=76) 71.6 (49.5 to 97.4) 80.9 (53.3 to 102) Serum ferritin (ng/mL), Pre (n=80), Post (n=60) 5.2 (0.6 to 288.6) 115.7 (2.3 to 679.3) *Median laboratory values are reported. **Follow-up laboratory testing occurred at median time of 6 weeks (range 1 to 30 weeks) post-infusion. Disclosures Powers: Gensavis Pharmaceuticals, LLC: Research Funding. McCavit:Pfizer: Research Funding; Gensavis LLC: Research Funding; Novartis: Speakers Bureau. Adix:Gensavis Pharmaceuticals, LLC: Research Funding. Buchanan:Gensavis Pharmaceuticals, LLC: Research Funding.