{'fraction_non_alphanumeric': 0.04432556362246848, 'fraction_numerical': 0.02942300343905235, 'mean_word_length': 5.817708333333333, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 1, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Severe COVID‐19 infection in a child receiving immunotherapy for cancer

To the Editor: An asymptomatic 23-month-old female with high-risk neuroblastoma in remission was admitted for her third cycle of consolidation therapy with dinutuximab, granulocyte-macrophage colonystimulating factor (GM-CSF), and isotretinoin.1 Surveillance testing for SARS-CoV-2 by real-time polymerase chain reaction (rtPCR) 48 h prior to admission and contact screening were negative. On hospital day 4, she developed fever (103.5F), tachypnea (respiratory rate 60), and hypoxemia (SpO2 93% on room air) attributed to immunotherapyrelated capillary leak syndrome.1 Dinutuximab and GM-CSF were discontinued, while diuretics, antipyretics, antibiotics, and oxygen were initiated.Worsening fever, respiratory failure, and shock necessitated transfer to the intensive care unit for mechanical ventilation and vasoactive support. Repeat SARS-CoV-2 rtPCR was positive. Echocardiogram demonstrated severe pulmonary hypertension (tricuspid regurgitation jet 4.6 m/s), right atrial and ventricular dilation, and right ventricular dysfunction. Inhaled nitric oxide and iloprost were initiated for pulmonary hypertension, with epinephrine, vasopressin, and milrinone continuous infusions for hemodynamic support. Evaluation for coinfections was negative. Laboratory analyses revealed disseminated intravascular coagulation (prothrombin time 23.6 s, INR 2.1, partial thromboplastin time > 49.4 s, fibrinogen 159 mg/dL, D-dimer 2.18 ug/mL), transaminitis (aspartate transaminase 508 U/L, alanine aminotransferase 166 U/L), inflammation (lactate dehydrogenase 2489 U/L, C-reactive protein 7.3 mg/dL, ferritin 19 900 ng/mL), and cardiac dysfunction (brain natriuretic peptide 2589.4 pg/mL, troponin I 0.144 ng/mL). To control inflammation, dexamethasone and anakinra were initiated. Four aliquots of convalescent plasma (total dose 33.33 mL/kg) were administered daily, starting 24 h after intubation, and prophylactic anticoagulation with enoxaparin was given. Remdesivir treatment was initially precluded by transaminitis but was administered (3 mg/kg/dose) following resolution on hospital day 20. Worsening pulmonary hypertension and respiratory status required initiation of venoarterial extracorporeal membrane oxygenation on hospital day 23. Clinical improvement allowed weaning of support on hospital day 36. Multiple pneumothoraces developed acutely on hospital day 40. Despite maximal support, the patient died. GM-CSF, a proinflammatory cytokineproducedat tissue injury sites, signals myeloid recruitment and augments inflammatory cascades. At