Use of recombinant human thrombomodulin in a pediatric case of COVID-19-associated coagulopathy: A case report

Coronavirus disease 2019 (COVID-19)-associated coagulopathy (CAC) is a known extrapulmonary complication of severe acute respiratory syndrome coronavirus 2 infection, primarily studied in adults. As a result, pediatric data are limited, and management strategies remain under investigation. Recombinant human soluble thrombomodulin (rh-TM), an anticoagulant with anti-inflammatory and antifibrinolytic properties, has shown promise in sepsis-induced coagulopathy; however, it has not been widely studied in children with CAC. A previously healthy 5-year-old girl presented with severe CAC secondary to COVID-19. She initially presented with persistent fever, gastrointestinal and respiratory symptoms, and gingival bleeding. Laboratory evaluation revealed significant coagulopathy characterized by high D-dimer (≥110.3 μg/mL), fibrinogen/fibrin degradation products (328.6 μg/mL), thrombin-antithrombin complex (≥120 ng/mL), and plasmin-α2 plasmin inhibitor complex (7.7 μg/mL), along with thrombocytopenia and prolonged prothrombin time and international normalized ratio and activated partial thromboplastin time. Imaging showed ground-glass opacities on chest computed tomography (CT) and increased ¹⁸F-fluorodeoxyglucose uptake in positron emission tomography-CT. A multidisciplinary treatment regimen was initiated, including intravenous immunoglobulin, remdesivir, rh-TM, corticosteroids, low-dose aspirin, and budesonide inhalation. Levels of coagulation markers gradually normalized, and the patient's clinical symptoms resolved without further complications. She was discharged on day 29 of illness and remained relapse-free after 1 year of follow-up. This case highlights the potential utility of rh-TM as part of a tailored multimodal treatment strategy for pediatric CAC. Early recognition and individualized, stage-specific therapy may contribute to favorable outcomes. However, further studies are warranted to evaluate the safety and efficacy of rh-TM in children with CAC.