On 31 December 2019, the first case of COVID-19, was reported in Wuhan. A public health emergency of international concern was declared on 30 January 2020 and the first case in Scotland, on 2 March. The effect of COVID-19 appears to be less in the paediatric population and there are fewer cases reported in the literature in comparison to the adult population. Here, we report a case of a previously well 5-week-old infant who presented with fever and increased sleepiness. There was no known contact with any unwell individuals. COVID-19 was identified through a septic screen work up. The infant’s course was uneventful and she has made a full recovery. This case highlights the need to have a low index of suspicion in the diagnosis of COVID-19 and the need to be vigilant in use of personal protective equipment, even in paediatric patients with subtle symptoms.
- public health
- infectious diseases
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On 31 December 2019, the first case of, what would soon be called COVID-19, was reported in Wuhan, China. A cluster of workers from the Huanan seafood market were found to have pneumonia of unknown cause. On 13 January 2020, the first case of COVID-19 was found outside of China. Affected numbers started to rise rapidly, spreading across the globe and on 30 January 2020, a public health emergency of international concern, was declared.1 The first case in Scotland was reported on 2 March 2020 in a returning traveller from Italy.
Despite ever increasing numbers of cases, there remain few reported paediatric cases. We report here one of a small number of positive paediatric cases in Scotland.
A 5-week-old female infant, presented to the hospital on 21 March. She was a previously well baby born at 39 weeks by elective section without any history of antenatal, perinatal or postnatal complications. There were no risk factors for sepsis identified and there was no history of maternal illness during pregnancy.
On 21 March a 5-week-old baby presented to our district general hospital in Scotland. There was a 1-day history of increased sleepiness in the infant and three reported choking episodes which had occurred at home. These were short-lived, occurring with milky vomits and the infant was noted to be pale; however, remained conscious throughout without any change in respiration. The infant was bottle feeding well, passing urine and had no cough, coryza, tachypnoea, diarrhoea or fever. There was no history of any travel or of any known unwell contacts.
On presentation to accident and emergency the infant was noted to have a temperature of 38.1°C. On examination she appeared well; however, started appearing mottled very shortly after admission. The infant had no increased work of breathing, a clear chest with normal heart sounds and soft and non-tender abdomen. There were no rashes. Her observations on arrival to the paediatric ward were: heart rate 150 beats/min, respiratory rate 48 breaths/min, oxygen saturations 100% in room air, blood pressure 102/50 mmHg and temperature 37.4°C.
Full septic screen investigations including blood, urine and cerebrospinal fluid (CSF) cultures and a respiratory sample, were performed. The infant was given antibiotics and admitted to the paediatric ward.
Blood tests showed a haemoglobin of 142 g/L, white cell count of 5.5×109/L with a mild lymphopenia of 2.0×109/L. C reactive protein was <5 mg/dL. CSF microscopy and cell count were unremarkable. Blood culture was negative. Urine culture was negative, and so was CSF virology and culture. A throat swab grew Candida and was PCR positive for SARS-CoV-2. No other respiratory viruses were detected. The positive COVID-19 swab was reported 16 hours from the infant’s admission time. No chest X-ray was performed.
Due to the initial temperature of 38.1°C recorded in the emergency department and the history given, the infant was investigated and treated for possible late-onset neonatal sepsis.
Following completion of a septic screen, the infant was given intravenous cefotaxime as per local antibiotic guidelines for suspected sepsis in this age group. The infant was noted to appear mottled at this time so was given a 10 mL/kg fluid bolus of 0.9% sodium chloride and was subsequently given maintenance intravenous fluids.
Outcome and follow-up
The infant was observed on the paediatric ward while receiving her antibiotics for suspected sepsis. She was intermittently noted to have brief and self-resolving drifts in her oxygen saturations to 92%–93% in room air. This was never sustained and did not require oxygen therapy. During this time, the infant also developed mild nasal congestion. She was nursed in a side room, isolated with her mother, with staff adhering to personal protective equipment (consisting of fluid resistant surgical mask, apron and double gloves as per Health Protection Scotland guidance) at all times. No aerosol-generating procedures were required. Her mother, initially not symptomatic, started to develop a mild cough at the time of the infants discharge. Her mother was not tested for COVID-19 as her symptoms were mild, she did not require hospital admission and already had to self-isolate for 14 days. These symptoms did not worsen at home.
Following 48 hours of antibiotics and negative blood, urine and CSF cultures, the infant was discharged home with a course of nystatin and clotrimazole for oral thrush and instruction for the household to self-isolate for 14 days as per current national guidelines. The infant has remained well since discharge as have her mother and brother who she lives with and she will not require any follow-up.
To date, there has been more focus on the adult population in the literature. Within cases reported in the Paediatric population, there have been few publications regarding COVID-19 in the paediatric population of the UK. The first case of COVID-19 through transmission was reported by Le et al in Vietnam.2
A recent systematic review identified 7780 COVID-19 positive paediatric patients from across 26 countries worldwide. Of these, 59.1% had presented with fever, similar to the patient reported here. The average age however, was 8.9 years, significantly older than this patient.3
Since the initial writing of this case, there was also a health advisory, released by the US Centers for Disease Control and Prevention4 and the Royal College of Paediatrics and Child Health5 concerning a multisystem inflammatory syndrome in children, seen in association with some cases of COVID-19, resulting in multi-organ failure.
In this young infant, there was no history of travel or known unwell contacts. Hoang et al reported known contact with a family member who had tested positive for COVID-19 in 75.6% of patients included in their systematic review.3 There is debate regarding vertical transmission of COVID-19 but regardless, it seems unlikely here given the age of patient and with the baby’s mother developing symptoms after the baby.6 7
The diagnosis in this case was reached only through process of standard practice for an infant of this age presenting with fever. Obtaining a respiratory sample as part of this process was key to identifying this positive patient in this case. A diagnosis of COVID-19 should be considered in any paediatric patient presenting with fever, regardless of age. In addition, febrile neonates should continue to be screened for other infections due to the possibility of coinfection.
In this case, procurement of a respiratory swab as part of a standard septic screen was key in identifying the patient as COVID-19 positive. Had this not been performed as part of the septic screen and COVID-19 not identified, this would have resulted in infection control measures not being taken and the family would not have been advised 14 days of self-isolation, in turn leading to possible further spread of the virus.
The diagnosis of COVID-19 needs to be considered in any paediatric patient presenting with fever, regardless of patient age, travel history or unwell contact history.
It has been reassuring that this infant has been mildly affected only, despite testing COVID-19 positive. She has made a full recovery.
With thanks to the patient and her family for consenting to the sharing of her case.
Contributors RF wrote the initial and revised manuscript. Manuscript review and editing by KB and RG.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Parental/guardian consent obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
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