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Zhang Yuehua1#, Li Hongai2#, Lin Daojiong2, Xiao Meifang2, Wang Jiachong1, Wei Yong2, Lei Zhixian2, Zeng Zhenqiong1, Li Ling2,Xiang Wei3
1Haikou People’s Hospital, Haikou 570208, China; 2Hainan Maternal and Children’s Medical Center,Haikou 570311, China;3Key Laboratory of Tropical Translation Medicine of Ministry of Education, Haikou 571199, China
Corresponding author: Xiang Wei,Email:xiangwei8@163.com
# Contributed equally
A three-month-old infant was admitted to Haikou people’s hospital for ”fever for 4-hour” on January 26, 2020. The temperature was 38.2℃ and with no respiratory symptoms that time. On January 21, her parents and grandparents took her and drove from Wuhan City, Hubei Province to Haikou, stopped at Hengshan city, Hunan Province and arrived on January 25. After hospitalization, upon evaluation, her body temperature was 38.0 ℃, heart rate was 130 beats/min, breath rate was 30 times/min, body weight was 7 kg. She had congestion in the pharynxno, but not in conjunctiva and no cyanosis, she breath smoothly without obvious wet and dry snoring sounds in both side of lung. She had strong heart sounds, regular heart rhythm and no murmurs.The abdomen was flat and soft, the spleen could not be touched but the liver could be touched at 1 cm below the ribs. Neurological examination was normal. The laboratory examination results showed WBC: 9.68*109/L, neutrophil: 44.6%, lymphogranulocyte: 44.3%, hemoglobin: 113g/L, platelets:494*109/L, CRP: 5.6mg/L, PCT: 73ng/L; Influenza A and B test in respiratory tract samples were both negative. Blood culture (January 26) and two sputum cultures (January 26, February 1) were negative. A chest X-ray (Figure 1) (January 26) showed a patchy in the right lung. The result of RT-PCR nucleic acid detection of COVID-19 in throat swab samples was initially critical value (January 26) but positive after 1 day and 4 days.
Paramivir, Azithromycin and Ceftazidime were used to anti microorganisms from January 26. Supportive treatment including Ambroterol, nebulization and oxygen therapy were strengthened when she got cough and foaming on January 29. Under active treatment, the patient’s temperature became normal on January 27, respiratory symptoms relieved and the result of nucleic acid detection in throat swab samples turned negative on February 3, 5 and 9. On February 5, the result of nucleic acid detection in urine sample was negative but in sputum sample was positive, and result of nucleic acid detection in stool sample was positive for two consecutive times (February 5 and 9). Finally, the patient reached the discharge standards including that the temperature was normal for more than 3 days, the respiratory symptoms improved significantly and the result of nucleic acid detection of COVID-19 had been negative for two consecutive times, and discharged on February 10. On February 13, The patient's throat swabs and stool samples were re-examined, the result of nucleic acid detection in throat swabs was negtive and that in stool sample was still positive.
When we first reported this case in Chinese, we didn't know clearly how the disease spread in her families[1]. While tracing the history of disease exposure in the patient and her families, we know that the infant was taken by the parents to swim with no protective measures at a swimming pool near the community they lived in Wuhan. The parents worn mask that time. On January 21, they began to drive a car to Xiaogan to pick grandparents up and then drove to Haikou, arrived on January 25 together and were all isolated and observed in a hotel. On January 26 the infant got a fever and was sent to hospital. The parents did not wear masks as required or take personal protection when accompanied the infant in the hospital. On February 2, the father began cough and fever and was diagnosed COVID-19 pneumonia. Simultaneously, the mother was confirmed diagnosis of COVID-19 asymptomatic infection, she had positive nucleic acid test result and a typical CT imaging showing revealed exudative lesions in the left lung and right upper lung and but without fever or any other respiratory symptoms. The grandparents had no symptoms and negative nucleic acid test during the 14-day isolation. However, it is worth noting that the patient was looked after by grandmother after being discharged from hospital on February 10. While on February 13, the grandmother developed fever and was diagnosed with COVID-19 pneumonia.
With the peak of the epidemic and more regions carrying out pathogenic testing, the number of child-infected COVID-19 cases is increasing significantly, attracting the attention of all parties[2-3]. For this patient, she was only 3-month old with not much contact with the external environment except her families, but she was the first COVID-19 patient in her family including parents and grandparents. Hence, we speculate that she might get infected when she was taken to swim in Wuhan. For the parents, they did not wear masks as required or take personal protection when accompanied the infant in the hospital and then both had a confirmed diagnosis of COVID-19 7 days later, which prompt that the infant might be the spreader of the parents' infection. In addition, the mother was asymptomatic infection without any symptoms, which suggests that asymptomatic infection poses difficulties in clinically diagnosis of COVID-19. One more interesting thing was that although infant’s result of nucleic acid detection in throat swab samples had been negative for three consecutive times, the stool sample on February 5 and 9 were still positive. After discharging from hospital on February 10, the grandmother who looked after the infant was diagnosed with COVID-19 3 days later(February 13). On the same day,the infant’s result of nucleic acid detection in stool sample was still positive, which prompt that the infant may be the spreader of her grandmother's infection and reminded us that the patients may still excrete the virus and have an infectious risk during the recovery period. What’s more, the current clinical diagnosis and treatment guides which suggests the discharge standards is debatable. Based on the diagnosis and treatment of this case, all age groups are susceptible to COVID-19, the family is highly contagious after exposure.
References:
[1] Zhang YH, Lin DJ, Xiao MF, et al. 2019 novel coronavirus infection in a three-month-old baby[J].Zhonghua Er Ke Za Zhi,2020,58(3):182-184.
[2] The Society of Pediatrics, Chinese Medical Association,  the Editorial Board, Chinese Journal of Pediatrics.Recommendations for the diagnosis, prevention and control of the 2019 novel coronavirus infection in children (first interim edition)[J].Zhonghua Er Ke Za Zhi,2020,58(3):169-174.
[3] Cai JH, Wang XS, Ge YL, et al. First case of 2019 novel coronavirus infection in children in Shanghai[J].Zhonghua Er Ke Za Zhi,2020,58(2):86-87.