1) DATE OR PRESENTATION: March 18, 2020
2) CASE PRESENTATION:
Here, we report the first case in the Middle East of a 16-month-old Lebanese female, previously healthy, who had symptomatic COVID-19.
The patient was transferred from another hospital due to increasing hypoactivity and severe diarrhea. The referring hospital had ruled out coronavirus infection due to the absence of cough. Parents reported that the infant was healthy and had regular food intake until symptoms started six days prior to presentation. They denied exposure to or contact with infectious risk factors and affirmed that no cough/rhinorrhea symptoms were present.
3) PHYSICAL EXAM:
Upon examination, the patient was febrile (40°C) with a respiratory rate of 24 breaths per minute and a heart rate of 166 bpm. Chest auscultation revealed rhonchi.
4) PERTINENT LABORATORY VALUES:
Laboratory studies revealed leukocytosis with a white cell count of 15,000 cu mm (range: 3,400-9,600) and elevated C-reactive protein level reaching 231.16 mg/L (range: 0-5). Cultures for blood, urine, and stool were taken. This warranted nasopharyngeal swabs for an RT-PCR to test for SARS-CoV-2, which turned out positive. Blood culture was positive for Streptococcus pneumoniae. Stool and urine cultures were negative.
5) PERTINENT IMAGING:
A chest radiograph showed left upper lobe consolidation and bilateral lower lobe infiltrates.
6) TREATMENT AND OUTCOMES:
In the meantime, the patient was put on a hydration regimen and was started on ceftriaxone (75 mg/kg/day) and metronidazole (10 mg/kg, every eight hours). On day 2 of admission, the patient became afebrile and exhibited improvement in physical activity.
Upon further investigation, the father admitted that he had ‘flu-like’ symptoms two weeks before presentation but denied travel history or contact with a defined case of COVID-19. The mother also confessed having similar symptoms but did not seek medical consultation at the time. This hinted that the patient likely contracted the virus from her parents, who, in turn, might have been infected through community transmission. The family was transferred to a designated quarantine for isolation. On day 5, the RT-PCR test of the infant was negative, and the patient’s symptoms had resolved.
7) LESSONS LEARNED:
Cases of COVID-19 in children are not as rare as they might have been thought. This is the first case reported from the Middle East that involves a 16-month-old female infant. Around 2.4% of cases with COVID-19 were reported to be among the pediatric population in China. Ages ranged between 3 months and 14 years, with males being predominantly affected.
Uniquely, our patient presented with fever and diarrhea; cough and other respiratory symptoms were not reported. Previous COVID-19 studies in the pediatric population noted that common symptoms include fever, cough, sore throat, and rhinorrhea. Diarrhea has not been reported yet. This warrants a more comprehensive definition of the symptoms that govern COVID-19 in the pediatric population, as gastrointestinal symptoms have been documented in our case and among adults.
The RT-PCR test was negative after five days of treatment and 11 days after the onset of symptoms. This suggests that children might clear the virus more rapidly than adults. Similarly, previous research in children indicates that the RT-PCR test becomes negative within 12 days (range: 6-22) after the presentation of symptoms.
Fear of social stigma drove the patient’s parents to hide information of their respiratory tract illnesses. It is important to address this issue at public health levels and to stress and highlight the social responsibility associated with reporting any relevant medical data related to the COVID-19 pandemic.
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