Question normal

Date of Presentation: 23rd March 2020

A 17-year-old overseas student studying in the United Kingdom returned to Hong Kong Special Administrative Region (HKSAR) on 20th March 2020. She subsequently underwent compulsory quarantine in accordance with the “health quarantine arrangements on inbound travellers from overseas guidelines” from the Centre for Health Protection, HKSAR. She had no known contact with confirmed COVID-19 patients. On the day of arrival to HKSAR, there was sudden onset of complete loss of smell and taste sensation when she tried to eat spicy noodles. She had no fever, coryza, or fatigue. She was previously healthy without history of allergic rhinitis and was not taking any medications. She presented to the Accident and Emergency Department (AED) of a regional hospital on the fourth day after her symptom onset, where deep throat saliva was saved for testing of COVID-19. SARS-CoV-2 was detected by reverse-transcription-polymerase chain reaction (RT-PCR) in her saliva sample. She was then admitted to our unit on the eighth day of her disease. She reported full spontaneous recovery of anosmia and ageusia since the previous day. She complained of mild chest discomfort and headache.

She was afebrile with stable vital signs in room air. Examination of nostrils did not show congestion or obstruction by nasal turbinates, and systemic examination was normal. Blood tests including complete blood picture, liver and renal function tests, lactate dehydrogenase, blood gas, C-reactive protein, erythrocyte sedimentation rate, and clotting profile were all within normal ranges. Chest X-ray was normal.

She was managed conservatively with Paracetamol for pain relief. During the hospital stay, she remained stable with gradual resolution of chest discomfort and headache. Her pooled nasopharyngeal and throat swabs for SARS-CoV-2 RT-PCR were tested negative on the 21st and 22nd day of illness, and she was discharged on the 23rd day after symptom onset (16th day of hospitalisation).

Lessons Learned:
Anosmia and ageusia are not uncommon presentations of COVID-19 infection in children and adolescents, and it may be the first and predominant symptoms, in the absence of fever or other respiratory symptoms.

The subjective nature of smell and taste sensation makes objective assessment difficult, especially in younger children. Its rapid onset and spontaneous recovery may create difficulty in identifying infected children, further obscuring its clinical picture and manifestations in the paediatric population. The recovery of smell and taste sensation do not equate to a decrease in viral load, or clearance of the SARS-CoV-2 virus.

In our patient, SARS-CoV-2 virus was only tested due to her travel from an endemic country. In view of active community transmission around the world, we must be alert to any individual presenting with anosmia and/or ageusia. The public should be advised to self-isolate and seek help from healthcare professionals if they show symptoms of new onset anosmia or ageusia. Healthcare workers attending to patients with such symptoms should implement strict infection control and isolation measures to protect against COVID-19 infection in healthcare settings.

Lastly, we need to consider including anosmia and ageusia into the diagnostic and testing criteria for COVID-19 infection!