MINIREVIEW: COVID-19 in pediatrics

Summary by: Sonia Fanelli; Reviewer: Francesca Bardi

The first study describes the case of a 26-day old male neonate with a PCR-confirmed SARS-CoV-2 infection presenting with fever and neurologic manifestations, such as paroxysmal episodes, hypertonia and facial cyanosis. The patient remained hospitalised for 6 days in a negative pressure room and became afebrile from day 2, with favourable outcome. The second case reports the favourable outcome of neurosurgery performed under general anesthesia in a 8-month old male infant with COVID 19 presenting with hydrocephalus and deteriorating clinical picture suggestive for shunt malfunctioning.

Fever associated with neurologic manifestations in a SARS-CoV-2-positive neonate

In China, the incidence of Coronavirus disease (COVID 19) in children has been shown to range from 0.8% to 2% of the total reported cases. Infants present with a milder disease course with predominance of respiratory symptoms, compared to adults. In Spain, Chacón-Aguilar and colleagues described the case of a 26-day-old male patient without previous medical history presenting with fever and neurologic manifestations such as paroxysmal episodes, hypertonia and facial cyanosis. During his hospital stay, the findings of the physical examination were normal save for fever of 24 hours’ duration (peak, 38.8°C) associated with nasal discharge, vomiting, irritability and watery stools. A series of blood, urine, stool and cerebrospinal fluid analysis, as well as a nasal wash respiratory virus panel were performed, once the newborn arrived to the emergency department. However, only elevated serum levels of creatine kinase (380 U/L) and lactate dehydrogenase (390 U/L) were observed. Viral antigen tests were negative, whereas the polymerase chain reaction (PCR) test for detection of SARS-CoV-2 was positive. It is notable that there was a relevant history of multiple symptomatic neighbors. The patient remained hospitalised for 6 days in a negative pressure room and became afebrile from day 2, with favourable outcome.

The first reported case of neurosurgery in an infant with COVID 19

Administering general anaesthesia to infants with respiratory infections is a challenge because anaesthetic drugs can contribute to their infection-associated immune suppression and  dysregulated inflammatory response, thus exacerbating intubation-related mechanical stress and inflammation. Carrabba and co-workers reported the case of an 8-month-old male patient affected by hydrocephalus and who tested positive for SARS-CoV-2. The neonate presented with a mild temperature, a dry cough and an occipital cerebrospinal fluid collection suggestive for shunt malfunctioning. While the baby deteriorated and vomited repeatedly, the need for shunt revision turned urgent. At the same time, he manifested upper respiratory symptoms due to COVID 19 and concerns about general anaesthesia emerged, as no reports exist regarding such a risky procedure in SARS-CoV-2-positive infants. Nevertheless, the neurosurgery was arranged in a negative pressure room, considering that neurological deterioration would have progressed if no intervention had been taken. The infant underwent two neurosurgical revisions of the shunt under general anaesthesia without respiratory complications and recovered promptly both times, with favourable neurosurgical course. 

Conclusions

In light of the two cases reported herein, two important conclusions can be drawn:

  1. In the current epidemiological context, it is essential to include the SARS-CoV-2 PCR test in the workup of infants presenting with fever of unknown origin. There is evidence on other coronavirus types demonstrating that these viruses have neurotropic properties, as patients with neurologic manifestations such as convulsions, decreased level of consciousness and encephalitis have been reported.
  2. Relative resistance of babies and children to COVID 19 has been generally observed so far. This highlights the possibility that paucisymptomatic infants with such a disease can undergo surgical procedures without additional morbidity. Further studies are needed to confirm the findings as well as extend the knowledge regarding the implications for other surgical interventions in SARS-CoV-2-positive pediatric patients.

Bibliography:

[1] Chacón-Aguilar R, Osorio-Cámara JM, Sanjurjo-Jimenez I, González-González C, López-Carnero J, Pérez-Moneo-Agapito B. COVID-19: Fever syndrome and neurological symptoms in a neonate [published online ahead of print, 2020 Apr 27]. An Pediatr (Engl Ed). 2020;92(6):373-374.

[2] Carrabba G, Tariciotti L, Guez S, Calderini E, Locatelli M. Neurosurgery in an infant with COVID-19. Lancet. 2020;395(10234):e76.

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