Summary: Gastrointestinal symptoms, coupled with a fever or history of exposure to COVID-19, could indicate coronavirus infection in children.
Children suffering from sickness and diarrhea, coupled with a fever or history of exposure to coronavirus, should be suspected of being infected with COVID-19, recommends a new study published in Frontiers in Pediatrics.
The research also suggests that the gastrointestinal symptoms first suffered by some children hints at potential infection through the digestive tract, as the type of receptors in cells in the lungs targeted by the virus can also be found in the intestines.
“Most children are only mildly affected by COVID-19 and the few severe cases often have underlying health issues. It is easy to miss its diagnosis in the early stage, when a child has non-respiratory symptoms or suffers from another illness,” says author of this study, Dr. Wenbin Li, who works at the Department of Pediatrics, Tongji Hospital, Wuhan, China.
He continues, “Based on our experience of dealing with COVID-19, in regions where this virus is epidemic, children suffering from digestive tract symptoms, especially with fever and/or a history of exposure to this disease, should be suspected of being infected with this virus.”
In this study, Li and his colleagues detail the clinical features of children admitted to hospital with non-respiratory symptoms, which were subsequently diagnosed with pneumonia and COVID-19.
“These children were seeking medical advice in the emergency department for unrelated problems, for example, one had a kidney stone, another a head trauma. All had pneumonia confirmed by chest CT scan before or soon after admission and then confirmed to have COVID-19. While their initial symptoms may have been unrelated, or their COVID-19 symptoms were initially mild or relatively hidden before their admission to hospital, importantly, 4 of the 5 cases had digestive tract symptoms as the first manifestation of this disease.”
By highlighting these cases, Li hopes that doctors will use this information to quickly diagnose and isolate patients with similar symptoms, which will aid early treatment and reduce transmission.
The researchers also link the children’s gastrointestinal symptoms, which have been recorded in adult patients, to an additional potential route of infection.
Li explains, “The gastro-intestinal symptoms experienced by these children may be related to the distribution of receptors and the transmission pathway associated with COVID-19 infection in humans. The virus infects people via the ACE2 receptor, which can be found in certain cells in the lungs as well as the intestines. This suggests that COVID-19 might infect patients not only through the respiratory tract in the form of air droplets, but also through the digestive tract by contact or fecal-oral transmission.”
While COVID-19 tests can occasionally produce false positive readings, Li is certain all these five children were infected with the disease, but he cautions that more research is needed to confirm their findings.
“We report five cases of COVID-19 in children showing non-respiratory symptoms as the first manifestation after admission to hospital. The incidence and clinical features of similar cases needs further study in more patients.”
Clinical Characteristics of 5 COVID-19 Cases With Non-respiratory Symptoms as the First Manifestation in Children
An outbreak of the novel coronavirus disease 2019 (COVID-19) occurred in Wuhan, China, in December 2019, which then rapidly spread to more than 80 countries. However, detailed information on the characteristics of COVID-19 in children is still scarce. Five patients with non-respiratory symptoms as the first manifestation were hospitalized from the emergency department, and were later confirmed to have COVID-19, between 23 January and 20 February 2020, at the Wuhan Children’s Hospital. SARS-CoV-2 nucleic acid detection was positive for all the patients. Four of the patients were male and one was female, and their ages ranged from 2-months to 5.6 years. All lived in Wuhan. One patient had a clear history of exposure to SARS-CoV-2, one had a suspected history of exposure, while the others had no exposure history. For three of the five patients, the primary onset disease required an emergency operation or treatment, and included intussusception, acute suppurative appendicitis perforation with local peritonitis, and traumatic subdural hemorrhage with convulsion, while for the other two it was acute gastroenteritis (including one patient with hydronephrosis and a stone in his left kidney). During the course of the disease, four of the five patients had a fever, whereas one case had no fever or cough. Two patients had leukopenia, and one also had lymphopenia. In the two cases of severe COVID-19, the levels of CRP, PCT, serum ferritin, IL-6, and IL-10 were significantly increased, whereas the numbers of CD3+, CD4+, CD8+ T lymphocytes, and CD16 + CD56 natural killer cells were decreased. We also found impaired liver, kidney, and myocardial functions; the presence of hypoproteinemia, hyponatremia, and hypocalcemia; and, in one case, abnormal coagulation function. Except for one patient who had a rotavirus infection, all patients tested negative for common pathogens, including the influenza virus, parainfluenza virus, respiratory syncytial virus, adenovirus, enterovirus, mycoplasma, Chlamydia, and Legionella. Chest CT images of all the patients showed patches or ground-glass opacities in the lung periphery or near the pleura, even large consolidations. This case series is the first report to describe the clinical features of COVID-19 with non-respiratory symptoms as the first manifestation in children.