Page 26 - Delaware Medical Journal - May/June 2020

CASE REPORT
with dry mucous membranes and decreased skin turgor. His vital
signs on arrival to our emergency department were: heart rate, 165/min; RR, 30/ min; blood pressure, 92/52 mm hg; pulse oximeter, 100% on 4 L/min. Intravenous (IV) access was obtained and lab work was drawn.
On arrival, patient had tachypnea but maintained pulse oximetry saturation > 90%. He was continued on 4L nasal cannula of oxygen to decrease his work of breathing and tachypnea. At time of admission, lab work revealed a venous blood gas with a pH of 6.93, pCO2 24, and bicarb 6. Critical care panel was significant for lactate 3.3. Basic metabolic panel demonstrated
a normal sodium of 143 and elevated chloride of 127. Complete blood count was significant for leukocytosis to 35.1 with neutrophil predominance of 40%, the lymphocytic count was 33%, and thrombocytosis to 776 K/cc. His urine analysis was negative for glucose and showed no ketones. Chest x-ray and abdominal x-ray were unremarkable. GI PCR was negative. SARS-CoV-2 PCR nasal swab was positive. His blood and urine cultures remained negative. Patient was admitted to
the intensive care unit for fluid management, monitoring of respiratory status, and electrolyte derangement. During hospital course, the patient had a fever spike of 38.0 degrees Celsius
on hospital day 1, but was afebrile for the remainder of the hospitalization. He was started on an infusion of dextrose 5% with 1⁄2 normal saline
plus 77 mEq/L of sodium acetate, at one-and-a-half times maintenance rate. Patient was weaned to room air on hospital day 3. Patient was advanced to a normal diet on hospital day 4. Patient was discharged home on hospital
day 5. He was discharged home with family after guidance of quarantine recommendations.
DISCUSSION
Our case report demonstrates an
infant with primarily gastrointestinal symptoms and severe dehydration secondary to COVID-19. According
to reports by the Centers for Disease Control and Prevention in analysis
of 291 U.S. children with COVID-19, 11% had nausea or vomiting and
13% had diarrhea.1 These symptoms may contribute to the need for hospitalization in neonates or infants who may have difficulty maintaining hydration status. While respiratory distress in most children and adults
is secondary to lung pathology in COVID-19, our infant’s tachypnea
was likely a compensatory respiratory mechanism of his metabolic acidosis consistent with initial pCO2 of 24 and normal chest x-ray. His respiratory status improved in conjunction with improvement of metabolic acidosis. This picture also did not fit the
recently observed acute inflammatory response syndrome in children due
to COVID-19 infection, as there
was no evidence of shock or cardiac dysfunction and he had stable blood pressure. Contrary to previous reports of infants with COVID-19, our patient had no household contact with active symptoms prior to his presentation, though his father did work in a high- risk area.4 Retrospective reviews in both China and the U.S. demonstrate that infants younger than 1 year
may have a higher proportion of hospitalization than older children. Our case demonstrates that dehydration may be a component in hospitalization. More research is necessary to classify high-risk pediatric patients and etiology of hospitalization for infants. COVID-19 testing should be considered in young infants with gastrointestinal symptoms, even if afebrile, where no other etiology is determined.
CONCLUSION
We report a case of COVID-19 in a 5-week- old infant presenting with a picture of gastroenteritis, severe dehydration, and metabolic acidosis and compensatory respiratory alkalosis. To our knowledge, this is
CONTRIBUTORS
■ MEGHAN MEGHPARA, DO is a graduate of Rowan School of Osteopathic Medicine and completed residency at Nemours/Alfred I. duPont Hospital for Children. She is currently in her first year of Pediatric Emergency Fellowship.
■ BRENDA BENDER, MD is a pediatric emergency medicine physician at Nemours/ Alfred I. duPont Hospital for Children.
■ MAGDY W. ATTIA, MD is a pediatric emergency medicine attending physician at Nemours/Alfred I. duPont Hospital for Children and Professor of Pediatrics at Sidney Kimmel Medical College at Thomas Jefferson University.
REFERENCES
1. Bialek S, Gierke R, Hughes M, McNamara LA, Pilishvili T, Skoff T. Coronavirus Disease 2019 in Children — United States, February 12–April 2, 2020. Centers for Disease Control and Prevention. https://www.cdc. gov/coronavirus/2019-ncov/faq.html. Published April 22, 2020. Accessed May
6, 2020, DOI: http://dx.doi.org/10.15585/ mmwr.mm6914e4.
2. Dong, Yuanyuan, et al. “Epidemiology of COVID-19 Among Children in China.” Pediatrics, vol. 145, no. 5, 1 May 2020, doi:10.1542/peds.2020-0702.
3. Wei, Min, et al. “Novel Coronavirus Infection in Hospitalized Infants Under 1 Year of Age in China.” Jama, vol. 323, no. 13, 2020, p. 1313., doi:10.1001/jama.2020.2131.
4. Zimmermann, Petra, and Nigel Curtis. “Coronavirus Infections in Children Including COVID-19: An Overview of the Epidemiology, Clinical Features, Diagnosis, Treatment, and Prevention Options in Children.” The Pediatric Infectious Disease Journal vol. 39,5 (2020): 355-368. doi:10.1097/INF.0000000000002660
122
Del Med J | May/June 2020 | Vol. 92 | No. 3