Cases of 2 Infants with COVID-19 Highlight Need for Clinician Vigilance

Clinicians ought to be on the lookout for SARS-CoV-2 in febrile infants and be quick to order testing when suspicious, according to a new article outlining cases of coronavirus disease 2019 (COVID-19) in 2 infants.

In both cases, infants tested positive for the virus, even though neither had significant symptoms of the disease beyond a fever. Neither infant developed significant symptoms and both were discharged in stable condition. The article was published in Clinical Infectious Diseases.

Corresponding author Adam J. Ratner, MD, MPH, of the New York University Grossman School of Medicine, and colleagues, reported that even though COVID-19 is generally thought to be mild in young patients, it is still critical that health care practitioners diagnose the disease in infants, and do so as soon as possible.

“The epidemic coronaviruses, including MERS-CoV, SARS-CoV, and SARS-CoV-2, have the potential for spread within healthcare settings, making case identification and prompt isolation crucial to protecting patients, physicians, and staff,” the authors wrote.

The first case was a 25-day-old infant who had been carried to full term and arrived in the emergency department with a fever of 101.3 degrees, a facial rash, and irritability, but did not have any other symptoms. The infant’s parents, on the other hand, each had sore throats and subjective fevers, though neither had sought medical care for themselves.

The patient’s physicians ran a range of tests, including a respiratory polymerase chain reaction panel, but all came back negative. The respiratory panel, however, did not include SARS-CoV-2, so the clinicians ordered a test for the novel coronavirus, which came back positive.

The patient did not require any antivirals. He was discharged from the hospital and the parents were told to follow US Centers for Disease Control and Prevention guidelines.

In the second case, a 56-day-old infant who had been born at 35 weeks was brought to the emergency department with a 100.8-degree temperature. The child had no symptoms, nor did his parents or siblings. After the infant tested positive for COVID-19, he was empirically prescribed ceftriaxone until blood and urine cultures were negative for more than 36 hours. The patient was discharged in stable condition.

Ratner and colleagues wrote that the cases show why it is important to use precautions, even when symptoms are non-existent or limited, in febrile infants.

“For both cases presented above, because SARS-CoV-2 testing was sent, and contact/droplet/eye shield precautions were instituted in the emergency department, with N95 masks used during NP swab collection because of the potential for aerosol generation,” the investigators wrote.

“In addition, family members were required to wear surgical masks and upon discharge received instructions for home isolation.”

The investigators noted there were no non-COVID-19 etiologies for fever in either infant, which is similar to findings in older children with SARS-CoV-2. The second infant had a low absolute lymphocyte count, which aligns with the experience of many adult patients with the infection.

Ratner and colleagues said the need to routinely hospitalize and test febrile infants could be an unrecognized source of SARS-CoV-2 introduction into hospitals.

“This report emphasizes the importance of maintaining a high index of suspicion for SARS-CoV-2 infection in febrile infants during a community outbreak and the value of instituting testing and infection control guidelines in emergency department and pediatric hospital settings,” authors concluded.