An infant with a mild SARS-CoV-2 infection detected only by anal swabs: a case report

brazjinfectdis2020;24(3):247–249

w w w . e l s e v i e r . c o m / l o c a t e / b j i d

The

Brazilian

Journal

of

INFECTIOUS

DISEASES

Case

report

An

infant

with

a

mild

SARS-CoV-2

infection

detected

only

by

anal

swabs:

a

case

report

Juan

Li

_,

_Jing

_Feng

_,

_Tian-hu

_Liu

_,

_Feng-cheng

_Xu

_,

_Guo-qiang

_Song

a_{PiduDistrictPeople’sHospital,DepartmentofInfectiousDiseases,Chengdu,SichuanProvince,China}

b_{PiduDistrictPeople’sHospital,DepartmentofCardiology,Chengdu,DeyuanChengdu,SichuanProvince,China}

c_{ChangxingCountyHospital,ofTraditionalChineseMedicine,DepartmentofRespiratoryMedicine,Huzhou,ZhejiangProvince,China}

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Articlehistory:

Received20March2020 Accepted20April2020 Availableonline6May2020

Keywords:

Severeacuterespiratorysyndrome coronavirus2

Baby Analswab

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Severeacuterespiratorysyndromecoronavirus2(SARS-CoV-2)emergedinWuhan,China and hasspread rapidly worldwide.We presenta mild SARS-CoV-2infection ina baby withnon-productivecoughandnormalchestcomputedtomography,inwhomonlyanal swabstestedpositivebyreal-timePCRtestingforSARS-CoV-2.Shewasgivenatomization inhalationtherapywithrecombinanthumaninterferonalfa-1bfor10days.Heranalswabs remainedpositiveforeightdays,whereasherthroatswabswerepersistentlynegativeby real-timePCRtesting.Mildandasymptomaticcases,especiallyinchildren,mightpresent withPCRnegativepharyngeal/nasalswabsandPCRpositiveanalswabs.Thosepatientsare potentialsourcesofinfectionviafecal–oraltransmissionforCOVID-19.

©2020SociedadeBrasileiradeInfectologia.PublishedbyElsevierEspa ˜na,S.L.U.Thisis anopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/ licenses/by-nc-nd/4.0/).

Introduction

Severeacuterespiratorysyndromecoronavirus2 (SARS-CoV-2) emerged in Wuhan and has spread rapidly in China, South Korea, and worldwide. Since December 2019, more than120,000peoplehavebeeninfected.1–3 _{TheSARS-CoV-2}

genomehasanucleotideidentityof89%withbat SARS-like-CoVZXC21and82%withhumanSARS-CoV.4

Themostcommonsymptomsofinfectionarefever(43.8% onadmission and 88.7%duringhospitalization) and cough (67.8%).Diarrheaisuncommon(3.8%).Themedianincubation periodisfour days(interquartilerange2–7). Onadmission,

∗ _{Correspondingauthor.}

E-mailaddress:wzyxysgq@126.com(G.Song).

ground-glass opacities are the most common radiological findingonchestcomputedtomography(CT)(56.4%).No radio-graphicorCTabnormalitywasfoundin157of877patients (17.9%)withnon-severediseaseorin5of173patients(2.9%) withseveredisease.Lymphocytopeniawaspresentin83.2% ofthepatientsonadmission.5_{Thediagnosisisconfirmedby}

testingpharyngealornasalswabsforviralnucleicacids. In aChinese Center forDisease Controland Prevention (CDC)report,theoverallcase-fatalityratewas2.3%,with1023 deaths among44,672confirmedcases.6 _{Thepandemic has}

causedmanysocialpublichealthproblems,leadingto eco-nomicrecessionandpanic.7_{Thisisaglobalhealthproblem}

andnotjustaprobleminChina.

https://doi.org/10.1016/j.bjid.2020.04.009

1413-8670/©2020SociedadeBrasileiradeInfectologia.PublishedbyElsevierEspa ˜na,S.L.U.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

248

Fig.1–NormalchestCTfindingsatdifferentsections:AandD,BandE,andCandFrepresentthesamelevels.

Whilepatients withpositive pharyngeal or nasal swabs have received much attention, asymptomatic or mildly ill patientswithpositive analswabshavenot. Weknowlittle aboutthesepatients,whomaybeshadowsinthesun. How-ever, they are potential sources of infection via fecal–oral transmission. Here, we present an asymptomatic baby in whomanalswabswerepositivewhilepharyngealswabswere persistentlynegativebyreal-timePCRtesting.

Case

report

An8-month-8-day-oldgirlwashospitalizedwithoneday his-toryofcoughandrunny noseonFeb25,2020.Thepatient wasafebrilewithnoshortnessofbreath,clubbing,cyanosis, orabdominaldistension.Thepatientwasgivenoralambroxol hydrochloridesolution 15mg,three timesper day,withno improvement.The patient’s mother, diagnosedwith SARS-CoV-22daysearlier,hadpositivepharyngealswabbyreal-time PCRtestingandchestCTshowingground-glassopacities.

On physical examination, the patient had a body tem-peratureof38◦C,pulseof116beats/min,respiratoryrateof 30breaths/min,andoxygensaturationinroomairof99%.She wasconsciousandappearedacutelyill.Therewereno fluctua-tionsinthenasalwingsbutsomesecretioninthenasalcavity, withredness,congestion,andanormalvoicewasobserved. Thebreathsoundswerenormalinbothlungs,withnodryor wetrales.Heartauscultationwasnormal.Theabdomenwas soft,andbowelsoundswerenormal.

LaboratorytestswerenegativeforinfluenzaAandBviral antigens.Theleukocytecountwas11.91×109_/L,witha

neu-trophilcountof2.91×109_{/L(24.4%)andlymphocytecountof}

7.87×109_{/L(66.1%).TheC-reactiveproteinlevelwas3.49mg/L.}

Theprothrombintimeandd-dimerlevelwerenormal,aswell asalaninetransaminase, alaninetransaminase, urea nitro-gen,andcreatininelevels.ChestCTresultshadnoabnormal findings(Fig.1).Recombinanthumaninterferonalfa-1bvia atomizationinhalation(20␮g,twice/day)wasinitiated.

Anal swabs were positive on February 27 and March4. ThesymptomsimprovedonMarch7,andanalswabswere

negativeonMarch9and10.Thepatientwasdischargedon March11.Throatswabswerepersistentlynegativethroughout thehospitalstay.Real-timePCRforCOVID-19onpharyngeal and anal swabswere performed bythePengzhou (Sichuan Province, China)CDC.TheChengdu CDC repeatedthe PCR testingandobtainedthesameresults.

Discussion

DiagnosisofSARS-CoV-2dependsonimaging, epidemiolog-icalhistory,andnucleicacidtesting.Duringtheearlystage ofthepandemic,mostpatientswereinChina,especiallyin Wuhan,HubeiProvince.8_{Asthenumberofpatientsgrew}

geo-metrically,theChinesegovernmentlockeddownWuhanand effectivelyisolatedinfectedpeoplefromnon-infectedpeople. In early March2020, the disease waseffectively controlled inChina.9,10_{However,manyconfirmedandsuspectedcases}

haveappearedinotherregionsandcountries.11_Ithasbecome

a global pandemic,and its rapidspread and high lethality requirespecialattention.12

Although the infection and mortalityrates are lower in infantsand youngchildrenthaninadults,8 _{youngpatients}

cannotcommunicate effectively,which limitstheabilityto obtaintheirmedicalhistory.Ourpatientdevelopedasudden onsetcough,andhermother wasconfirmedtobeinfected. Althoughthebaby’spharyngealswabsandchestCTwere neg-ative,heranalswabsremainedpositiveforeightdays.

Notenoughattentionisgiventoasymptomaticormildly infectedpatientswithpositiveanalswabs.Here,wepresenta mildlyillbabywhoseanalswabswerereal-timePCRpositive for SARS-CoV-2, whilemany pharyngeal swabswere nega-tive. SARS-CoV-2was stable underthe conditions tested.13

Themainhostreceptorisangiotensinconvertingenzyme2, whichislocatedongastrointestinalepithelialcells,andthe fecesof20%ofSARS-CoV-2patientsremainpositiveforviral RNAafternegativeconversionofviralRNAintherespiratory tract.14_{Wangetal.detectedliveSARS-CoV-2instoolsamples}

brazj infect dis.2020;24(3):247–249

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lackedthecapacitytodeterminewhetherthestoolviruswas stillactive.

Physiciansshouldbeawarethatasymptomaticormildly ill children with history of exposure and negative pha-ryngeal/nasalswabs and positive anal swabs are potential sourcesofinfection via fecal–oral transmission for COVID-19. In addition to nasal/pharyngeal swabs, we believe that children should be tested for SARS-CoV-2 using anal swabs.

Conclusion

InfantswithahistoryofSARS-CoV-2exposureandmild symp-tomsshouldbetestedusinganalswabs.

Ethical

approval

Thestudy was approvedby Pidu District People’sHospital (Batch2020-03-18-001).

Funding

Nofounding.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

Informed

consent

Thisstudy was aretrospective observationalnature study, patientidentityremainedanonymous,andhavenoinvasive procedure,sotheethicscommitteewaivedinformedconsent.

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