Discussion
Here we present 2 cases of COVID-19 in infants hospitalized for poorly tolerated high fever and neurological symptoms in whom acute bronchiolitis developed at a delay of 2 to 8 days. According to the literature, the most frequent clinical features of COVID-19 among symptomatic children are fever, cough, diarrhoea and asthenia4,5.Isolated fever with neurological symptoms such as axial hypotonia or drowsiness and moaning sounds is also the clinical picture commonly associated with COVID-19 in infants6,7. Pneumonia is the most common diagnosis among symptomatic children with COVID-19 4. High-resolution CT scan usually shows ground-glass opacities or bilateral lung consolidations, especially in the periphery, and lung ultrasonography, as in our case 1, reveals signs of lung involvement.
In contrast, to the best of our knowledge, acute bronchiolitis due to SARS-CoV-2 infection has never been reported. The wheezing episodes described in our patients were likely due toSARS-CoV-2 infection for the following reasons: first, RT-PCR tests for RSV and IV were always negative in both children, and second, the epidemic season for both viruses was over and the lockdown in France was still active at the time of the cases. Finally, previous study of virus repartition in positive respiratory samples from infants with acute bronchiolitis detected close to a 5% frequency of coronaviruses OC43 and 229E8. Moreover, a recent experimental model of COVID-19 in ferrets showed lung lesions compatible with bronchiolitis9. Our patients showed bronchiolitis symptoms several days after those of COVID-19, which may explain the lack of wheezing episodes reported in the literature10.
Case 2 was diagnosed with recurrent wheezing presumably due to SARS-CoV-2 infection. RSV as well as rhinovirus bronchiolitis is a risk factor for recurrent wheezing and asthma11,12,but little is known about the long-term impact of SARS-CoV-2 infection in lung function trajectory, which emphasizes the need to follow these children.
In conclusion, we describe the delayed occurrence of acute bronchiolitis in infants with SARS-CoV-2 infection. Whether the infection in symptomatic or asymptomatic infants may predispose to recurrent wheezing or asthma remains to be determined.
References
1. 20200518-covid-19-sitrep-119.pdf.
2. Parri N, Lenge M, & Buonsenso D, Coronavirus Infection in Pediatric Emergency Departments (CONFIDENCE) Research Group. Children with Covid-19 in Pediatric Emergency Departments in Italy. N. Engl. J. Med. (2020) doi:10.1056/NEJMc2007617.
3. Dong Y, Mo X, Hu Y, Qi X, Jiang Z, Tong S. Epidemiology of COVID-19 Among Children in China. Pediatrics (2020) doi:10.1542/peds.2020-0702.
4. Lu X, Zhang L, Du H, Zhang J, Li YY, Qu J, Zhang W, Wang Y, Bao S, Li Y, et al. Chinese Pediatric Novel Coronavirus Study Team. SARS-CoV-2 Infection in Children. N. Engl. J. Med. 382 , 1663–1665 (2020).
5. Chao JY, Derespina KR, Herold BC, Goldman DL, Aldrich M, Weingarten J, Ushay HM, Cabana MD, Medar SS. Clinical Characteristics and Outcomes of Hospitalized and Critically Ill Children and Adolescents with Coronavirus Disease 2019 (COVID-19) at a Tertiary Care Medical Center in New York City. J. Pediatr. (2020) doi:10.1016/j.jpeds.2020.05.006.
6. Yilmaz O, Gochicoa-Rangel L, Blau H, Epaud R, Lands LC, Lombardi E, Moore PE, Stein RT, Wong GWK, Zar HJ. Brief report: International perspectives on the pediatric COVID-19 experience. Pediatr. Pulmonol. (2020) doi:10.1002/ppul.24800.
7. Nathan N, Prevost B, & Corvol H. Atypical presentation of COVID-19 in young infants. Lancet Lond. Engl. 395 , 1481 (2020).
8. Legrand L, Vabret A, Dina J, Petitjean-Lecherbonnier J, Gouarin S, Cuvillon D, Tripey V, Brouard J, Freymuth F. Epidemiological and phylogenic study of human metapneumovirus infections during three consecutive outbreaks in Normandy, France. J. Med. Virol.83 , 517–524 (2011).
9. Kim Y-I, Kim S-G, Kim S-M, Kim E-H, Park S-J, Yu K-M, Chang J-H, Kim EJ, Lee S, Casel MAB. et al. Infection and Rapid Transmission of SARS-CoV-2 in Ferrets. Cell Host Microbe 27 , 704–709.e2 (2020).
10. Musolino AM, Supino MC, Buonsenso D, Ferro V, Valentini P, Magistrelli A, Lombardi MH, Romani L, D’Argenio P, Campana A, Roman Lung Ultrasound Study Team for Pediatric COVID-19 (ROMULUS COVID Team). Lung Ultrasound in Children with COVID-19: Preliminary Findings.Ultrasound Med. Biol. (2020) doi:10.1016/j.ultrasmedbio.2020.04.026.
11. Jackson DJ, Gangnon RE, Evans MD, Roberg KA, Anderson EL, Pappas TE, Printz MC, Lee WM, Shult PA, Reisdorf E et al. Wheezing rhinovirus illnesses in early life predict asthma development in high-risk children. Am. J. Respir. Crit. Care Med. 178 , 667–672 (2008).
12. Sigurs N, Bjarnason R, Sigurbergsson F & Kjellman B. Respiratory syncytial virus bronchiolitis in infancy is an important risk factor for asthma and allergy at age 7. Am. J. Respir. Crit. Care Med.161 , 1501–1507 (2000).