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

braz

j

infect

dis

2

0

2

0;2

4(3):247–249

www.elsevier.com/locate/bjid

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

a

,

Jing

Feng

a

,

Tian-hu

Liu

b

,

Feng-cheng

Xu

b

,

Guo-qiang

Song

c

,∗

a

Pidu

District

People’s

Hospital,

Department

of

Infectious

Diseases,

Chengdu,

Sichuan

Province,

China

b

Pidu

District

People’s

Hospital,

Department

of

Cardiology,

Chengdu,

Deyuan

Chengdu,

Sichuan

Province,

China

c

Changxing

County

Hospital,

of

Traditional

Chinese

Medicine,

Department

of

Respiratory

Medicine,

Huzhou,

Zhejiang

Province,

China

a

r

t

i

c

l

e

i

n

f

o

Article

history:

Received

20

March

2020

Accepted

20

April

2020

Available

online

6

May

2020

Keywords:

Severe

acute

respiratory

syndrome

coronavirus

2

Baby

Anal

swab

a

b

s

t

r

a

c

t

Severe

acute

respiratory

syndrome

coronavirus

2

(SARS-CoV-2)

emerged

in

Wuhan,

China

and

has

spread

rapidly

worldwide.

We

present

a

mild

SARS-CoV-2

infection

in

a

baby

with

non-productive

cough

and

normal

chest

computed

tomography,

in

whom

only

anal

swabs

tested

positive

by

real-time

PCR

testing

for

SARS-CoV-2.

She

was

given

atomization

inhalation

therapy

with

recombinant

human

interferon

alfa-1b

for

10

days.

Her

anal

swabs

remained

positive

for

eight

days,

whereas

her

throat

swabs

were

persistently

negative

by

real-time

PCR

testing.

Mild

and

asymptomatic

cases,

especially

in

children,

might

present

with

PCR

negative

pharyngeal/nasal

swabs

and

PCR

positive

anal

swabs.

Those

patients

are

potential

sources

of

infection

via

fecal–oral

transmission

for

COVID-19.

©

2020

Sociedade

Brasileira

de

Infectologia.

Published

by

Elsevier

Espa

˜

na,

S.L.U.

This

is

an

open

access

article

under

the

CC

BY-NC-ND

license

(http://creativecommons.org/

licenses/by-nc-nd/4.0/

).

Introduction

Severe

acute

respiratory

syndrome

coronavirus

2

(SARS-CoV-

2)

emerged

in

Wuhan

and

has

spread

rapidly

in

China,

South

Korea,

and

worldwide.

Since

December

2019,

more

than

120,000

people

have

been

infected.

1–3

The

SARS-CoV-2

genome

has

a

nucleotide

identity

of

89%

with

bat

SARS-like-

CoVZXC21

and

82%

with

human

SARS-CoV.

4

The

most

common

symptoms

of

infection

are

fever

(43.8%

on

admission

and

88.7%

during

hospitalization)

and

cough

(67.8%).

Diarrhea

is

uncommon

(3.8%).

The

median

incubation

period

is

four

days

(interquartile

range

2–7).

On

admission,

∗

Corresponding

author.

E-mail

address:

[email protected]

(G.

Song).

ground-glass

opacities

are

the

most

common

radiological

ﬁnding

on

chest

computed

tomography

(CT)

(56.4%).

No

radio-

graphic

or

CT

abnormality

was

found

in

157

of

877

patients

(17.9%)

with

non-severe

disease

or

in

5

of

173

patients

(2.9%)

with

severe

disease.

Lymphocytopenia

was

present

in

83.2%

of

the

patients

on

admission.

5

The

diagnosis

is

conﬁrmed

by

testing

pharyngeal

or

nasal

swabs

for

viral

nucleic

acids.

In

a

Chinese

Center

for

Disease

Control

and

Prevention

(CDC)

report,

the

overall

case-fatality

rate

was

2.3%,

with

1023

deaths

among

44,672

conﬁrmed

cases.

6

The

pandemic

has

caused

many

social

public

health

problems,

leading

to

eco-

nomic

recession

and

panic.

7

This

is

a

global

health

problem

and

not

just

a

problem

in

China.

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

1413-8670/©

2020

Sociedade

Brasileira

de

Infectologia.

Published

by

Elsevier

Espa

˜

na,

S.L.U.

This

is

an

open

access

article

under

the

CC

BY-NC-ND

license

(http://creativecommons.org/licenses/by-nc-nd/4.0/).

248

b

r

a

z

j

i

n

f

e

c

t

d

i

s

.

2

0

2

0;2

4(3):247–249

Fig.

1

–

Normal

chest

CT

ﬁndings

at

different

sections:

A

and

D,

B

and

E,

and

C

and

F

represent

the

same

levels.

While

patients

with

positive

pharyngeal

or

nasal

swabs

have

received

much

attention,

asymptomatic

or

mildly

ill

patients

with

positive

anal

swabs

have

not.

We

know

little

about

these

patients,

who

may

be

shadows

in

the

sun.

How-

ever,

they

are

potential

sources

of

infection

via

fecal–oral

transmission.

Here,

we

present

an

asymptomatic

baby

in

whom

anal

swabs

were

positive

while

pharyngeal

swabs

were

persistently

negative

by

real-time

PCR

testing.

Case

report

An

8-month-8-day-old

girl

was

hospitalized

with

one

day

his-

tory

of

cough

and

runny

nose

on

Feb

25,

2020.

The

patient

was

afebrile

with

no

shortness

of

breath,

clubbing,

cyanosis,

or

abdominal

distension.

The

patient

was

given

oral

ambroxol

hydrochloride

solution

15

mg,

three

times

per

day,

with

no

improvement.

The

patient’s

mother,

diagnosed

with

SARS-

CoV-2

2

days

earlier,

had

positive

pharyngeal

swab

by

real-time

PCR

testing

and

chest

CT

showing

ground-glass

opacities.

On

physical

examination,

the

patient

had

a

body

tem-

perature

of

38

◦

C,

pulse

of

116

beats/min,

respiratory

rate

of

30

breaths/min,

and

oxygen

saturation

in

room

air

of

99%.

She

was

conscious

and

appeared

acutely

ill.

There

were

no

ﬂuctua-

tions

in

the

nasal

wings

but

some

secretion

in

the

nasal

cavity,

with

redness,

congestion,

and

a

normal

voice

was

observed.

The

breath

sounds

were

normal

in

both

lungs,

with

no

dry

or

wet

rales.

Heart

auscultation

was

normal.

The

abdomen

was

soft,

and

bowel

sounds

were

normal.

Laboratory

tests

were

negative

for

inﬂuenza

A

and

B

viral

antigens.

The

leukocyte

count

was

11.91

×

10

9

/L,

with

a

neu-

trophil

count

of

2.91

×

10

9

/L

(24.4%)

and

lymphocyte

count

of

7.87

×

10

9

/L

(66.1%).

The

C-reactive

protein

level

was

3.49

mg/L.

The

prothrombin

time

and

d-dimer

level

were

normal,

as

well

as

alanine

transaminase,

alanine

transaminase,

urea

nitro-

gen,

and

creatinine

levels.

Chest

CT

results

had

no

abnormal

ﬁndings

(Fig.

1).

Recombinant

human

interferon

alfa-1b

via

atomization

inhalation

(20

␮g,

twice/day)

was

initiated.

Anal

swabs

were

positive

on

February

27

and

March

4.

The

symptoms

improved

on

March

7,

and

anal

swabs

were

negative

on

March

9

and

10.

The

patient

was

discharged

on

March

11.

Throat

swabs

were

persistently

negative

throughout

the

hospital

stay.

Real-time

PCR

for

COVID-19

on

pharyngeal

and

anal

swabs

were

performed

by

the

Pengzhou

(Sichuan

Province,

China)

CDC.

The

Chengdu

CDC

repeated

the

PCR

testing

and

obtained

the

same

results.

Discussion

Diagnosis

of

SARS-CoV-2

depends

on

imaging,

epidemiolog-

ical

history,

and

nucleic

acid

testing.

During

the

early

stage

of

the

pandemic,

most

patients

were

in

China,

especially

in

Wuhan,

Hubei

Province.

8

As

the

number

of

patients

grew

geo-

metrically,

the

Chinese

government

locked

down

Wuhan

and

effectively

isolated

infected

people

from

non-infected

people.

In

early

March

2020,

the

disease

was

effectively

controlled

in

China.

9,10

However,

many

conﬁrmed

and

suspected

cases

have

appeared

in

other

regions

and

countries.

11

It

has

become

a

global

pandemic,

and

its

rapid

spread

and

high

lethality

require

special

attention.

12

Although

the

infection

and

mortality

rates

are

lower

in

infants

and

young

children

than

in

adults,

8

young

patients

cannot

communicate

effectively,

which

limits

the

ability

to

obtain

their

medical

history.

Our

patient

developed

a

sudden

onset

cough,

and

her

mother

was

conﬁrmed

to

be

infected.

Although

the

baby’s

pharyngeal

swabs

and

chest

CT

were

neg-

ative,

her

anal

swabs

remained

positive

for

eight

days.

Not

enough

attention

is

given

to

asymptomatic

or

mildly

infected

patients

with

positive

anal

swabs.

Here,

we

present

a

mildly

ill

baby

whose

anal

swabs

were

real-time

PCR

positive

for

SARS-CoV-2,

while

many

pharyngeal

swabs

were

nega-

tive.

SARS-CoV-2

was

stable

under

the

conditions

tested.

13

The

main

host

receptor

is

angiotensin

converting

enzyme

2,

which

is

located

on

gastrointestinal

epithelial

cells,

and

the

feces

of

20%

of

SARS-CoV-2

patients

remain

positive

for

viral

RNA

after

negative

conversion

of

viral

RNA

in

the

respiratory

tract.

14

Wang

et

al.

detected

live

SARS-CoV-2

in

stool

samples

from

two

conﬁrmed

patients.

15

Unfortunately,

our

laboratory

b

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249

lacked

the

capacity

to

determine

whether

the

stool

virus

was

still

active.

Physicians

should

be

aware

that

asymptomatic

or

mildly

ill

children

with

history

of

exposure

and

negative

pha-

ryngeal/nasal

swabs

and

positive

anal

swabs

are

potential

sources

of

infection

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

Infants

with

a

history

of

SARS-CoV-2

exposure

and

mild

symp-

toms

should

be

tested

using

anal

swabs.

Ethical

approval

The

study

was

approved

by

Pidu

District

People’s

Hospital

(Batch

2020-03-18-001).

Funding

No

founding.

Conﬂicts

of

interest

The

authors

declare

no

conﬂicts

of

interest.

Informed

consent

This

study

was

a

retrospective

observational

nature

study,

patient

identity

remained

anonymous,

and

have

no

invasive

procedure,

so

the

ethics

committee

waived

informed

consent.

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