Can SARS-CoV-2 cause life threatening bronchiolitis in Infan
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An 11 month old boy presented with elevated temperature (38°C), tachypnea and expiratory stridor. His previous medical history was unremarkable with the exception of four episodes of lower RTI. He required intubation due to impending hypoxemic and hypercapnic respiratory failure and was immediately transferred to PICU. Mechanical ventilation proved to be extremely difficult. Upon arrival, he had bilaterally absent breath sounds (“silent chest”), an O2 saturation of 89%, tachycardic (180 beats/min), however cardiovascularly surprisingly stable. Arterial BGA showed severe respiratory acidosis.

Serial chest X ray examinations showed impressive hyperinflation combined with rapidly shifting areas of atelectasis. He stabilized after about 12 hours but required muscle paralysis and intermittent manually assisted ventilation to enable acceptable CO2 elimination. Weaning from the ventilator was successful on day 5. During his convalescence, a transient unspecific macular rash affecting mainly the trunk was noticed. SARS-CoV-2 specific PCR only turned positive on day 8 when the patient had already fully recovered. Laboratory diagnostics showed leukocytes of 11.2 × 109 /L on day 1 and day 8, but interestingly enough lymphocytopenia (2.4 × 109 /L) and an elevated C reactive protein (14 mg/L) were only present on day 1 but not on day 8.
Following full clinical recovery, the infant was sent home for quarantine on day 14.

A small subpopulation of children appears to be at a higher risk for significant illness or complications from SARS-CoV-2. Recently the community of pediatricians has become aware that the control of the inflammatory immune response in children may be insufficient and may as such lead to a multisystem inflammatory (COVID-19 MIS C8) or Kawasaki like syndrome.

SARS CoV-2 is suspected to cause life threatening bronchiolitis in infants and therefore it is suggested to maintain a high level of suspicion of COVID-19, irrespective of an initially negative SARS CoV-2 RT PCR testing, when other causes of bronchiolitis are unidentifiable in young children.

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