Clinical Characteristics of 5 COVID-19 Cases With Non-respiratory Symptoms as the First Manifestation in Children

Abstract

An outbreak of the novel coronavirus disease 2019 (COVID-19) occurred in Wuhan, China, in December 2019, which then rapidly spread to more than 80 countries. However, detailed information on the characteristics of COVID-19 in children is still scarce. Five patients with non-respiratory symptoms as the first manifestation were hospitalized from the emergency department, and were later confirmed to have COVID-19, between 23 January and 20 February 2020, at the Wuhan Children's Hospital. SARS-CoV-2 nucleic acid detection was positive for all the patients. Four of the patients were male and one was female, and their ages ranged from 2-months to 5.6 years. All lived in Wuhan. One patient had a clear history of exposure to SARS-CoV-2, one had a suspected history of exposure, while the others had no exposure history. For three of the five patients, the primary onset disease required an emergency operation or treatment, and included intussusception, acute suppurative appendicitis perforation with local peritonitis, and traumatic subdural hemorrhage with convulsion, while for the other two it was acute gastroenteritis (including one patient with hydronephrosis and a stone in his left kidney). During the course of the disease, four of the five patients had a fever, whereas one case had no fever or cough. Two patients had leukopenia, and one also had lymphopenia. In the two cases of severe COVID-19, the levels of CRP, PCT, serum ferritin, IL-6, and IL-10 were significantly increased, whereas the numbers of CD3+, CD4+, CD8+ T lymphocytes, and CD16 + CD56 natural killer cells were decreased. We also found impaired liver, kidney, and myocardial functions; the presence of hypoproteinemia, hyponatremia, and hypocalcemia; and, in one case, abnormal coagulation function. Except for one patient who had a rotavirus infection, all patients tested negative for common pathogens, including the influenza virus, parainfluenza virus, respiratory syncytial virus, adenovirus, enterovirus, mycoplasma, Chlamydia, and Legionella. Chest CT images of all the patients showed patches or ground-glass opacities in the lung periphery or near the pleura, even large consolidations. This case series is the first report to describe the clinical features of COVID-19 with non-respiratory symptoms as the first manifestation in children.

Keywords: clinical characteristics; first manifestation; non-respiratory symptoms; novel coronavirus disease 2019; pediatrics.

Figure 1

Chest CT images for case 1 showing a small dense shadow in the left lung on day 4 after symptom onset (A,B); bilateral ground-glass opacity, large consolidation, and bilateral pleural effusion on day 9 after symptom onset (C,D).

Figure 2

Chest CT images for case 2 showing a round-like mass shadow in the dorsal segment of the lower right lobe with a slight ground-glass opacity on the edge, a strip shadow in the local area of the left lower lobe, and an arc dense under the bilateral pleura on day 3 after symptom onset (A–D).

Figure 3

Chest CT images for case 3 showing a patchy dense shadow in the posterior part of the left lung with a blurred boundary on day 2 after symptom onset (A,B).

Figure 4

Chest CT images for case 4 showing a large dense shadow with some consolidation in the right lung and a few high-density shadows in the upper lobe of the left lung on day 6 after symptom onset (A,B) and patchy dense shadows mixed with ground-glass opacity in the bilateral upper lobe tip, right middle lobe, and left lower lobe, and air bronchogram inside on day 15 after symptom onset (C,D).

Figure 5

Chest CT images for case 5 showing bilateral scattered spots of shadows and consolidation in the upper right lobe on day 3 after symptom onset (A,B).