Coronaviruses are large, enveloped, positive strand RNA viruses that can
be divided into 4 genera: alpha, beta, delta, and gamma, of which alpha
and beta CoVs are known to infect humans, which is called human
coronaviruses (HcoVs). Emergence of 2019-nCoV has attracted global
attention, and WHO has declared the COVID-19 a public health emergency
of international concern1. In the first retrospective
study on the epidemiological characteristics and transmission dynamics
of children’s COVID-19 in China various characteristics were presented
but to our knowledge this is the first pediatric case presenting like
Steven Johnson Syndrome.
An eight-year-old boy who had been healthy previously other than rash
history with amoxicilin clavulonate 2 times, when admitted with fever
was prescribed amoxicillin-clavulonate for tonsillitis inadvertently,
developped rash a day after, increasing in intensity, with respiratory
symptomps (ronchuses at basal zones) diagnosed as Steven Johnson
Syndrome under therapy of 2 mg/kg prednisolone and 0.5g/kg IVIG was
admitted to intensive care unit.
On admission, he had respiratory distress, hypoxia, cough and bilateral
pericardiac infiltration in chest X-ray (CXR), cofluenting hyperemic
rash all over the body especially trunk area(Figure 1). Clindamycin and
oseltamivir was initiated. On day 2 of admission while rash was
decreasing, respiratory failure increased, chest x-ray worsened ,
computed tomography showed intense consolidation, especially at basal
posterior zones, ground glass opacities and emphysematous changes at
upper zones which were not specific to previous COVID CTs (Fig 2). But
still nasopharyngeal aspirate was studied for COVID which was
negative.These changes were attributed to SJS lung involvement. So
cyclosporin was initiated. Patient got better under therapy, rash and
oxygen need dissappeared. But still chest x ray continued to worsen so
deep tracheal aspirate was studied 2 days after the nasophrayngeal
aspirate which was positive. Azitromycine, hydroxychloroquinine was
added to therapy. Both respiratory symptoms and chest xray responded
well.
As of May 27th, 2020, 5,698,246 cases were infected with COVID-19, there
were 352,461 deaths. In a previous report out of the 1391 children
assessed a total of 171 (12.3%) were confirmed to have COVID-19
infection. The median age of the infected children was 6.7 years. Fever
was present in 41.5% of the children at any time during the illness.
Other common signs and symptoms included cough and pharyngeal erythema.
A total of 27 patients (15.8%) did not have any symptoms of infection
or radiologic features of pneumonia. Whereas 12 patients had radiologic
features of pneumonia but did not have any symptoms of
infection2.
Children’s COVID-19 cases were less severe than adults’ cases, which may
be related to both exposure and host factors1. It was
speculated that children were less sensitive to COVID-19 because the
maturity and function (e.g., binding ability) of ACE2 in children may be
lower than that in adults3. Also, children often
experience respiratory infections (e.g., respiratory syncytial virus
(RSV)) in winter, and may have higher levels of antibody against virus
than adults and children’s immune system is still developing, and may
respond to pathogens differently to adults.
Cylosporin might also be effective in treatment of COVID-19, as there
are few studies regarding that it could be an option. In a previous
study it was stated that cylosporin A inhibits the replication of
diverse coronaviruses at non-cytotoxic, low-micromolar
concentrations4.
In our case first nasopharyngeal aspirate was negative, but deep
tracheal aspirate was positive after 2 days. More data is warranted to
ensure whether deep tracheal aspirate is needed to diagnose COVID-19
sensitively.
In our case although relation between Steven Johnson Syndrome and
COVID-19 is not clear, as amoxicilin clavulonate could also be cause of
the syndrome. But the possibility of presentation of COVID-19 as rash or
even Steven Johnson Syndrome should be kept in mind in cases that are
presenting with pulmonary findings, similar to our case.
References
1. Dong Y, Mo X, Hu Y, et al. Epidemiological Characteristics of 2143
Pediatric Patients With 2019 Coronavirus Disease in China [published
online ahead of print, 2020 Mar 16]. Pediatrics .
2020;e20200702. doi:10.1542/peds.2020-0702
2. Lu X, Zhang L, Du H, et al. SARS-CoV-2 Infection in Children
[published online ahead of print, 2020 Mar 18]. N Engl J Med .
2020;10.1056/NEJMc2005073. doi:10.1056/NEJMc2005073
3. Fang F, Luo XP. Zhonghua Er Ke Za Zhi .
2020;58 (2):81–85. doi:10.3760/cma.j.issn.0578-1310.2020.02.001
4. de Wilde AH, Zevenhoven-Dobbe JC, van der Meer Y, et al. Cyclosporin
A inhibits the replication of diverse coronaviruses. J Gen Virol .
2011;92 (Pt 11):2542–2548. doi:10.1099/vir.0.034983-0