Authors (including presenting author) :
Jaime S. Rosa Duque1, Phoebe Q. Mak2, Joshua S.C. Wong2, Chi-man Victor Chan3, Chit Kwong Chow4, Wa Keung Chiu4, Wilson K.Y. Yeung3, Ivan C.S. Lam2, Gilbert T. Chua1, Marco H.K. Ho1, Kelvin K.W. To5, Patrick Ip1, Mike Y.W. Kwan2
Affiliation :
1Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
2Department of Paediatrics and Adolescent Medicine, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
3Department of Paediatrics and Adolescent Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong Special Administrative Region, China
4Department of Paediatrics and Adolescent Medicine, United Christian Hospital, Hong Kong Special Administrative Region, China
5Department of Microbiology, Queen Mary Hospital, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
Introduction :
Since the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) became known to cause the highly contagious coronavirus disease 2019 (COVID-19), the World Health Organization (WHO) declared this infection a pandemic on 11 March 2020. Many governments implemented stringent policies such as lockdown of cities, social distancing restrictions, quarantine requirements for travellers and isolation of patients. Nevertheless, these containment strategies were unable to avert its rapid spread across the world. As such, this deadly virus has led to over 7 million reported cases and 400,000 deaths globally within a half year. The COVID-19 can cause sinopulmonary, cardiovascular, neurological, cutaneous and gastrointestinal illnesses, paediatric multisystem inflammatory syndrome in children, or an individual may be an asymptomatic carrier.
SARS-CoV-2 enters cells via interaction between the SARS-CoV-2 spike protein receptor-binding domain (RBD) and the host cell receptor, angiotensin-converting enzyme 2 (ACE2). SARS-CoV-2 has been shown to replicate in human intestinal organoid. Viral particles can be detected from enteric tracts of affected patients who experience nausea, vomiting, abdominal pain, diarrhoea, or individuals may have no gastrointestinal symptoms at all. Gastrointestinal infection or colonisation, evident by detection of SARS-CoV-2 RNA, may occur for >4 weeks and may last longer than in the respiratory system. Here we studied the clinical manifestations, timeline and outcomes of 4 paediatric patients in Hong Kong (HK) who demonstrated faecal viral shedding of SARS-CoV-2.
Objectives :
Patient 1
A 16-year-old Chinese boy with attention-deficit/hyperactivity disorder and allergic rhinitis (AR) lived in London, United Kingdom (UK) as a student. He returned to HK and was admitted due to sore throat, chest pain and cough for 3 days. Nasopharyngeal aspirate (NPA), throat swab (TS) and stool were positive for SARS-CoV-2 by reverse transcriptase-polymerase chain reaction (RT-PCR). Chest x-ray revealed bilateral perihilar infiltrates, and he had elevated troponin I up to 98.4 (< 21 ng/L) but normal creatine kinase, lactate dehydrogenase and electrocardiogram tracings. After temporary discontinuation of his methylphenidate, the troponin I decreased to 41.4 ng/L, and he suffered no cardiac complications. SARS-CoV-2 was persistently detected in his nasopharyngeal swabs (NPS)/TS and stool, but he only had occasional loose stools. He received 7 days of amoxicillin-clavulanate and 3 days of azithromycin, and subsequently, his pneumonia resolved. SARS-CoV-2 from his NPS/TS and stool became negative for 2 consecutive days on days 38 and 42, respectively, and he was allowed off isolation. Anti-SARS-CoV-2-receptor-binding-domain (RBD) and anti-SARS-CoV-2-nucleocapsid (NP) IgGs were detectable on day 45.
Patient 2
A 16-month-old Chinese boy with glucose-6-phosphate dehydrogenase deficiency, cow’s milk and egg allergies and AR resided in London, UK. When he returned to HK, he was tested SARS-CoV-2 positive via NPS/TS and rectal swab by RT-PCR after his parents developed febrile COVID-19 illnesses. Although he remained mostly asymptomatic throughout hospitalisation, SARS-CoV-2 remained detectable via NPS/TS until day 23 (negative on days 27 and 30) and stool until day 60, after which he was discharged. Anti-SARS-CoV-2-RBD and anti-SARS-CoV-2-NP IgGs were detectable on day 60. His father, who also tested SARS-CoV-2 positive by NPS/TS but turned negative by days 30 and 31, remained with him under inpatient isolation for 2 months as he felt the need to provide parental care for this young toddler.
Methodology :
Patient 3
A 17-year-old boy with AR and exophoria who travelled to Edinburgh, UK for 2 months initially tested negative for SARS-CoV-2 RT-PCR via NPS/TS by the HK surveillance program upon his arrival. Ten days later, he presented with 9 days of headache, rhinorrhoea, sore throat, abdominal pain and loose stools with detectable SARS-CoV-2 sampled from his NPS/TS and stool. These remained positive throughout his hospitalisation even when his symptoms resolved a few days afterwards. However, due to updated discharge criteria made by the HK Government in May 2020, the patient was allowed off isolation on day 48 with >10 days stable condition under inpatient observation and measurable anti-SARS-CoV-2-RBD IgG. The serum level of his anti-SARS-CoV-2-NP IgG was reported as equivocal. SARS-CoV-2 remained detectable by NPS/TS 3 weeks and stool 7 days (day 43) prior to hospital discharge, which was not retested.
Patient 4
A 14-month-old girl who returned from a trip to the UK was found to have SARS-CoV-2 in her stool from the surveillance program upon arrival to HK. She remained mostly asymptomatic but remained hospitalised while SARS-CoV-2 was persistently detected in her stool by RT-PCR on day 13, which was not retested. SARS-CoV-2 was never detected in her respiratory tract samples. She returned home after she was found to have anti-SARS-CoV-2-RBD and anti-SARS-CoV-2-NP IgGs on day 29.
Result & Outcome :
In this series of patients, 2 had no major gastrointestinal symptoms, while 2 had mild abdominal discomfort and loose stools that resolved spontaneously. These 4 patients were the first set of all the children identified to have mild, loose stools, diarrhoea, and/or their stool viral samples were found to contain SARS-CoV-2 within the first 6 months of COVID-19 outbreak within our regional territory. The HK Government has a strict, statutory reporting and tracking system for several communicable infectious diseases, including COVID-19. By law, these patients were to remain hospitalised and followed by us until they fulfilled the discharge criteria as mandated by the HK Government. We gathered the information of these patients for this case series. Patients 1 and 2 had 42 and 60 days of viral shedding from the enteric tract, respectively. The range of timing that their respiratory sampling had 2 consecutive negative results prior to 2 consecutive sampling from their enteric tracts became negative was wide, which were 4 to 37 days, respectively. Based on literature review and our knowledge, patient 2 had the longest duration of viral shedding from the enteric tract (60 days) and time of negative sampling between respiratory and enteric tracts (37 days) reported in children at the time. This prolonged hospitalisation was difficult for him and his father as they were segregated into a single, small room. Patients 3 and 4 were discharged based on measurable anti-SARS-CoV-2-RBD IgG, >10 days stable condition under observation and >10 days from the onset of COVID-19 symptoms or first detectable SARS-CoV-2, the combination of which suggests a low risk of future complications and infectivity in the community. Although in our locality, 4 children suffered from such a predicament, cumulatively from our literature review, the number of children who have prolonged faecal excretion and potential spread of infection of SARS-CoV-2 by this route is approximately 150-200 in total. Therefore, this issue is a huge concern affecting many patients and deserves further deliberation. With more consistency in the guidelines, non-infectious and otherwise healthy children colonized with SARS-CoV-2 may avoid prolonged hospitalization and its associated detrimental effects on physical and psychosocial well-being, and hospitals can retain more reserve in valuable space and resources to support the genuinely needy patients during the COVID-19 pandemic.
