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Letters to the Editor

Hematuria Associated With SARS-CoV-2 Infection in a Child

Almeida, Flávia Jacqueline MD, PhD; Olmos, Rodrigo Diaz MD, PhD; Oliveira, Danielle Bruna Leal PhD; Monteiro, Cairo Oliveira MsC; Thomazelli, Luciano Matsumiya PhD; Durigon, Edison Luiz PhD; Sáfadi, Marco Aurélio Palazzi MD, PhD

Author Information
The Pediatric Infectious Disease Journal: July 2020 - Volume 39 - Issue 7 - p e161
doi: 10.1097/INF.0000000000002737
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To the Editors:

Despite the fact that respiratory symptoms are the predominant presentation of COVID-19 among symptomatic infected patients, it is important to emphasize that multiple organ involvement including the gastrointestinal tract, central nervous system, cardiovascular system, liver, bone marrow and kidney have already been reported in patients infected with SARS-CoV-2.1

Herein we describe a case of SARS-CoV-2 infection presenting with hematuria along with respiratory symptoms in a child.

A 10-year-old Caucasian female child, previously healthy, was admitted to the emergency department with a one-day history of fever (38°C), mild respiratory symptoms (cough and sore throat) and gross hematuria. Her physical examination was unremarkable. Urinalysis showed the presence of normally shaped red blood cells and renal ultrasound showed no abnormalities. Renal function was normal. The child was in quarantine, away from social contact for 2 weeks, due to the COVID-19 pandemic confinement measures imposed in the City of Sao Paulo. However, her parents are medical doctors, seeing patients with COVID-19. Therefore, real-time reverse transcriptase-polymerase chain reaction (RT-PCR) tests for SARS-CoV-22 were carried out using a panel of validated in-house singleplex real-time (RT-PCR) assays developed at the Centers for Disease Control and Prevention, Atlanta, GA, USA, for 15 respiratory viruses, including: influenza A and B virus; coronavirus NL63, 229E, HKU1and OC43; enterovirus; parainfluenza virus 1, 2, 3 and 4; human metapneumovirus; rhinovirus; respiratory syncytial virus; and adenovirus3 on nasopharyngeal swabs and a RT-PCR test for SARS-CoV-2 in urine. The child did not have any other febrile episode after the third day of symptoms and a progressive improvement of the hematuria, that subsided after five days, was observed. Three days after the onset of symptoms of the child her mother started with fever, dry cough, sore throat and fatigue. Nasopharyngeal swabs from both parents (the mother, that was symptomatic and the father, asymptomatic at that moment) were collected. All nasopharyngeal swabs specimens were positive for the detection of SARS-CoV-2 RNA and negative for all other respiratory viruses. The urine sample was negative for SARS-CoV-2 RNA. On day 7 after the onset of symptoms, RT-PCR for the detection of SARS-CoV-2 RNA in nasopharyngeal swabs were still positive in the child as well as her parents. Nasopharyngeal samples repeated on day 21 were all negative.

Hematuria and renal injury have been commonly described in viral respiratory infections including influenza A and B, adenovirus and other pathogens. Kidney injury in adults hospitalized with COVID-19 appears to be a frequent finding, with a wide range of manifestations, from mild hematuria to severe renal failure. The pathogenesis of the renal injury is probably multi-factorial, including direct cytopathic effects of the virus, immune-complexes mediated damage, as well as indirect effects on renal tissue, such as hypoxia, shock, and rhabdomyolysis, due to the cytokine inflammatory response to the virus.4

A plausible explanation for the multi-organ manifestations of COVID-19 is the finding that angiotensin-converting enzyme 2, the receptor for SARS-CoV-2 and responsible for host cell entry and subsequent viral replication in humans, is broadly expressed in the alveolar epithelial cells, the myocardium, the endothelium, the gastrointestinal tract, bone marrow, kidneys among other tissues.5

One of the most striking features of COVID-19 is the overwhelmingly lower risk of severe forms of disease in children, when compared with older age groups.6 To date, we are not aware of reported cases of renal complications in children with COVID-19. Although the child described in this letter had a mild manifestation with a good outcome, pediatricians should be aware of these presentations in children, particularly among infants and children with underlying renal conditions, theoretically prone to more severe complications.

Consent: Written informed consent was obtained from the parents and from the patient for the publication of this letter.

Flávia Jacqueline Almeida, MD, PhD
Department of Pediatrics
Santa Casa de São Paulo School of Medical Sciences
São Paulo – SP, Brazil

Rodrigo Diaz Olmos, MD, PhD
Department of Internal Medicine
University Hospital
School of Medicine
University of Sao Paulo
São Paulo – SP, Brazil

Danielle Bruna Leal Oliveira, PhD
Cairo Oliveira Monteiro, MsC
Luciano Matsumiya Thomazelli, PhD
Edison Luiz Durigon, PhD
Laboratory of Molecular and Clinical Virology
Department of Microbiology
Institute of Biomedical Sciences
University of São Paulo
São Paulo – SP, Brazil

Marco Aurélio Palazzi Sáfadi, MD, PhD
Department of Pediatrics
Santa Casa de São Paulo School of Medical Sciences
São Paulo – SP, Brazil

REFERENCES

1. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395:497–506.
2. Corman VM, Landt O, Kaiser M, et al. Detection of 2019 novel coronavirus (2019-nCoV) by real-time RT-PCR. Euro Surveill. 2020;25:2000045.
3. Sakthivel SK, Whitaker B, Lu X, et al. Comparison of fast-track diagnostics respiratory pathogens multiplex real-time RT-PCR assay with in-house singleplex assays for comprehensive detection of human respiratory viruses. J Virol Methods. 2012;185:259–266.
4. Cheng Y, Luo R, Wang K, et al. Kidney disease is associated with in-hospital death of patients with COVID-19. Kidney Int. 2020;97:829–838.
5. Hamming I, Timens W, Bulthuis ML, et al. Tissue distribution of ACE2 protein, the functional receptor for SARS coronavirus. A first step in understanding SARS pathogenesis. J Pathol. 2004;203:631–637.
6. Safadi MAP. The intriguing features of COVID-19 in children and its impact on the pandemic. J Pediatr (Rio J). 2020;S0021-7557(20)30141-8. doi: 10.1016/j.jpedp.2020.04.001. [Epub ahead of print]
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