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Letters to the Editor

Neonatal Early-Onset Infection With SARS-CoV-2 in a Newborn Presenting With Encephalitic Symptoms

Lorenz, Norbert MD; Treptow, Anna MD; Schmidt, Stefan MD; Hofmann, René MD; Raumer-Engler, Mandy MD; Heubner, Georg MD; Gröber, Konstantin MD

Author Information
The Pediatric Infectious Disease Journal: August 2020 - Volume 39 - Issue 8 - p e212
doi: 10.1097/INF.0000000000002735
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To the Editors:

A recent review described in detail coronavirus infections, including SARS-CoV-2, in children.1 Neonatal early-onset coronavirus disease 2019 (COVID-19) seems to be a rare novel disease,2 the knowledge about vertical transmission is ambiguous.3,4 This case report adds to the current knowledge the appearance of encephalitic symptoms in a newborn with neonatal early SARS-CoV2 infection and raises the question of a possible vertical transmission.

A healthy female newborn of 40 weeks +3 days of gestation was born by vacuum extraction (APGAR 9/9/10). The mother’s temperature was elevated during delivery (maximum 38.1°C). She reported a mild respiratory infection and loss of smell and taste.

The newborn appeared lethargic, developed therapy refractory fever (38.6°C) at 24 hours after birth, progressing to encephalitic symptoms (lethargic but severely hyperexcitable, high pitched crying) at 54 hours of life. Transferred to the tertiary center neonatal intensive care unit, the newborn and the mother were isolated, and the mother was tested positive for SARS-CoV-2.

A Multiplex-polymerase chain reaction (PCR) test of 14 meningitis/encephalitis agents (FilmArray-BioFire, bioMérieux S.A., Craponne, France) was negative, and bacterial cultures of cerebrospinal fluid (CSF) and blood were sterile. Influenca-/RSV-EIA in nasopharyngeal swaps and Enterovirus-PCR/Noro-/Rotavirus EIA in the feces were negative. Although the newborn’s nasopharyngeal and rectal swaps were tested positive for SARS-CoV-2, CSF was tested negative for SARS-CoV-2 [nasopharyngeal and rectal swaps: real-time reverse transcriptase–PCR test (RT-PCR), Lightmix MODULAR WUHAN CoV RdRP (TIB MOLBIOL, Berlin, Germany). CSF: RT-PCR, RIDAGENE SARS-CoV-2 RUO (R-Biopharm, Darmstadt, Germany)]. Both tests are not validated in rectal swaps and CSF.

The patient’s cerebral sonography and CSF laboratory tests were unremarkable.

The newborn was treated in thermoneutral environment with intravenous fluids and paracetamol. Despite a normal chest radiograph at admission, the newborn developed respiratory distress at about 80 hours of life and needed continuous positive airway pressure- and oxygen therapy (maximal FiO2 0.26) until day 6 of life. At day 10, life severe staccato-like cough emerged and another chest radiograph confirmed bilateral viral pneumonia. Persistent and relevant hypopnea was treated successfully by oral caffeine. The newborn’s nasopharyngeal and rectal swaps remained positive for SARS-CoV-2 14 days after birth, when the patient was discharged free of symptoms.

Reported COVID-19 cases in newborns were mostly mild and could not always be distinguished from other causes of perinatal morbidity.2 To our knowledge, this is the first report of encephalitic symptoms in a neonate with COVID-19. In addition, our patient presented a double-peaked course of the pulmonary symptoms. This is rare in newborns, but common in adults. COVID-19 encephalitis with seizures was communicated recently in a 24-year-old Japanese male, in whom CSF was tested positive for SARS-CoV-2.5 It remains unclear, if the encephalitis symptoms in our patient were caused by SARS-CoV-2, the fever or by immunologic phenomena. However, several cerebral neuroinvasive coronavirus infections in children were reported.1 A brainstem SARS-CoV-2-infection could explain why our patient developed relevant hypopnea. The very early first symptoms in our newborn raise again the question of a vertical transmission.

Norbert Lorenz, MD
Anna Treptow, MD
Stefan Schmidt, MD
Department of Neonatology, Perinatal Center Dresden, Dresden Municipal Hospital, Teaching-Hospital of Technical University, Dresden, Germany

René Hofmann, MD
Mandy Raumer-Engler, MD
Georg Heubner, MD
Department of Neuropediatrics, Children’s Hospital, Dresden Municipal Hospital, Teaching-Hospital of Technical University, Dresden, Germany

Konstantin Gröber, MD
Institute of Clinical Chemistry, Dresden Municipal Hospital, Teaching-Hospital of Technical University, Dresden, Germany

REFERENCES

1. Zimmermann P, Curtis NCoronavirus infections in children including COVID-19: an overview of the epidemiology, clinical features, diagnosis, treatment and prevention options in children. Pediatr Infect Dis J. 2020;39:355–368.
2. Zeng L, Xia S, Yuan W, et al.Neonatal early-onset infection with SARS-CoV-2 in 33 neonates born to mothers with COVID-19 in Wuhan, China [published online ahead of print, 2020 Mar 26]. JAMA Pediatr. 2020;e200878.
3. Dong L, Tian J, He S, et al.Possible vertical transmission of SARS-CoV-2 From an infected mother to her newborn [published online ahead of print, 2020 Mar 26]. JAMA. 2020;e204621.
4. Zhu H, Wang L, Fang C, et al.Clinical analysis of 10 neonates born to mothers with 2019-nCoV pneumonia. Transl Pediatr. 2020;9:51–60.
5. Moriguchi T, Harii N, Goto J, et al.A first case of meningitis/encephalitis associated with SARS-coronavirus-2. Int J Infect Dis. 2020;pii:S1201-9712(20)30195-8.
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