The COVID-19 pandemic involves delaying non-emergency healthcare appointments to prevent transmission and preserve PPE. The availability of this equipment and testing capacity may vary depending on patients and healthcare systems. This case emphasizes the importance of identifying patients carrying SARS-CoV-2, regardless of symptoms, prior to procedures. Because children have milder symptoms than adults, and asymptomatic carriers may have high viral loads and be infectious, progressive policies to identify SARS-CoV-2 should be considered.1
2 CASE REPORT
Otherwise healthy 13-month-old man presented in the emergency department after an episode of coughing / suffocation with subsequent vomiting and intolerance to food and secretions. There was no previous fever, cough, shortness of breath, sore throat or other symptoms of an upper respiratory tract infection. Chest radiographs show a circular radiopaque foreign body in the cervical esophagus, coinciding with a coin. The SARS – CoV – 2 test was performed after testing in all preoperative patients. SARS – CoV – 2 of a nasopharyngeal swab sample was detected using Xpert®Analysis of Xpress SARS-CoV-2 (Cepheid / Danaher).
In the operating room, all staff wore personal protective equipment (PPE) consisting of an N95 and / or a respirator for air purification, eye protection, a standard surgical gown and gloves.2 A rapid induction of a general anesthesia sequence was performed to limit virus aerosolization. Solid esophagoscopy with a straight intubating laryngoscope identifies a penny in the cervical esophagus. This was removed with optical alligator forceps without complications. No suction performed. The patient was discharged with a 2-week quarantine plan at home. No healthcare worker present during the case developed symptoms in the next 2 weeks.
Prior to the SARS-CoV-2 test, the patient’s family stated that the child had no ill contacts. After initial testing, the care team found that the patient’s mother had anosmia and dysgeusia that had passed 2 weeks ago. The father had a fever 3 weeks before. They had no other symptoms, positive contacts, travel history, or testing for SARS-CoV-2.
The initial test performed in the emergency department is the rapid test described above. This detected only one nucleic acid target (i.e., N2 but not the E gene) near the end of the amplification cycles of the assay (at 40.5 with a maximum number of amplification cycles at 45). At that time, a protocol for an institutional operating room was being developed and a decision was made by the operating room staff to perform a second analysis, Abbott RealTime SARS – CoV – 2 (Abbott Molecular). The second test was found to be negative. In view of the initial test, the procedure was performed using the precautions for COVID-19 as above.
COVID-19 is less common in children, with 1.7% of cases in the United States diagnosed in those under 18 years of age.3 This can cause centers to avoid testing in order to be good stewards of test materials. However, due to the potential risk of transmission in aerosol generation (AGP) procedures, suppliers should not be put to sleep. This is especially true in otolaryngology, where AGPs involving sites with a high viral load are common. Preoperative testing allows for appropriate PPE, instead of overuse of limited supplies of N95s and PPE.
In our patient, testing would be delayed if the criteria were limited to current or recent COVID-19-compatible symptoms. This case also emphasizes the importance of anosmia as an identifying symptom and in-depth history taking.4 Accordingly, viral secretion may occur in SARS-CoV-2-positive individuals for 37 days, although the potential for long-term transmission remains unclear.2
Our patient had an initial positive test followed by a negative test. This initial test may be false positive, the second test is more likely to be false negative. Although false-positive results may be obtained due to cross-contamination, this is unlikely as this was the only positive test in our laboratory for a period of two days. In this case, testing assumes the presence of a positive COVID with a low viral load. This probably explains why the second COVID-19 test, a 40-cycle assay, was negative. These results are consistent with an asymptomatic patient accompanied by COVID-19 positive parents with symptoms occurring 2-3 weeks earlier.
The potential for viral transmission in this particular case is unknown. Although few patients report gastrointestinal symptoms, the risk of gastrointestinal transmission is also unknown.4 However, the risk of aerosolization is high during intubation and extubation,5 offering an argument for preoperative testing of all procedures under general anesthesia. In addition, a prospective follow-up study targeting individuals aged 16-23 years showed evidence that asymptomatic spread of the disease occurred during the incubation period before the onset of symptoms.6
Experience in China shows that 3.8% of healthcare professionals treating COVID-19-positive patients eventually become infected with the virus.2 It is currently unknown how many healthcare workers are infected by patients with low viral load. Further work on the mechanism and route of infection, as well as further evidence on whether the virus can be transmitted through asymptomatic children, is likely to be clarified in the future. We advocate caution and caution in preoperative testing of all pediatric patients prior to surgery, especially those patients with possible exposure to COVID-19 identified by strict screening for symptoms in close contact.5 In centers without rapid testing capacity, we defend the presumption of COVID-19 positivity, especially in cases where urgent surgical treatment is required.
The identification of COVID-19 in pediatric patients, regardless of history or symptoms, is essential in selecting appropriate PPE and protecting healthcare professionals in the operating room.
Published with the written consent of the patient.
CONFLICT OF INTERESTS
The authors have no conflict of interest, nothing to reveal.
CONTRIBUTIONS OF THE AUTHOR
SDR MD: Participates in manuscript preparation, design and intellectual content. JML MD, LKK and XTZ: Participates in the review of intellectual content. KSH: participates in revisions, intellectual content. LHSR: Participates in the concept, design, preparation and intellectual content.
Funding for the publication of this manuscript is provided by the Department of Otolaryngology of Head and Neck Surgery at Lurie Children’s Hospital. No external sources of funding were used. All data obtained are presented in the above manuscript.
- 1,, ,, , et al. Severe acute coronavirus respiratory syndrome.
- 2,, ,, , et al. Clinical course and risk factors for mortality in adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020; 395: 1054– 1062.
- 3 (SARS-CoV-2) infection in children and adolescents: a systematic review. JAMA pediatrician. 2020. CDC COVID Response Team – 19, Coronavirus Disease 2019 in Children – USA, February 12 – April 2 (April 10, 2020) https://www.cdc.gov/mmwr/volumes/69/wr/mm6914e4.htm. April 30, 2020
- 4,, ,, , et al. Clinical features of coronavirus disease 2019 in China. N Engl J Med. 2020; 382(18.): 1708– 1720.
- 5,, ,, , et al. Aerosol generation procedures and risk of transmission of acute respiratory infections to healthcare professionals: a systematic review. PlosOne. 2012; 7(4): 1– 8, e35797.
- 6,, ,, , et al. Rapid asymptomatic transmission of COVID-19 during the incubation period, showing strong infectivity in a group of young people aged 16-23 years outside Wuhan and characteristics of young patients with COVID-19: a prospective study to monitor contacts. J Infectious. 2020; 80(6): e1– e13.