Keywords
croup - laryngotracheobronchitis - COVID-19 - SARS-CoV-2 - stridor
Introduction
Croup, also known as acute laryngotracheobronchitis, is characterized by acute inflammation
of larynx, trachea, and bronchus and clinically presents with barky cough, stridor,
and respiratory distress. Croup is commonly due to viral pathogens infections and
most often due to parainfluenza viruses, respiratory syncytial virus, influenza A
and B, adenovirus, and measles and rarely bacterial.[1]
[2] Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may be asymptomatic
or may present with fever, coryza, cough, and/or shortness of breath. It can also
have plethora of other manifestations such as nausea, vomiting, diarrhea, dehydration,
abdominal pain, headache, pharyngitis, rash, myalgia, cyanosis, tachypnea, tachycardia,
apnea, etc. But, to the best of our knowledge, croup as a manifestation of COVID-19
has been reported only twice before in children.[3]
[4] We report a 3-month-old child with classic symptomatology and radiographic sign
suggestive of croup due to SARS-CoV-2 infection.
Case Report
A 3-month-old developmentally normal female child was brought to emergency ward with
a history of fever and cough of 3 days, noisy, and hurried breathing for 1 day. At
admission, baby was afebrile (temperature: 98.6°F), heart rate was 145/minute, respiratory
rate was 50/minute with suprasternal and subcostal retractions, blood pressure was
94/60 mmHg, capillary refill time was <3 seconds, and SpO2 was 98% in room air. Respiratory system examination revealed inspiratory stridor
more on crying with increased work of breathing, bilateral equal air entry with normal
vesicular breath sounds, and conducted sounds. Other systems examination was unremarkable.
Investigations: Hemoglobin was 9.9 g/dL, total leucocyte count was 17,540 cells/mm3 with 73.5% neutrophils, 20.2% lymphocytes, platelet count was 6.17 lakh/mm3, and erythrocyte sedimentation rate was 45 mm at 1 hour. CRP was negative (3.37 mg/L).
Liver and renal function tests were within normal limits. Neck and chest X-ray showed
steeple sign with patchy opacities in right paracardiac region ([Fig. 1]). The nasopharyngeal swab reverse transcription polymerase chain reaction for SARS-CoV-2
infection was positive. However, we could not test for other respiratory pathogens.
Inflammatory markers like serum ferritin, lactate dehydrogenase, procalcitonin and
d-Dimer were normal. Baby's mother also tested positive for SARS-CoV-2 on the next
day.
Fig. 1 Neck and chest X-ray showing steeple sign with patchy opacities in right paracardiac
region.
Baby was treated with nebulized epinephrine (0.5 mL/kg; three doses over 48 hours),
intravenous (IV) dexamethasone (0.15 mg/kg/day once a day for 2 days), salbutamol
nebulization, and IV ceftriaxone. Fever was present only on the day of admission for
12 hours. Baby's stridor and cough completely resolved by 48 hours. Even though baby
recovered by 48 hours, baby was admitted for 3 more days to observe for complications
of COVID-19 infection. On 5th day of admission, there was no stridor, vitals were
stable and baby was discharged.
Discussion
Croup is a common upper respiratory tract infection of young children and is most
commonly due to viral etiology.[1] Croup is often preceded by cough, coryza, and fever, followed by sudden onset of
barking cough, hoarse voice, and inspiratory stridor.[2] The diagnosis of croup is mostly clinical and determining the etiology is rarely
helpful.[3]
[4] Usually, viral croup is a self-limiting illness that typically resolves within 3
to 7 days in most cases.[4] Our baby presented with classical clinical features of croup and neck X-ray showed
steeple sign.
The novel coronavirus SARS-CoV-2 has been shown to have protean manifestations. Though
most pediatric cases present with no or mild upper respiratory symptoms, a small percentage
of them can progress to severe forms such as acute respiratory distress syndrome or
multiorgan system dysfunction.[4]
[5]
[6] Cough and fever are the two most commonly reported symptoms, while rhinorrhea, nausea,
vomiting, fatigue, diarrhea, dehydration, abdominal pain, headache, pharyngitis, rash,
myalgia, cyanosis, tachypnoea, tachycardia, and apnea are other important presentations
of SARS-CoV-2 infection.[3] Most of the pediatric cases require just close observation or symptomatic treatment
and only a minority of them require intensive care treatment.[5]
SARS-CoV-2 infection presenting with croup is quite rare.[3]
[4] In children, only two published reports are available in the literature to the best
of our knowledge.[3]
[4] Pitstick et al reported a 14-month-old child with croup due to SARS-CoV-2 infection
with classical symptoms and was treated symptomatically and recovered.[4] Our child who was COVID-19 positive, also presented with classical features of croup
with steeple sign; hence, we made a diagnosis of croup due to SARS-CoV-2 infection
and treated symptomatically for which the child responded well. We used 0.15 mg/kg
of dexamethasone instead of the recommended dose of 0.6 mg/kg in view of COVID-19
positivity, and the response was good. However, Venn et al used multiple doses of
0.6 mg/kg dexamethasone in all three cases.[3] In one child heliox (70% helium/30% oxygen), remdesivir and bilevel positive airway
pressure was used. Authors opined that this therapeutic decision was infrequent in
their hospital's practice and is reserved for atypical cases not responding as expected
to initial treatment.[3] Current COVID-19 guidelines recommend dexamethasone to patients who are mechanically
ventilated or are requiring oxygen as in adults.[3] Therefore, we used only 0.15 mg/kg with good response. However, Pitstick et al have
not mentioned the dose they have used.[4]
In a study from Wuhan, out of 171 SARS-CoV-2 positive children, 19% presented with
upper respiratory tract illness and 65% presented with pneumonia. Most of the cases
had mild course and only three children required mechanical ventilation.[5] In another study involving 64 pediatric patients, most common symptoms were cough
(75%) and fever (56%).[6] In both studies, croup as a manifestation was not reported. However, in a study
involving 702 COVID-19 adult patients, 188 (26.8%) reported dysphonia during the clinical
course of the disease and seven dysphonic patients reported aphonia. Probably dysphonia
may be caused by vocal fold edema or inflammation.[7] Testing for COVID-19 helps in appropriate isolation precautions so that we can limit
disease transmission. We had kept our infants mother in isolation to avoid spread
of COVID infection. There are various social impacts of COVID-19 quarantine period.
Maugeri et al observed a significant positive correlation between the variation of
physical activity and mental well-being suggesting that the decrease in total physical
activity had a profound negative impact on psychological health and well-being during
COVID-19 pandemic in Italy.[8] A study from Canada also concluded that health-promoting measures directed toward
increasing physical activity levels in inactive individuals may be essential to improving
well-being during COVID-19. Even during public health restrictions, outdoor physical
activity should be offered where feasible as it improves well-being of patients.[9]
Conclusion
Croup like presentation in young infant may also be due to SARS-CoV-2 infection. Therefore,
screening for COVID 19 is ideal in every child with croup syndrome so that appropriate
isolation and standard precautions in managing these cases may be initiated.
