A Curious Case of : Laryngotracheitis Caused by COVID-19 Claire E. Pitstick, DO, Katherine M. Rodriguez, MD, Ashley C. Smith, MD, Haley K. Herman, MD, James F. Hays, MD, Colleen B. Nash, MD, MPH

We describe a case of croup in a 14-month-old boy caused by severe acute abstract respiratory syndrome coronavirus 2, the virus that causes coronavirus disease 2019. The patient presented with classic consistent with croup. Workup was remarkable for a positive point-of-care test for severe acute respiratory syndrome coronavirus 2. This case represents recognition of a new clinical entity caused by coronavirus disease 2019.

Croup, or laryngotracheitis, is (SARS-CoV-2) has been shown to be a common childhood syndrome a multifaceted pathogen. Most pediatric involving subglottic inflammation patients with confirmed cases present commonly associated with fever, asymptomatically or with mild upper “barking” cough, and stridor.1 This is respiratory symptoms, but a small a viral illness most often secondary to percentage can progress to acute human parainfluenza viruses, but it is respiratory distress syndrome or 4 also associated with respiratory multiorgan system dysfunction. There Department of Pediatrics, Rush University Medical Center, syncytial virus, rhinovirus, enterovirus, are no known documented cases of Chicago, Illinois and others. As a result, croup is SARS-CoV-2 causing croup in the All authors drafted the manuscript, contributed to typically seen in the late fall and early pediatric population. We report the the literature review and manuscript revision, and winter seasons, and patients usually case of a 14-month-old boy with classic approved the final manuscript as submitted and have associated viral symptoms, such symptomatology and radiographic agree to be accountable for all aspects of the work. as and nasal congestion. The confirmation of croup who was DOI: https://doi.org/10.1542/peds.2020-012179 diagnosis of croup is clinical. On subsequently found to have Accepted for publication Aug 17, 2020 physical examination, patients have coronavirus disease 2019 (COVID-19) Address correspondence to Claire E. Pitstick, DO, inspiratory stridor, which may occur at infection. Department of Pediatrics, Rush University Medical rest or only while crying. A thorough Center, 1645 W Jackson Blvd, Suite 200, Chicago, IL 60612. E-mail: [email protected] physical examination and sometimes PATIENT PRESENTATION imaging will help exclude diagnoses, PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, such as or retropharyngeal In early May 2020, a term, 1098-4275). abscess. The severity of croup relates to unvaccinated 14-month-old boy who Copyright © 2021 by the American Academy of the child’s degree of respiratory status was recently diagnosed with influenza Pediatrics and work of breathing. Although not A in February presented to the FINANCIAL DISCLOSURE: The authors have indicated fi necessary to diagnose croup, a emergency department with 2 days of they have no nancial relationships relevant to this article to disclose. radiograph may reveal subglottic fever, cough, and stridor. His maximum FUNDING: narrowing or “steeple sign.”2 A chest temperature was 38°C at home. Cough No external funding. radiograph can also help exclude an and stridor were intermittent, with POTENTIAL CONFLICT OF INTEREST: The authors have fl aspirated foreign body. Viral croup is increased work of breathing only when indicated they have no potential con icts of interest to disclose. a self-limited illness that typically crying. He had normal appetite and resolves over several days.3 urine output. Parents denied diarrhea, vomiting, or rash. He had been staying To cite: Pitstick CE, Rodriguez KM, Smith AC, et al. A The novel coronavirus, severe acute home with family, including his 3-year- Curious Case of Croup: Laryngotracheitis Caused by COVID-19. Pediatrics. 2021;147(1):e2020012179 respiratory syndrome coronavirus 2 old sister, who had a febrile illness

Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 147, number 1, January 2021:e2020012179 CASE REPORT 1 week before. His father worked at no known complications during his represents a new presentation of a brick factory. recovery. His COVID-19 antibodies COVID-19 in pediatric patients. We The patient presented to were not tested; therefore, it is recommend that infants and children a community emergency department unknown whether he seroconverted. presenting with symptoms for difficulty breathing. He arrived concerning for croup be tested for with a fever of 39.3°C, which resolved DISCUSSION COVID-19 so that appropriate with acetaminophen. He was initially isolation precautions can be taken to Our case indicates that SARS-CoV-2 limit disease transmission. tachycardic to 194 beats per minute, can cause croup in pediatric patients. his blood pressure was 103/85 This presentation of disease is not mm Hg, his respiratory rate was 40 unprecedented because other ABBREVIATIONS breaths per minute, and he was coronaviruses have previously been saturating 100% on room air. Physical shown to cause croup.5 Our patient COVID-19: coronavirus disease fi fi examination ndings were signi cant displayed no signs of or 2019 fl for tachypnea, nasal aring, and lower infection, as SARS-CoV-2: severe acute respira- inspiratory stridor. has been seen in the majority of tory syndrome symptomatic adult and pediatric coronavirus 2 DIAGNOSIS AND OUTCOME cases of COVID-19. A case series of Our patient was found to be positive 171 pediatric patients with COVID-19 in Wuhan, China, revealed that 65% for COVID-19 via point-of-care REFERENCES testing. A respiratory pathogen of patients presented with fi pneumonia and 19% presented with 1. Engorn B, Flerlage J. The Harriet Lane nucleic acid ampli cation panel 4 (which was not used to test for upper respiratory tract illness. Most Handbook, 20th ed. Philadelphia, PA: Saunders; 2015 COVID-19) was negative for other pediatric patients to date have had viral etiologies, including other types relatively mild courses of illness, with 2. Mills JL, Spackman TJ, Borns P, Mandell of coronavirus, influenza, few developing GA, Schwartz MW. The usefulness of parainfluenza, respiratory syncytial requiring intubation and mechanical lateral neck roentgenograms in laryngotracheobronchitis. Am J Dis virus, rhinovirus, and enterovirus. ventilation; only 3 of the patients in Child. 1979;133(11):1140–1142 There was no leukocytosis; the total the Wuhan cohort required intubation and mechanical 3. Thompson M, Vodicka TA, Blair PS, white blood cell count was 8000 cells 4 per mL, with 5200 neutrophils (57% ventilation. Buckley DI, Heneghan C, Hay AD; TARGET Programme Team. Duration of segmented cells, 8% band cells) and However, SARS-CoV-2 causes a broad m symptoms of respiratory tract 2400 lymphocytes per L (30%). The spectrum of diseases, ranging from infections in children: systematic C-reactive protein level was elevated asymptomatic infection to acute review. BMJ. 2013;347:f7027 at 34 mg/dL. Because of early respiratory failure, as well as the 4. Lu X, Zhang L, Du H, et al.; Chinese concern for epiglottitis given the emerging multisystem inflammatory ’ Pediatric Novel Coronavirus Study patient s unvaccinated status, neck syndrome in children causing Team. SARS-CoV-2 infection in children. and chest radiographs were obtained, Kawasaki-like disease with shock N Engl J Med. 2020;382(17):1663–1665 which revealed subglottic narrowing. requiring ICU admission.6 In 5. van der Hoek L, Sure K, Ihorst G, et al. There was no radiographic evidence a recently published case series of 64 Croup is associated with the novel of epiglottitis or focal consolidation. pediatric patients in Chicago with coronavirus NL63. PLoS Med. 2005;2(8): fi After initial treatment in the con rmed COVID-19, the most e240 community emergency department common symptoms encountered 6. Verdoni L, Mazza A, Gervasoni A, et al. with racemic epinephrine and were cough (75%) and fever (56%).7 An outbreak of severe Kawasaki-like dexamethasone, he was transferred to In this series, 10 patients required disease at the Italian epicentre of the our quaternary care center for hospital admission. Of the 7 patients SARS-CoV-2 epidemic: an observational overnight observation. He arrived who required admission to the ICU, cohort study. Lancet. 2020;395(10239): stable on room air, with mild the majority had underlying 1771–1778 inspiratory stridor only when crying, comorbid conditions, including 7. Mannheim J, Gretsch S, Layden JE, and was tolerating oral hydration. He congenital heart disease, chronic lung Fricchione MJ. Characteristics of 7 had an uneventful hospitalization and disease, or genetic syndromes. SARS- hospitalized pediatric coronavirus was discharged from the hospital the CoV-2 has thus been shown to cause disease 2019 cases in Chicago, Illinois, following day with supportive care a wide array of clinical presentations March-April 2020. J Pediatric Infect Dis and outpatient follow-up. There were and severity of disease. Our case Soc. 2020;9(5):519–522

Downloaded from www.aappublications.org/news by guest on September 24, 2021 2 PITSTICK et al A Curious Case of Croup: Laryngotracheitis Caused by COVID-19 Claire E. Pitstick, Katherine M. Rodriguez, Ashley C. Smith, Haley K. Herman, James F. Hays and Colleen B. Nash Pediatrics originally published online September 10, 2020; originally published online September 10, 2020;

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Downloaded from www.aappublications.org/news by guest on September 24, 2021 A Curious Case of Croup: Laryngotracheitis Caused by COVID-19 Claire E. Pitstick, Katherine M. Rodriguez, Ashley C. Smith, Haley K. Herman, James F. Hays and Colleen B. Nash Pediatrics originally published online September 10, 2020; originally published online September 10, 2020;

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/early/2020/12/15/peds.2020-012179

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2020 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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