SUDANESE JOURNAL OF PAEDIATRICS

2021; Vol 21, Issue No. 2

CASE REPORT

COVID-19 infection in a Down syndrome child

Sunil Malik (1) , Aarti Kathuria (2)

(1) Associate Professor, Department of Pediatrics, Subharti Medical College, Meerut, India

(2) Junior Resident, Department of Pediatrics, Subharti Medical College, Meerut, India

Correspondence to:

Sunil Malik

Department of Pediatrics, Subharti Medical College, Meerut, India.

Email: drneelmalik [at] gmail.com

Received: 11 March 2021 | Accepted: 31 May 2021

How to cite this article:

Malik S, Kathuria A. COVID-19 infection in a Down syndrome child. Sudan J Paediatr. 2021;21(2): 182–185.

https://doi.org/10.24911/SJP.106-1615470988

ABSTRACT

The clinical spectrum of COVID-19 infection varies from asymptomatic to critical illness. In children, it is usually asymptomatic or milder in severity. Younger infants and children with underlying medical illnesses are more prone to develop severe diseases. Fever and cough are common presentations in children. Angiotensin-converting enzyme 2 receptor and transmembrane serine protease 2 are key proteins in the cell entry process of the virus in the gastrointestinal (GI) tract. Children with Down syndrome (DS) have increase mortality rates from COVID-19 compared to the general pediatric population. We are reporting a case of a DS baby with COVID-19 infection who presented with GI manifestations leading to hypernatremic dehydration with multiorgan dysfunction syndrome.

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KEYWORDS

COVID-19; Down syndrome; Infant.

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INTRODUCTION

COVID-19 is known to affect children of all age groups. The clinical spectrum of the disease may vary from asymptomatic to critical illness. Various reports suggest that children have a milder form of the disease compared to adults [1]. Limited data suggest 16%-58% of infected children may remain asymptomatic [2,3]. Younger infants and children with underlying medical illnesses are more prone to develop severe disease [1].

Usually, fever is the most common presentation in COVID-19 positive children. Almost half of the patients present with fever and cough. Gastrointestinal (GI) manifestation varies from 4%-9%. One systematic review found the incidence of vomiting 4%-9%, diarrhea 6%-13% and abdominal pain in around 4% of infected patients [4].

Down syndrome (DS), initially described by John Langdon Down in 1866, is the most common chromosomal anomaly worldwide, with a prevalence of approximately 1/1,000 live births. It is commonly associated with various dysmorphic features, intellectual disability, congenital heart disease (CHD), and other anomalies. It also constitutes the most common genetic cause of intellectual disability. The most common CHD associated with DS is atrioventricular septal defect, which is an independent risk factor for a thromboembolic event during childhood [5].

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CASE REPORT

Here, we are reporting a case of a 12-month-old baby brought to the emergency department with respiratory difficulty and altered sensorium for 1 day. The baby was apparently well 3 days back when he developed fever and multiple watery stools. The oral intake of the patient was drastically reduced over the last 2 days. For the above complaints, the baby was taken to a private hospital, where his COVID-19 antigen test came positive, for which he was referred to us. The child was a known case of DS (Trisomy 21) with CHD (mild peripheral pulmonary stenosis). Development was severely delayed and the child also had dysmorphic facies consistent with DS. On initial assessment, the baby was febrile, tachypneic (respiratory rate 42/minute), and spO₂ on room air was 84%. The child was in shock with severe dehydration, acidotic breathing, and altered sensorium. The chest was clear, with no signs of congestive heart failure. The arterial blood gases (ABG) was suggestive of severe metabolic acidosis (pH 7.15, bicarbonate 8.6 mmol/l, base excess -22.9). Treatment was started as per protocol in the form of intravenous (IV) fluid boluses, IV antibiotics, oxygen, and other supportive therapies. Remdesivir, low-molecular-weight heparin, and dexamethasone were also started in view of severe COVID infection.

Further investigations suggested dyselectrolytemia (Na 164 meq/l, K 3.3 meq/l, Calcium 7.8 mg/dl) and acute kidney injury (serum creatinine 2.28 mg/dl, blood urea 201 mg/dl). Blood counts revealed anemia, relative leucopenia with lymphocytosis (Haemoglobin 7.8 g/dl, white blood cell count 5310 /cumm, neutrophils 30%, lymphocytes 68%) (Table 1).

Chest X-ray showed no significant findings (Figure 1). The baby was managed as per protocol. Initially, serum sodium improved to 153 mmol/l; however, severe metabolic acidosis did not improve. On day 2 of admission, the patient landed in refractory shock and multi-organ dysfunction syndrome. The baby was kept on mechanical ventilation, inotropes were added. On day 3, despite the best possible efforts, the child could not survive.

Table 1. Laboratory parameters of the child.

Investigations	Hospital
	Day 1	Day 2 morning	Day 2 evening	Day 3
Haemoglobin (g/dl)	7.8
Platelet counts (×103/mm3)	192
Total leucocyte counts (×103/mm3)	5.31
Neutrophil/ lymphocytes (%)	30/68
AST/ALT (u/l)	80/94
Bilirubin total/direct (mg/dl)	0.3/0.1
Protein/albumin (g/dl)	6.7/ 3.5
Alkaline phosphatase (u/l)	264
PT/INR	20.1/1.65			19.6/1.61
APTT (seconds)	>180			27.3
Urea/creatinine (mg/dl)	201/2.28	211/2.24	201/2.29	155/1.63
Sodium/potassium (mmol/l)	164/3.3	153/4.0		152.0/5.3
Calcium (mg/dl)	7.8	7.0		<5.9
Uric acid (mg/dl)	>12	>12		>12.0
CRP (mg/l)	3.5

APTT = partial thromboplastin time; AST = aspartate aminotransferase; ALT: alanine aminotransferase; CRP = c-reactive protein; INR = international normalized ratio; PT = prothrombin time.

Figure 1. Chest X-ray of the patient.

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DISCUSSION

With the emergence of SARS-CoV-2 pandemic, the knowledge about disease manifestation and severity is also evolving rapidly. The data collected from recent studies confirm that the clinical spectrum of COVD-19 is different among adult and pediatric cases. The frequency and severity of the disease are lesser in children [6]. Cases among adult patients are being reported frequently, but pediatric case reports are lesser in number. So clinical information among pediatric patients is very limited and that is also true for a child with underlying medical diseases.

In covid infection, diarrhea most often occurs after 1-8 days of illness, while the mean age of presentation is 3.3 days. Few patients may have watery diarrhea as a first clinical presentation. Angiotensin-converting enzyme 2 receptor and transmembrane serine protease 2 are key proteins in the cell entry process of the virus in the GI tract [7]. Three phases characterize severe COVID-19 disease: the first being the viral phase; the second being the cytokine storm and the third encompassing acute respiratory distress syndrome , impaired cardiac function, and death [7]. The cytokine storm appears to be driven by a dysregulated host immune response and might contribute to mortality [8].

Children with DS have increase mortality rates from COVID-19 compared to the general pediatric population [9]. They usually have a higher prevalence of respiratory tract infections, immune dysfunction and co-morbidities associated with COVID-19, leading to poorer clinical outcomes. Chromosome 21 contains multiple genes involved in immune responses, especially four interferons (IFN) receptors; overexpression of these genes may induce an overactive immune system. Another study has found down-expression of NF-kB1 in cells from DS patients compared to normal subjects [10,11].

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CONFLICT OF INTEREST

The authors declare that they have no conflicts of interest.

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FUNDING

None.

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ETHICAL APPROVAL

Signed informed consent for participation and publication of medical details were obtained from the parents of the child. Ethical approval has been granted from the hospital authority. Confidentiality was ensured at all stages.

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REFERENCES

1. Dong Y, Mo X, Hu Y, Qi X, Jiang F, Jiang Z, et al. Epidemiological characteristics of 2143 pediatric patients with 2019 coronavirus disease in China. Pediatrics. 2020;58(4):e20200702. https://doi.org/10.1542/peds.2020-0702
2. Assaker R, Colas AE, Julien-Marsollier F, Bruneau B, Marsac L, Greff B et al. Presenting symptoms of COVID-19 in children: a meta-analysis of published studies. Br J Anaesth. 2020;125(3):e330–2. https://doi.org/10.1016/j.bja.2020.05.026
3. Sarangi B, Reddy VS, Oswal JS, Malshe N, Patil A, Chakraborty M, et al. Epidemiological and clinical characteristics of COVID-19 in Indian children in the initial phase of the pandemic. Indian Pediatr. 2020;57(10):914–7. https://doi.org/10.1007/s13312-020-1994-4
4. Meena J, Yadav J, Saini L, Yadav A, kumar J. Clinical features and outcome of SARS-CoV-2 infection in children: a systematic review and meta-analysis. Indian Pediatr. 2020;57:820–26. https://doi.org/10.1007/s13312-020-1961-0
5. Journeycake JM, Brumley LE. Down syndrome as an independent risk factor for thrombosis in children. Blood. 2006;108:489. https://doi.org/10.1182/blood.V108.11.1489.1489
6. Pavone P, Ceccarelli M, Taibi R, La Rocca G, Nunnari G. Outbreak of COVID-19 infection in children: fear and serenity. Eur Rev Med Pharmacol Sci. 2020;24(8):4572–5.
7. Matthai J, Shanmugam N, Sobhan P, Indian Society of Pediatric Gastroenterology, Hepatology and Nutrition; Pediatric Gastroenterology Chapter of Indian Academy of Pediatrics. Coronavirus Disease (COVID-19) and the gastrointestinal system in children. Indian Pediatr. 2020;57(6):533–5. https://doi.org/10.1007/s13312-020-1851-5
8. Espinosa JM. Down syndrome and COVID-19: a perfect storm? Cell Rep Med. 2020;1:100019. https://doi.org/10.1016/j.xcrm.2020.100019
9. Turk MA, Landes SD, Formica MK, Goss KD. Intellectual and developmental disability and COVID-19 case-fatality trends: TriNetX analysis. Disabil Health J. 2020;13:100942. https://doi.org/10.1016/j.dhjo.2020.100942
10. de Weerd NA, Nguyen T. The interferons and their receptors- distribution and regulation. Immunol Cell Biol. 2012;90:48391 https://doi.org/10.1038/icb.2012.9
11. Altable M, de la Serna JM. Down’s syndrome and COVID-19: risk or protection factor against infection? A molecular and genetic approach. Neurol Sci. 2021;42(2):407–13. https://doi.org/10.1007/s10072-020-04880-x