Clinical and Imaging Features of COVID-19 in a Neonate

  • Ying Xiong
    Affiliations
    Department of Radiology, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology (Ringgold standard institution), Wuhan, Hubei, China
    Search for articles by this author
  • Qiang Zhang
    Affiliations
    Department of Neurology, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology (Ringgold standard institution), Wuhan, Hubei, China
    Search for articles by this author
  • Lingyun Zhao
    Affiliations
    Department of Radiology, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology (Ringgold standard institution), Wuhan, Hubei, China
    Search for articles by this author
  • Jianbo Shao
    Affiliations
    Wuhan Children’s Hospital (Ringgold standard institution), Wuhan, Hubei, China
    Search for articles by this author
  • Wenzhen Zhu
    Correspondence
    CORRESPONDENCE TO: Wenzhen Zhu, PhD, Department of Radiology, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, Hubei 430030, China
    Affiliations
    Department of Radiology, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology (Ringgold standard institution), Wuhan, Hubei, China
    Search for articles by this author
      We report the clinical history, laboratory findings, and imaging features of coronavirus disease 2019 (COVID-19) in a neonate whose mother was also a patient. The newborn was the youngest patient with COVID-19 in the world at the time he was diagnosed. This case has brought more attention and understanding to the epidemic and mode of transmission of the disease.

      Key Words

      Abbreviations:

      COVID-19 (coronavirus disease 2019), SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2)

      Case Report

      A 34-year-old woman from Wuhan (the center of the coronavirus disease 2019 [COVID-19] outbreak), who was 40 weeks pregnant, checked in to the hospital with low fever and contraction pains, which she reported had started 8 h previously. She indicated that she lived in Wuhan, China and had no clear COVID-19 exposure history.
      On admission, her body temperature was elevated to 37.8°C. There was no obvious dyspnea and cough. Laboratory studies showed some abnormalities (Table 1), suggesting the possibility of viral infection. Because it was thought likely that the patient had been infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Wuhan residential history, fever, decreased lymphocytes, and elevated C-reactive protein and erythrocyte sedimentation rate), unenhanced, low-dose chest CT imaging (with a lead skirt around her belly) and real-time fluorescence polymerase chain reaction (real-time PCR) for the SARS-CoV-2 nucleic acid were done with the consent of the patient. The CT scan showed multiple ground-glass opacities distributed bilaterally (Fig 1). The real-time PCR result for SARS-CoV-2 nucleic acid, based on the patient’s oropharyngeal swab, was positive.
      Table 1Laboratory Test Results of the Pregnant Woman
      ParameterValueNormal Range
      WBC count6.72 × 109/L(4-10) × 109/L
       Neutrophils80%40%-75%
       Lymphocytes14.4%20%-50%
       Eosinophils0.0%0.4%-8.0%
      C-reactive protein11.5 mg/L0–10 mg/L
      Erythrocyte sedimentation rate26 mm/h< 20 mm/h
      IL-644.18 pg/mL< 7 pg/mL
      Figure thumbnail gr1
      Figure 1A (bilateral upper lobes) and B (the left lower lobe), Unenhanced CT images of the 34-year-old mother. The CT scan showed multiple ground-glass opacities, some of which may be seen along the bronchial vessels in the left upper lobe, as well as some ground-glass opacities in the right upper lobe and the left lower lobe (arrows).
      Using the highest level of prevention against nosocomial infection, a caesarean section was performed. The amniotic fluid was stained (grade III) with meconium. The neonate’s weight was 3.25 kg and the Apgar score was 8-9. The neonate had no obvious dyspnea (oxygen saturation was 92%-99% without inhaling oxygen). With the consent of his parents, chest radiography and real-time PCR of the baby’s oropharyngeal swab were also carried out directly after delivery. The chest radiograph showed no obvious abnormality on the day after his birth (Fig 2A). The real-time PCR result for the SARS-CoV-2 nucleic acid was positive. The diagnosis of COVID-19 was made 36 h after the baby’s birth. The neonate did not have a fever or cough. The postnatal response was not as good from the second day of his birth. He was then transferred to Wuhan Children’s Hospital, where he underwent another radiographic examination and another nucleic acid detection with nasal swab specimens. The second radiographic examination, done 4 days after his birth, showed very small bronchovascular shadows and ground-glass opacity in the right lower lobe (Fig 2B), and the rechecked nucleic acid detection result was positive. The routine blood tests showed very slight changes in hemoglobin and neutrophil count (Table 2). The neonate was given full care and nutritional support, without antibiotics. His body weight was increasing steadily, with good postnatal response and very light physiologic jaundice. He underwent a third radiographic examination on day 15 after birth; no obvious abnormalities were observed. Together with negative real-time PCR results for the SARS-CoV-2 nucleic acid, from both oropharyngeal and anal swabs, the baby was approved for discharge on day 17 after birth.
      Figure thumbnail gr2
      Figure 2A-C, Chest radiographs of the newborn. There was no obvious abnormality on the day after his birth (A). Four days after his birth, the second radiographic image showed very small bronchovascular shadows and opacities in the right lower lobe (B). Fifteen days after his birth, the suspicious shadow in the lower right lobe had dissipated (C).
      Table 2Laboratory Test Results of the Newborn
      TimeParameterValueNormal Range
      1 d after birthWBC count13.24 × 109/L(5-20) × 109/L
       Neutrophils9.51 × 109/L(3.9-9.4) × 109/L
       Lymphocytes2.43 × 109/L(2-17) × 109/L
       Monocytes1.16 × 109/L(0.2-3.1) × 109/L
      Hemoglobin146 g/L170-200 g/L
      14 d after birthWBC count9.17 × 109/L(5-20) × 109/L
       Neutrophils3.80 × 109/L(3.9-9.4) × 109/L
       Lymphocytes4.38 × 109/L(2-17) × 109/L
       Monocytes0.74 × 109/L(0.2-3.1) × 109/L
      Hemoglobin124 g/L115-135 g/L
      C-reactive protein< 0.5 mg/L0–10 mg/L

      Discussion

      From late December 2019, there has been an outbreak of pneumonia in China caused by a novel coronavirus (2019-nCoV),
      • Wang C.
      • Horby P.W.
      • Hayden F.G.
      • Gao G.F.
      A novel coronavirus outbreak of global health concern.
      named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The disease is spreading at striking speed. As of March 8, the confirmed cases in China had reached 80,735.
      People are generally susceptible. The elderly and those with underlying diseases are more seriously ill after infection. Children and infants also can be infected. The main route of transmission is via respiratory droplets, as well as physical contact.
      • Zhu N.
      • Zhang D.
      • Wang W.
      • et al.
      China Novel Coronavirus Investigating and Research Team
      A novel coronavirus from patients with pneumonia in China, 2019.
      ,
      • Huang C.
      • Wang Y.
      • Li X.
      • et al.
      Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.
      At present, we are not sure whether the neonate was infected after birth (which was conducted with the highest level of care to prevent infection), especially during the delivery process, or whether this case suggests the potential for a new way to contract COVID-19. A single-center study retrospectively reviewed nine pregnant women and indicated that, at present, there is insufficient evidence of vertical transmission in late pregnancy.
      • Chen H.
      • Guo J.
      • Wang C.
      • et al.
      Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records.
      However, neonatal cases have also been reported elsewhere.
      • Hong H.
      • Wang Y.
      • Chung H.T.
      • Chen C.J.
      Clinical characteristics of novel coronavirus disease 2019 (COVID-19) in newborns, infants and children.
      The neonate described here was the youngest COVID-19 patient in the world when he was diagnosed, and unlike his mother, whose chest CT scan showed typical viral pneumonia changes, the newborn baby showed no obvious abnormality in his first chest radiograph. We have two conjectures: (1) The immune system of the newborn baby was immature and did not start an inflammatory storm that can cause lesions in lungs; and (2) the course of the disease was too short, so that the lesion was quite mild. However, the second chest radiograph showed a very slight change. We cannot exclude the possibility that the very small ground-glass shadows in the right lower lobe in the second radiograph were early imaging hints of COVID-19 infection. Because SARS-CoV-2 antibody detection was not widely applied at the hospital at the time they were admitted, we lack this information. Fortunately, the baby was in good condition and state of growth. The disease condition of neonates is usually slight.
      • Hong H.
      • Wang Y.
      • Chung H.T.
      • Chen C.J.
      Clinical characteristics of novel coronavirus disease 2019 (COVID-19) in newborns, infants and children.
      After 2 weeks of care and treatment, the real-time PCR result for SARS-CoV-2 nucleic acid had changed to negative. Neonatologists should be vigilant when assessing newborns delivered by infected mothers and work to improve knowledge of prevention and transmission of COVID-19.

      Acknowledgment

      Financial/nonfinancial disclosures: None declared.
      Role of sponsors: The sponsor had no role in the design of the study, the collection and analysis of the data, or the preparation of the manuscript.

      References

        • Wang C.
        • Horby P.W.
        • Hayden F.G.
        • Gao G.F.
        A novel coronavirus outbreak of global health concern.
        Lancet. 2020; 395: 470-473
        • Zhu N.
        • Zhang D.
        • Wang W.
        • et al.
        • China Novel Coronavirus Investigating and Research Team
        A novel coronavirus from patients with pneumonia in China, 2019.
        N Engl J Med. 2020; 382: 727-733
        • Huang C.
        • Wang Y.
        • Li X.
        • et al.
        Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.
        Lancet. 2020; 395: 497-506
        • Chen H.
        • Guo J.
        • Wang C.
        • et al.
        Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records.
        Lancet. 2020; 395: 809-815
        • Hong H.
        • Wang Y.
        • Chung H.T.
        • Chen C.J.
        Clinical characteristics of novel coronavirus disease 2019 (COVID-19) in newborns, infants and children.
        Pediatr Neonatol. 2020; 61: 131-132