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Two symptomatic cases of MERS found in Saudi Arabian children
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Middle East respiratory syndrome, or MERS, is not limited to adults, according to study findings in The Pediatric Infectious Disease Journal.
Findings from Saudi Arabia indicate that children with MERS may be asymptomatic and can test positive during contact investigation of older patients with the coronavirus infection.
Ziad A. Memish, MD, FRCP, FACP, deputy minister of public health and director of the WHO Collaborating Center for Mass Gathering Medicine, and colleagues reviewed clinical records for 11 patients aged 2 to 16 years who tested positive for MERS in Saudi Arabia. Nine patients were asymptomatic and two were symptomatic.
One of the two symptomatic patients was a 2-year-old boy with cystic fibrosis who was admitted with fever and respiratory distress. He had no history of travel, no contact with animals or known MERS patients. He was treated with ceftazidime and gentamicin. A sputum culture showed multidrug-resistant Pseudomonas. His condition rapidly deteriorated and he was transferred to the ICU. The patient was electively intubated and put on conventional mechanical ventilation but switched to high-frequency oscillatory ventilation due to worsening acidosis. Sixty days after admission, he died of respiratory failure and multi-organ failure.
The second symptomatic patient was a 14-year-old girl with Down syndrome who was admitted with a cough and fever. She had a repaired ventriculoseptal defect with residual severe mitral regurgitation, a history of systolic and diastolic left ventricular impairment, and hypertension. The patient was obese and had obstructive sleep apnea and hypothyroidism. Her blood cultures were negative and she had no sputum production. She received nebulization treatment, IV diuretics, imipenem and oseltamivir (Tamiflu, Genentech). She gradually improved and was discharged 7 days after admission. The patient remains in good health.
Eight of the nine asymptomatic patients were in contact with a family member with MERS. They did not require hospitalization and had no symptoms of illness.
“MERS [coronavirus] disease is not limited to adults. Most cases of childhood MERS [coronavirus] infection was asymptomatic and tested positive during contact investigation of older patients. Severe disease can occur in children with underlying conditions,” the researchers concluded.
Disclosure: The researchers reported no relevant financial disclosures.
Perspective
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Roberta L. DeBiasi, MD, MS
The MERS epidemic, its recent acceleration in the Arabian Peninsula, and the first reported imported cases in the United States, have led to increasing concern by pediatricians regarding the impact of the disease on children. The most recent WHO update (May 9) documents 536 laboratory-confirmed cases with 145 deaths, with a median age of 49 years (range, 9 months to 94 years). Memish and colleagues provide the first detailed clinical and virologic description of pediatric MERS cases from the Saudi Arabian epicenter. Their summary of 11 PCR-confirmed cases, ranging in age from 2 to 16 years, includes two symptomatic patients, both of whom had underlying comorbidities (cystic fibrosis and Down syndrome), and nine asymptomatic patients, all of whom were family contacts of adult MERS cases. Both symptomatic patients had bilateral diffuse pulmonary infiltrates, and one of the patients died. Interestingly, semiquantitative viral loads did not differ between asymptomatic and symptomatic patients, or between the symptomatic patient who died and the one who survived. As pointed out by the authors, the markedly high observed case-fatality rate for MERS patients — initially reported as high as 65%, and currently 30% overall — is likely to continue to fall, as milder and asymptomatic cases are identified in conjunction with epidemiologic investigation of ongoing severe cases. This current report, and prior less detailed reports, indicates that pediatric cases may overall be milder. Thus, the overall burden of pediatric disease is likely not fully captured by applying current WHO and CDC case definitions that focus on lower respiratory tract disease. Pediatricians worldwide will need to continue their vigilance for potential pediatric MERS cases as the epidemic unfolds.
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