J Korean Med Sci.  2022 Jun;37(24):e192. 10.3346/jkms.2022.37.e192.

Two Case Reports of Life-Threatening Croup Caused by the SARS-CoV-2 Omicron BA.2 Variant in Pediatric Patients

• Park S
• You J
• Lee J
• Park E

• KMID: 2530505
• DOI: http://doi.org/10.3346/jkms.2022.37.e192

Abstract

Croup is a common upper airway infection characterized by a barking cough, stridor, and hoarseness. It is usually caused by viral infection. A small number of croup caused by coronavirus disease 2019 (COVID-19) has been reported in children before the omicron variant surge. Previously reported cases indicated that croup caused by COVID-19 can be treated in the same manner as those with other viral causes. We describe two cases (9-monthold girl and 11-month-old boy) of previously healthy infants who presented with a barking cough and chest retraction and required endotracheal intubation and cardiopulmonary resuscitation. Despite receiving dexamethasone and nebulized racemic epinephrine (NRE) treatment for croup in the emergency department, these patients still developed acute respiratory failure. Reverse transcription polymerase chain reaction (RT-PCR) of nasopharyngeal samples revealed severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) omicron BA.2 variant (Stealth omicron) and no other common respiratory viral pathogens. Both patients were treated with mechanical ventilation, dexamethasone, and NRE in the pediatric intensive care unit. The duration of intubation was 112 hours and 80 hours, respectively. Both patients were discharged without complications. To the best of our knowledge, this is the first report of life-threatening croup produced by the omicron BA.2 variant and confirmed by RT-PCR. We suggest that this SARS-CoV-2 variant may cause severe croup that may not improve with conventional treatment, even in children without underlying diseases.

Keyword

Coronavirus Disease 2019 (COVID-19); SARS-CoV-2; Croup; Severe Croup; Cardiopulmonary Resuscitation (CPR)

Reference

1. Patel NA. Pediatric COVID-19: systematic review of the literature. Am J Otolaryngol. 2020; 41(5):102573. PMID: 32531620.

2. Lu X, Zhang L, Du H, Zhang J, Li YY, Qu J, et al. SARS-CoV-2 infection in children. N Engl J Med. 2020; 382(17):1663–1665. PMID: 32187458.

3. Bjornson CL, Johnson DW. Croup. Lancet. 2008; 371(9609):329–339. PMID: 18295000.

4. Bjornson CL, Johnson DW. Croup in children. CMAJ. 2013; 185(15):1317–1323. PMID: 23939212.

5. Yang WC, Lee J, Chen CY, Chang YJ, Wu HP. Westley score and clinical factors in predicting the outcome of croup in the pediatric emergency department. Pediatr Pulmonol. 2017; 52(10):1329–1334. PMID: 28556543.

6. Smith DK, McDermott AJ, Sullivan JF. Croup: diagnosis and management. Am Fam Physician. 2018; 97(9):575–580. PMID: 29763253.

7. Johnson DW. Croup. BMJ Clin Evid. 2014; 2014:0321.

8. Chang TH, Wu JL, Chang LY. Clinical characteristics and diagnostic challenges of pediatric COVID-19: a systematic review and meta-analysis. J Formos Med Assoc. 2020; 119(5):982–989. PMID: 32307322.

9. Brewster RC, Parsons C, Laird-Gion J, Hilker S, Irwin M, Sommerschield A, et al. COVID-19-associated croup in children. Pediatrics. Forthcoming. 2022; DOI: 10.1542/peds.2022-056492.

10. Lyngse FP, Kirkeby CT, Denwood M, Christiansen LE, Mølbak K, Møller CH, et al. Transmission of SARS-CoV-2 Omicron VOC subvariants BA.1 and BA.2: evidence from Danish households. medRxiv. January. 30. 2022; DOI: 10.1101/2022.01.28.22270044.

11. Cassedy EA, Kim S, Silver AH. An unexpected cause of croup in a pediatric patient. Clin Pediatr (Phila). 2021; 60(14):574–576. PMID: 34658288.

12. Kamali Aghdam M, Shabani Mirzaee H, Eftekhari K. Croup is one of the clinical manifestations of novel coronavirus in children. Case Rep Pulmonol. 2021; 2021:8877182. PMID: 33747592.

13. Pitstick CE, Rodriguez KM, Smith AC, Herman HK, Hays JF, Nash CB. A curious case of croup: laryngotracheitis caused by COVID-19. Pediatrics. 2021; 147(1):e2020012179. PMID: 32913132.

14. Lim CC, Saniasiaya J, Kulasegarah J. Croup and COVID-19 in a child: a case report and literature review. BMJ Case Rep. 2021; 14(9):e244769.

15. Kumar HC, Kumar KJ, Nadagoud S, Vg M. Croup: a rare manifestation of coronavirus disease 2019. J Child Sci. 2021; 11(1):e65–e67.

16. Venn AMR, Schmidt JM, Mullan PC. Pediatric croup with COVID-19. Am J Emerg Med. 2021; 43:287.e1–287.e3.

17. Tunç EM, Shin CKJ, Usoro E, Thomas-Smith SE, Trehan I, Migita RT, et al. Pediatric croup during the COVID-19 Omicron variant surge. medRxiv. February. 4. 2022; DOI: 10.1101/2022.02.02.22270222.

18. Choi YY, Kim YS, Lee SY, Sim J, Choe YJ, Han MS. Croup as a manifestation of SARS-CoV-2 omicron variant infection in young children. J Korean Med Sci. 2022; 37(20):e140. PMID: 35607737.

19. Fissel JA, Mestas J, Chen PY, Flores-Vazquez J, Truong TT, Bootwalla M, et al. Implementation of a streamlined SARS-CoV-2 whole-genome sequencing assay for expeditious surveillance during the emergence of the Omicron variant. J Clin Microbiol. 2022; 60(4):e0256921. PMID: 35317603.

20. Lee H, Choi S, Park JY, Jo DS, Choi UY, Lee H, et al. Analysis of critical COVID-19 cases among children in Korea. J Korean Med Sci. 2022; 37(1):e13. PMID: 34981683.