Children diagnosed with cystic fibrosis (CF) are categorized as high-risk for COVID-19 due to their underlying respiratory disease and may exhibit symptoms of severe and relapsing COVID infection with prolonged shedding of the virus, according to results of a new study published in the Indian Journal of Pediatrics.

The authors described 2 cases of children with CF who contracted COVID-19 infections: a 9-year-old boy and an 18-month-old toddler. The 9-year-old boy required noninvasive ventilation for several days and the 18-month-old toddler required high-flow nasal oxygen support.

Chest x-rays for the 9-year old demonstrated hyperinflation, mucous plugging, and interstitial shadows, while the 18-month-old exhibited interstitial infiltrates on his chest x-rays. Treatment included remdesivir, hydrocortisone, cefoperazone-sulbactam, and vancomycin, while the toddler received meropenem, vancomycin, and prednisolone.

Both children remained in the hospital with their initial COVID-19 infection for 14 days. At discharge, the 9-year-old still tested positive for COVID-19, while the toddler tested negative.

Within 4 days following initial discharge, the 9-year-old experienced a COVID-19 relapse, returning to the clinic after 20 days of unrelenting symptoms. He still tested positive for COVID-19. In addition to COVID-19, he developed CF-related diabetes, allergic bronchopulmonary aspergillosis, and Escherichia coli. He remained in the hospital for a 10-day course of treatment until discharge following a negative COVID-19 test.

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Similarly, after 34 days following initial discharge, the toddler received antibiotic administration for 10 days for a local pulmonary exacerbation. During this treatment at home, he experienced COVID-19 symptom relapse, leading to clinic readmission. He tested positive for COVID-19 a second time, requiring 14 days of intravenous antibiotics, prednisolone, and noninvasive oxygen therapy. Upon discharge, he tested negative for COVID-19, exhibiting a heightened viral immune response.

Both the boy and the toddler developed pulmonary exacerbations at 3 months following the initial COVID-19 infection. While the boy tested negative for COVID-19, his sputum contained E coli, Klebsiella pneumoniae, and methicillin-resistant Staphylococcus aureus. The toddler’s exacerbation at 3 months was successfully managed in an outpatient setting with oral antibiotics and prednisolone.

The authors had difficulty deducing whether the 18-month-old had COVID-19 reinfection because of the negative test sandwiched between 2 positive tests. In contrast, the 9-year-old exhibited definitive persistent COVID-19 infection. The authors referenced literature that attributed the development of CF-related diabetes in the 9-year-old to the presence of COVID-19 receptors on pancreatic exocrine cells, steroid use, and the stress response due to severe infection.

“Strict preventive measures should be taken to protect children with CF from [COVID-19],” they said. Infection with COVID-19 may result in prolonged symptoms, recurrent pulmonary exacerbations, and secondary pulmonary infections in children who once had well-managed CF.

Reference

Dhochak N, Jat KR, Soni KD, et al. Poor respiratory health following relapsing Sars-Cov-2 infection in children with cystic fibrosis. Indian J Pediatr. Published online January 28, 2022. doi:10.1007/s12098-021-04057-0