key: cord-0700018-190uo02t
authors: Schiff, Jared; Brennan, Courtney
title: Covid-19 presenting as a bulging fontanelle
date: 2021-01-28
journal: Am J Emerg Med
DOI: 10.1016/j.ajem.2021.01.062
sha: 3b4cdcc8a76b4fb76dce6b2057e438a84d03d98f
doc_id: 700018
cord_uid: 190uo02t

The 2019 novel coronavirus disease (COVID-19) has become a global pandemic that has struck the United States particularly hard. While it has disproportionately caused severe illness in the elderly and older adult population, many children have also been infected with the virus and some have become critically ill. It is important to recognize COVID-19 may present differently in children; specifically, those under twelve months of age. We report a case of COVID-19 infection in an infant characterized by a bulging anterior fontanelle without any additional symptoms.

Laboratory investigation included blood, urine, and cerebrospinal fluid collection. The complete blood count was notable for a leukocytosis of 14.34 K/ul with 60.5% lymphocytes and the creactive protein was mildly elevated to 1 mg/dL (full laboratory results provided in appendix). Urinalysis was negative for leukocyte esterase and nitrites. The patient underwent a lumbar puncture. Cerebral spinal fluid (CSF) results showed 30 RBC, 1 WBC, glucose of 49, and protein of 26. CSF gram stain and CSF film array meningitis/encephalitis were negative. She was treated empirically with ceftriaxone and a 20 ml/kg normal saline bolus. CSF and blood cultures remained negative, but urine culture ultimately grew 50-100K E. coli. Computed tomography was performed prior to lumbar puncture, and showed no evidence of intracranial mass, hemorrhage or hydrocephalus. A nasal swab for SARS-CoV-2 was obtained and subsequently resulted positive.

The patient was ultimately discharged home from the emergency department with outpatient follow-up with her primary medical doctor the next day. At the time of discharge, she had reassuring vital signs, an otherwise reassuring physical exam with improvement in her fussiness and oral intake, and no significant concern for sepsis.

We provided a novel presentation of Covid-19 in a less studied but high-risk population: infants. A bulging anterior fontanelle in an infant is a sign of increased intracranial pressure (ICP) or volume and raises concerns for an intracranial process that may require emergent intervention. The differential diagnosis is broad but the most notable causes include hydrocephalus, meningitis, intracranial mass, trauma and intracranial hemorrhage.⁷ If comprehensive evaluation reveals no specific cause, the diagnosis of benign intracranial hypertension may be considered in well-appearing infants. This is defined as "a syndrome of increased intracranial pressure with a normal ventricular system and a cerebrospinal fluid of normal composition." ⁸ Previous cases of benign intracranial hypertension with a bulging fontanelle have been described in the literature. Most cases are associated with viral illnesses including upper respiratory infections and gastroenteritis. Notably, Roseola infantum, caused by human herpesvirus 6 is a common etiology. Other etiologies such as otitis media and postvaccination status have also been described.⁹⁻ ¹ 5 In rare cases a specific etiology may not be found and may be considered idiopathic. In one study, the final diagnosis of pyelonephritis was made in 4 infants presenting with a bulging fontanelle. 15 However, unlike in our patient, these patients had evidence of pyuria on initial laboratory investigation, making the E. coli urinary tract infection in this patient a less likely cause of the bulging fontanelle. To our knowledge, there have been no previously reported cases of infants with SARS-CoV-2 infection presenting with a bulging fontanelle. Given that many cases of benign intracranial hypertension of infancy have a viral etiology, we suspect SARS-CoV-2 to be the etiology in our patient. This case showed that SARS-CoV-2 can have a novel presentation in infants. The rapid spread and severity of COVID-19 requires identifying all possible clinical features to help identify possible sources and prevent transmission. Therefore, we suggest consideration of SARS-CoV-2 testing as part of the evaluation of infants presenting to the emergency department with a bulging fontanelle. 

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