key: cord-0902417-rynom6e1
authors: Hariharan, Sankar Vaikom; Muthusamy, Sahana; Asokan, Santhosh Kumar
title: Persistent Viral Shedding after SARS-CoV-2 Infection in an Infant with Severe Combined Immunodeficiency
date: 2021-09-03
journal: Indian J Pediatr
DOI: 10.1007/s12098-021-03935-x
sha: ddc6e9d25e0659dba1c73d743b40ed06350e875e
doc_id: 902417
cord_uid: rynom6e1

nan

To the Editor: A 5-mo-old female child born to third degree consanguineous parents presented with recurrent fever episodes for 1 mo. She was a full term born baby with birth weight 2.54 kg, adequate immunization, and no undernutrition (weight -6 kg, length -64 cm). She had recurrent oral thrush and ulcers for 3 mo. On examination, pallor, oral thrush, and hepatosplenomegaly were noted. Investigations revealed high ESR with hilar prominence in chest radiograph. Gastric aspirate CBNAAT for tuberculosis became positive. COVID-19 antigen test and RT-PCR were positive. Antitubercular drugs were started and she was discharged once clinically improved.

Within a few days, she was readmitted with high-grade fever, vomiting, and loose stools with increasing hepatosplenomegaly. COVID-19 antigen test was persistently positive even after 30 d. Investigations showed neutrophilic leucocytosis with markedly elevated inflammatory markers, transaminitis, hyponatremia, hypoalbuminemia, and negative COVID-19 antibody. Second-line inflammatory markers were also elevated with aneurysm in left main coronary artery. She was diagnosed with multisystem inflammatory syndrome in children and was treated with intravenous immunoglobulins and anticoagulants.

In view of high fever spikes, chronic oral candidiasis, protracted diarrhoea, mycobacterial infection, and persistent viral shedding, she was screened for immunodeficiency, which showed low IgM/IgA and reduced T-cell markers suggestive of T-B+NK+SCID. A pathogenic homozygous nonsense variation in exon 3 of the IL7R gene confirmed the diagnosis. The patient is showing persistence of viral shedding even after 180 d of infection.

Despite defective adaptive immunity, children with SCID can present with dysregulated hyperimmune response [1] .

The median duration of viral RNA shedding after coronavirus infection is 15 d, ranging from 5-37 d [2] . However, viral shedding from the upper respiratory tract is prolonged in immunosuppressed postrenal transplant recipients [3] . Prolonged viral shedding even after 180 d in a child with SCID indicates the need for prolonged protective measures for immunocompromised patients.

Severe multi-system presentation of COVID-19 in a four-month-old infant with severe combined immunodeficiency and hemophagocytic lymphohistiocytosis

Symptomatic infection is associated with prolonged duration of viral shedding in mild coronavirus disease 2019: a retrospective study of 110 children in Wuhan

In-depth virological assessment of kidney transplant recipients with COVID-19