key: cord-0914525-5hqdaey2
authors: Marits, Ann Katrine; Fischler, Björn; Chromek, Milan
title: Paediatricians face challenging times as COVID‐19 can cloud other diagnoses and lead to treatment delays
date: 2020-12-29
journal: Acta Paediatr
DOI: 10.1111/apa.15725
sha: 8455b4c6409026e3a937bec9579d42cba5cdf4ac
doc_id: 914525
cord_uid: 5hqdaey2

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has posed major challenges for healthcare professionals worldwide, as the clinical picture of this newly discovered human pathogen is diverse. Sometimes, it leads to mild or severe forms of COVID-19 and a prolonged disease has been reported. It can also trigger multisystemic inflammatory syndrome in children (MIS-C) (1).

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has posed major challenges for healthcare professionals worldwide, as the clinical picture of this newly discovered human pathogen is diverse. Sometimes, it leads to mild or severe forms of COVID-19 and a prolonged disease has been reported. It can also trigger multisystemic inflammatory syndrome in children (MIS-C). 1 So far, one and a half million deaths have been reported worldwide. Unfortunately, this overwhelming health problem can also cause indirect damage, because other medical problems can be overlooked, or missed. 2 We describe a previously healthy 16-year-old girl who presented to our paediatric emergency department (PED) with fever, headache and back pain.

She had a history of recurrent urinary tract infections and she suffered an episode of dysuria two weeks before she presented to the PED. However, this disappeared after drinking plenty of cranberry juice. A week later, she started having fever, left-sided flank pain, vomiting and generally felt unwell. She was examined by a nasopharynx swab and underwent polymerase chain reaction testing for SARS-CoV-2, but the result was negative. Her family doctor suspected pyelonephritis and referred her to the PED.

On arrival, she appeared pale and tired and her temperature was 38°C. On physical examination, she had a tender upper abdomen and percussion tenderness at the left flank region. The pain improved after she was given ibuprofen. Blood tests showed high C-reactive protein (272 mg/L), but a normal white blood cell count (9.6 × 10 9 /L), normal neutrophil count (7.1 × 10 9 /L) and normal platelets (203 × 10 9 /L). She had a low plasma level of potassium (2.9 mmol/L), but normal sodium (135 mmol/L) and creatinine (59 µmol/L). Her urinary dipstick showed 1+ for protein, 2+ for haemoglobin as she was menstruating, but was negative for nitrite and leucocyte esterase.

The girl's Doppler ultrasound showed reduced perfusion of one kidney. A chest X-ray was also performed, but it did not show any pathology. The patient received the working diagnosis of MIS-C, mainly due to her high C-reactive protein level and was admitted for observation, without antibiotics, and with a preliminary plan to proceed with anti-inflammatory treatment for MIS-C. Additional When her temperature started to rise to 39°C shortly after admission, intravenous cefotaxim treatment was instigated. However, the first dosage was given more than 12 hours after her presentation to the PED. When the culture from her mid-stream urine sample came back the next day, it showed a significant growth of Escherichia coli (>10 5 colony-forming units/mL), which supported the diagnosis of a urinary tract infection. The patient recovered rapidly with intravenous antibiotics and was switched to oral treatment after a couple of days. Dimercaptosuccinic acid scintigraphy was performed seven days after admission and this showed decreased uptake of the isotope in the left kidney, with a reduction in the relative function of the left kidney, which was 43% compared to the 57% in the right kidney. This confirmed pyelonephritis (Figure 1 ). This paper describes a typical clinical picture of pyelonephritis, which was initially missed or confused with MIS-C. This led to a delay in antibiotic treatment, but with a seemingly good outcome for the patient. Although our patient's history may be quite common, with caution. It is important to bear COVID-19 in mind, but it is equally important not to let it cloud other diagnoses. 

Multisystem inflammatory syndrome in U.S. children and adolescents

Delayed diagnosis of paediatric appendicitis during the COVID-19 pandemic

Urinary tract infection. Why do some children get complications, while others dont?

The urine dipstick test useful to rule out infections. A meta-analysis of the accuracy

99mTechnetium-dimercaptosuccinic acid scan in the diagnosis of acute pyelonephritis in children: relation to clinical and radiological findings