Grand Rounds

Differential Diagnostic Challenges During the Covid-19 Pandemic for Pediatricians in an Eastern European Country

Szofia Hajósi-Kalcakosz1, Borbála Zsigmond1, Andrea Párniczky2, Réka Bodnár2
1Department of Infectious Diseases, Heim Pál Children's Hospital, Budapest, Hungary, 2Cystic Fibrosis Outpatient Care Unit, Heim Pál Children's Hospital, Budapest, Hungary

Address for Correspondence: Szofia Hajósi-Kalcakosz, Heim Pál Children’s Hospital, 1089, Ülloi Street 86., Budapest, Hungary. Email:

Keywords: Covid-19, SARS-CoV-2, cystic fibrosis, newborn screening

Clinical Problem:
A two-year-old girl was admitted to a local hospital in Hungary in March 2020 with fever, difficulty in breathing and one week history of coughing. She had chronic cough, frequent respiratory illnesses, and inability to gain weight since infancy. Due to her present respiratory symptoms, a SARS-CoV-2 PCR test was carried out and the result was positive, therefore she was transferred to our hospital. On presentation to us, she had tachypnea (respiratory rate: 58/min), wheezing, lung crackles, hepatomegaly and clubbing of the fingers. Her oxygen saturation was 95% on 3 L/min oxygen flow with the nebulizing mask. She was malnourished according to the Hungarian longitudinal growth chart: body weight: 9.8 kg (3rd percentile), height: 88 cm (50th percentile), body mass index 12.65 kg/m2 (<3rd percentile, Z score = -1.99). Laboratory evaluation showed high white blood cell count (27,820 cells/cumm) with neutrophilia (23,600 cells/cumm). Shortly after admission her work of breathing significantly increased, therefore high flow nasal cannula (HFNC) oxygen therapy was implemented. Despite the frequent use of bronchodilators and steroids, wheezing did not improve. On the 10th day of her illness, nasopharyngeal swab for SARS-CoV-2 by PCR was positive. At that time the CRP was in the normal range (CRP 1.65 mg/L), white blood cell count was slightly elevated (17,960 cells/cumm). Other inflammatory markers were not measured.
The PCR result was a surprise as the case did not fulfill the environmental criteria of Covid-19 infection. First of all, the girl came from the rural part of Eastern Hungary where the number of confirmed Covid-19 cases were extremely low, and secondly, no one in the family was confirmed to be positive either. Hence, nasopharyngeal swab for SARS-CoV-2 by PCR was repeated and SARS-CoV-2 IgM was taken. All the tests were found to be negative, therefore we excluded the diagnosis of Covid-19. On day 10 after admission, she was transferred to the Pediatric Intensive Care unit for invasive ventilation due to further respiratory distress on HFNC. She required 10 days of mechanical ventilation. Due to the worsening clinical picture, high resolution computed tomography was performed, which revealed bronchial wall thickening, mucus plugging and bronchiectasis. (Figure 1).

Figure 1. Chest CT: Peribronchial thickening, mucus plugging and severe bronchiectasis in the lungs

Is this COVID-19 infection in the girl?

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