Hematuria Associated With SARS-CoV-2 Infection in a Child

Abstract

To the Editors: Despite the fact that respiratory symptoms are the predominant presentation of COVID-19 among symptomatic infected patients, it is important to emphasize that multiple organ involvement including the gastrointestinal tract, central nervous system, cardiovascular system, liver, bone marrow and kidney have already been reported in patients infected with SARS-CoV-2.1 Herein we describe a case of SARS-CoV-2 infection presenting with hematuria along with respiratory symptoms in a child. A 10-year-old Caucasian female child, previously healthy, was admitted to the emergency department with a one-day history of fever (38°C), mild respiratory symptoms (cough and sore throat) and gross hematuria. Her physical examination was unremarkable. Urinalysis showed the presence of normally shaped red blood cells and renal ultrasound showed no abnormalities. Renal function was normal. The child was in quarantine, away from social contact for 2 weeks, due to the COVID-19 pandemic confinement measures imposed in the City of Sao Paulo. However, her parents are medical doctors, seeing patients with COVID-19. Therefore, real-time reverse transcriptase-polymerase chain reaction (RT-PCR) tests for SARS-CoV-22 were carried out using a panel of validated in-house singleplex real-time (RT-PCR) assays developed at the Centers for Disease Control and Prevention, Atlanta, GA, USA, for 15 respiratory viruses, including: influenza A and B virus; coronavirus NL63, 229E, HKU1and OC43; enterovirus; parainfluenza virus 1, 2, 3 and 4; human metapneumovirus; rhinovirus; respiratory syncytial virus; and adenovirus3 on nasopharyngeal swabs and a RT-PCR test for SARS-CoV-2 in urine. The child did not have any other febrile episode after the third day of symptoms and a progressive improvement of the hematuria, that subsided after five days, was observed. Three days after the onset of symptoms of the child her mother started with fever, dry cough, sore throat and fatigue. Nasopharyngeal swabs from both parents (the mother, that was symptomatic and the father, asymptomatic at that moment) were collected. All nasopharyngeal swabs specimens were positive for the detection of SARS-CoV-2 RNA and negative for all other respiratory viruses. The urine sample was negative for SARS-CoV-2 RNA. On day 7 after the onset of symptoms, RT-PCR for the detection of SARS-CoV-2 RNA in nasopharyngeal swabs were still positive in the child as well as her parents. Nasopharyngeal samples repeated on day 21 were all negative. Hematuria and renal injury have been commonly described in viral respiratory infections including influenza A and B, adenovirus and other pathogens. Kidney injury in adults hospitalized with COVID-19 appears to be a frequent finding, with a wide range of manifestations, from mild hematuria to severe renal failure. The pathogenesis of the renal injury is probably multi-factorial, including direct cytopathic effects of the virus, immune-complexes mediated damage, as well as indirect effects on renal tissue, such as hypoxia, shock, and rhabdomyolysis, due to the cytokine inflammatory response to the virus.4 A plausible explanation for the multi-organ manifestations of COVID-19 is the finding that angiotensin-converting enzyme 2, the receptor for SARS-CoV-2 and responsible for host cell entry and subsequent viral replication in humans, is broadly expressed in the alveolar epithelial cells, the myocardium, the endothelium, the gastrointestinal tract, bone marrow, kidneys among other tissues.5 One of the most striking features of COVID-19 is the overwhelmingly lower risk of severe forms of disease in children, when compared with older age groups.6 To date, we are not aware of reported cases of renal complications in children with COVID-19. Although the child described in this letter had a mild manifestation with a good outcome, pediatricians should be aware of these presentations in children, particularly among infants and children with underlying renal conditions, theoretically prone to more severe complications. Consent: Written informed consent was obtained from the parents and from the patient for the publication of this letter. Flávia Jacqueline Almeida, MD, PhDDepartment of PediatricsSanta Casa de São Paulo School of Medical SciencesSão Paulo – SP, Brazil Rodrigo Diaz Olmos, MD, PhDDepartment of Internal MedicineUniversity HospitalSchool of MedicineUniversity of Sao PauloSão Paulo – SP, Brazil Danielle Bruna Leal Oliveira, PhDCairo Oliveira Monteiro, MsCLuciano Matsumiya Thomazelli, PhDEdison Luiz Durigon, PhDLaboratory of Molecular and Clinical VirologyDepartment of MicrobiologyInstitute of Biomedical SciencesUniversity of São PauloSão Paulo – SP, Brazil Marco Aurélio Palazzi Sáfadi, MD, PhDDepartment of PediatricsSanta Casa de São Paulo School of Medical SciencesSão Paulo – SP, Brazil

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