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Death of child infected with Covid-19, 2 other viruses a rare case: Docs

The death of a 1½-year-old baby boy from encephalitis, or brain inflammation, after being infected with Covid-19 and two other viruses is extremely rare, doctors said.

The Ministry of Health (MOH) said in a statement on Monday (June 27) that it was Singapore's first Covid-19 death of a patient below the age of 12. The cause of death was encephalitis due to Covid-19, respiratory syncytial virus and enterovirus infections, it said.

Respiratory syncytial virus is a common respiratory virus that may cause mild, cold-like symptoms.

"While most cases are mild, severe respiratory syncytial virus can cause bronchiolitis (inflammation of the small airways in the lung) and pneumonia (infection of the lungs) in younger children," said Associate Professor Thoon Koh Cheng, a senior consultant, infectious disease service at the paediatrics department in KK Women's and Children's Hospital (KKH).

Enterovirus is a common childhood illness which may cause fever, mild respiratory, flu-like and gastrointestinal symptoms, Prof Thoon said. "In some rare cases, complications such as inflammation of the brain, spinal cord or heart may occur," he added.

Dr Yeo Tong Hong, a senior consultant and the head of neurology service at KKH, said that encephalitis may initially present with flu-like symptoms such as fever, general lethargy or headache. These flu-like symptoms can become more severe in some cases, which can lead to confusion, drowsiness, seizures or problems with breathing and heart muscle function.

"Encephalitis can be caused either by an infection invading the brain (infectious encephalitis) or through the immune system attacking the brain (autoimmune or post-infectious encephalitis)," he said.

"Viruses are the most common cause of infectious encephalitis, and it has also been reported to occur as a complication of Covid-19 infection. However, this is rare."

Professor Paul Tambyah, speaking as president of the Asia Pacific Society of Clinical Microbiology and Infection, said: "There have been isolated, extremely rare cases of encephalitis with Sars CoV-2 in adults mainly, but also in children. In contrast, the enteroviruses are well known as episodic causes of encephalitis."

He added: "The chances of being infected with three viruses at the same time are very low and suggest that there may be some rare immunological problem which might have predisposed this unfortunate infant to severe complications."

MOH said the baby had no past medical history. He was taken to the emergency department at KKH on the night of June 21, with a high fever and recurrent seizures, and subsequently began to lose consciousness.

He was then admitted to the Children's Intensive Care Unit in critical condition on June 22, and was diagnosed with severe meningoencephalitis.

The United Nations Children's Fund cited data that showed that 0.4 per cent of the 4.4 million reported Covid-19 deaths occurred in children and adolescents below the age of 20.

Prof Tambyah said this is much lower than the proportion of deaths from malaria or influenza that occur in children, for example, which shows just how rare Covid-19 deaths among children are.

"This (data) suggests that the children who do die from Covid-19 have some unusual rare predisposing cause, which needs to be investigated," he said.

"For the rest of the children, the disease is overwhelmingly mild, and simple basic health hygiene practices should suffice. Children should be taken to the doctor if unwell or if parents are concerned."

Most children with Covid-19 will do well, but a few may have worsening of their underlying asthma or develop wheeze or have seizures, he said.

Febrile seizures can occur with a number of viral infections and there are some useful materials online which can be tapped, for example, the online health information on this provided by the National University Hospital, he said.

Dr Lim Yang Chern, a paediatrician from Thomson Paediatric Centre, said the death of the infant was unlikely the "fault" of Covid-19 alone.

Without details of the case, he feels that it was likely due to the combination of multiple viral infections - the biggest suspects being the enterovirus and the coronavirus - and the resultant immune response that contributed or caused the severe encephalitis that then led to the demise of the child.

Prof Thoon said the majority of paediatric patients with Covid-19 show typical symptoms that are similar to adults, including fever, respiratory tract infection symptoms like cough or runny nose, vomiting, diarrhoea, sore throat, anosmia (loss of sense of smell), muscle pain and lethargy.

"Complications among paediatric Covid-19 cases are rare. Some examples include pneumonia, myocarditis (heart muscle inflammation) and inflammation of brain and spine."

He said children should get the Covid-19 vaccine when it is nationally recommended, in order to get protection from the coronavirus and also to reduce the risk of complications if they do get infected. This is apart from keeping up with public health measures, such as wearing surgical masks where possible.

"Should children develop worsening symptoms of persistent fever, lethargy or drowsiness, persistent cough, breathlessness, chest pain, poor oral intake, poor urine output or seizures, they should be seen by their doctor," said Prof Thoon.

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