Two Case Reports of Life-Threatening Croup Caused by the SARS-CoV-2 Omicron BA.2 Variant in Pediatric Patients

Abstract

Croup is a common upper airway infection characterized by a barking cough, stridor, and hoarseness. It is usually caused by viral infection. A small number of croup caused by coronavirus disease 2019 (COVID-19) has been reported in children before the omicron variant surge. Previously reported cases indicated that croup caused by COVID-19 can be treated in the same manner as those with other viral causes. We describe two cases (9-month-old girl and 11-month-old boy) of previously healthy infants who presented with a barking cough and chest retraction and required endotracheal intubation and cardiopulmonary resuscitation. Despite receiving dexamethasone and nebulized racemic epinephrine (NRE) treatment for croup in the emergency department, these patients still developed acute respiratory failure. Reverse transcription polymerase chain reaction (RT-PCR) of nasopharyngeal samples revealed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) omicron BA.2 variant (Stealth omicron) and no other common respiratory viral pathogens. Both patients were treated with mechanical ventilation, dexamethasone, and NRE in the pediatric intensive care unit. The duration of intubation was 112 hours and 80 hours, respectively. Both patients were discharged without complications. To the best of our knowledge, this is the first report of life-threatening croup produced by the omicron BA.2 variant and confirmed by RT-PCR. We suggest that this SARS-CoV-2 variant may cause severe croup that may not improve with conventional treatment, even in children without underlying diseases.

COVID-19–Associated Hospitalizations Among U.S. Infants Aged <6 Months — COVID-NET, 13 States, June 2021–August 2022

“…COVID-19-associated hospitalization rates are highest among adults aged ≥65 years (1); however, COVID-19 can and does cause severe and fatal outcomes in children, including infants (2,3). After the emergence of the SARS-CoV-2 B.1.1.529 (Omicron) BA.1 variant in December 2021, hospitalizations among children aged <5 years, who were ineligible for vaccination, increased more rapidly than did those in other age groups (4).…”

Case Report of COVID-19 and Pneumocystis coinfection in a pediatric patient with a history of receiving high dose steroid therapy

“…Although the majority of children that contract COVID-19 appear to have milder disease courses and a better prognosis than adults, a small number of patients may experience a severe and life-threatening disease progression [ 3 , 4 ]. Chronic lung disease, neurologic disease, cardiovascular disease, prematurity, airway abnormality, feeding tube dependence, diabetes, and obesity have been associated with severe COVID-19 in hospitalized children [ 4 ].…”

Severe pediatric COVID-19: a review from the clinical and immunopathophysiological perspectives

“…Physicians should also be kept aware of COVID-19-related croup [ 34 ] that has shown increased incidences with Omicron variants [ 35 , 36 ], manifests as vocal hoarseness, stridor, wheezing, or lung rales [ 34 , 37 , 38 ], and in critical cases may require endotracheal intubation and cardiopulmonary resuscitation, although COVID-19-associated croup is treated similarly to other viral causes of croup and respiratory distress is generally uncommon [ 39 ].…”