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.
This study aimed to establish the medical evidence of abuse by comparing the clinical differences between children with shaken baby syndrome (SBS) who had no signs of trauma and traumatic brain injury (TBI). Methods: Children aged <5 years with intracranial hemorrhage (ICH) were divided into SBS group and TBI group, which was developed because of intentional or accidental trauma including physical violence. We investigated clinical characteristics, ICH and brain injury patterns, funduscopic examinations, and the legal consequences for guardians. Results: Compared to TBI, children with SBS had a higher incidence of neurological symptoms, including seizures (80.0% vs. 15.4%, P=0.001) and mental changes (73.3% vs. 32.5%, P=0.003); they also had a longer time to hospitalization (SBS, 21.8±30.4 hours; TBI, 9.5±21.3 hours; P=0.046). The rate of bilateral ICH was significantly higher in the SBS group (73.3% vs. 19.0%, P=0.001). In the TBI group, the incidence of epidural hemorrhage (EDH) and subdural hemorrhage was equal (42.3%), but EDH was not seen in the SBS group. Multistage ICH (58.3%) and diffusion-limiting lesions (75.0%) were common in SBS, with high mortality and neurological sequelae (86.7%). Nevertheless, only a few guardians (13.3%) were separated from the victim and only one person (6.7%) who confessed to abuse was detained. Conclusion: Children with SBS who have never been affected to external physical forces can have multistage and bilateral ICH with severe brain damage, which is clinically different from TBI. Our data suggest that adequate protection and active legal actions are required in order to protect children who had sufficient characteristics of SBS.
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