Patient 1 is a 14-year-old boy (weight 50 kg) affected by celiac disease, whose mother tested positive for SARS-CoV-2. The boy presented with a 12-day history of mild dry cough and low-grade fever; SARS-CoV-2 was detected by means of real-time polymerase chain reaction (RT-PCR) on nasopharyngeal swab, and the patient was referred to our hospital because of persisting fever. At admission, general conditions were good, oxygen saturation level was 98% on room air, and body temperature was normal. Blood examinations, chest X-ray, and electrocardiogram (EKG) were normal. On day 2, SARS-CoV-2 RT-PCR was negative on nasopharyngeal and conjunctival swabs and on fecal and urine samples and was repeated every 72 h with the same results (Table 1).
On day 4 after admission, he developed fever (39.5 C), abdominal pain, and diarrhea. Lung CT scan and echocardiography were normal. Due to persisting gastrointestinal symptoms, abdominal ultrasound, and CT scan were performed and showed widespread thickening of the distal loops of the small intestine with a small amount of ascitic fluid. Due to the worsening of general conditions, the boy was admitted in our pediatric intensive care unit (PICU). Bone marrow biopsy showed neither hematologic malignancies nor activated macrophages. Colonscopy with retrograde ileoscopy showed no macroscopic lesion. Histological examination of multiple intestinal biopsies showed minimal inflammatory infiltrates. SARS-CoV-2 PCR was positive on ileum biopsy. Serological test showed SARS-CoV-2 IgA 1:160, IgG 1:80, and IgM 1:40. Microbiological workout was negative, including blood, throat, sputum, urine, and stool culture; respiratory and stool viral panel, blood viral panel including human immunodeficiency virus, hepatitis B virus, hepatitis C virus, cytomegalovirus, Epstein-Barr virus, parvovirus B19, herpes simplex virus 1 and 2, human herpes virus 6 and adenovirus, and interferon gamma release assay (QuantiFERON -TB gold).
On day 9, blood chemistry showed a significant increase of inflammatory markers, D-dimers, and troponin T, associated with lymphopenia (Table 2). Treatment with methylprednisolone 2 mg/kg/day and anakinra 100 mg q6h i.v. was started; in addition, the child was given treatment with lopinavir/ritonavir 400 mg q12h and broad spectrum antibiotics plus low molecular weight heparin (LMWH) 100 UI/kg q12h. Twenty-four hours later, fever disappeared and general conditions significantly improved.