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Id Subject Object Predicate Lexical cue
T1 0-67 Sentence denotes COVID-19 Infection Presenting With Cheilitis and Fever in a Toddler
T2 69-77 Sentence denotes Abstract
T3 78-271 Sentence denotes Coronavirus disease 2019 (COVID-19) is a newly found infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), first observed in Wuhan, China, in December 2019.
T4 272-510 Sentence denotes An otherwise healthy 13-month-old male presented with persistent fever and cheilitis as his initial findings of COVID-19 in April 2020 prior to the discovery and classification of the multisystem inflammatory syndrome in children (MIS-C).
T5 511-688 Sentence denotes Clinical symptoms of COVID-19 are still evolving in the pediatric population, ranging from being asymptomatic to varied symptoms, such as fever, abdominal pain, and myocarditis.
T6 689-763 Sentence denotes Other manifestations such as conjunctivitis and cheilitis can offer clues.
T7 764-855 Sentence denotes We speculate that cheilitis can be a sign of the hyperinflammatory state, as seen in MIS-C.
T8 857-869 Sentence denotes Introduction
T9 870-1067 Sentence denotes According to the American College of Emergency Physicians, fever is the most commonly encountered chief complaint to the emergency department in the United States, accounting for 15% of visits [1].
T10 1068-1238 Sentence denotes The recent outbreak of coronavirus disease 2019 (COVID-19) in the US and across the world has resulted in global catastrophe with innumerable deaths and hospitalizations.
T11 1239-1346 Sentence denotes COVID-19 is asymptomatic in a number of children, and its varied manifestations are still being elucidated.
T12 1347-1430 Sentence denotes Cheilitis has not been previously described as a clinical presentation of COVID-19.
T13 1431-1514 Sentence denotes Cheilitis refers to the inflammation of the lips causing a dry, cracked appearance.
T14 1515-1587 Sentence denotes It is found on the peri-oral region, vermilion border, or labial mucosa.
T15 1588-1750 Sentence denotes There are many different types of this condition, such as cheilitis simplex, angular, contact, exfoliative, drug-induced, actinic, glandular, and plasma cell [2].
T16 1751-2075 Sentence denotes The most common type is cheilitis simplex that is characterized by the dry, cracked appearance with peeling of the lips, which occurs due to a lack of moisture due to excessive lip licking or smacking [3]. We describe a patient with fever and cheilitis diagnosed with clinical pneumonia in the setting of COVID-19 infection.
T17 2077-2094 Sentence denotes Case presentation
T18 2095-2271 Sentence denotes A 13-month-old male presented to our pediatric emergency department (ED) in early April 2020 with the chief complaint of fussiness, decreased appetite, and fever for five days.
T19 2272-2366 Sentence denotes His mother reported that there was no resolution of his fever despite the use of antipyretics.
T20 2367-2492 Sentence denotes At the presentation time, his mother denied cough, runny nose, ear pulling, shortness of breath, rash, vomiting, or diarrhea.
T21 2493-2549 Sentence denotes She reported no recent travel nor sick contacts at home.
T22 2550-2684 Sentence denotes Social history was remarkable for crowded and close living conditions, with five other family members sharing a two-bedroom apartment.
T23 2685-2815 Sentence denotes The patient remained isolated at home since the pandemic began, but other family members had been out of the house for groceries. 
T24 2816-2922 Sentence denotes He was nontoxic on physical exam, appearing but fussy and febrile with a temperature of 102.7°F (Table 1).
T25 2923-3034 Sentence denotes Physical exam was remarkable for dry, cracked lips with fissuring along the vermilion border and labial mucosa.
T26 3035-3142 Sentence denotes His mucous membranes were dry, and there was pharyngeal erythema without exudates or tonsillar hypertrophy.
T27 3143-3191 Sentence denotes The chest was clear to auscultation bilaterally.
T28 3192-3313 Sentence denotes The patient had no conjunctivitis, lymphadenopathy, hepatosplenomegaly, nor edema or rash on the trunk, hands, and feet. 
T29 3314-3362 Sentence denotes Table 1 Vital signs of the patient on admission
T30 3363-3405 Sentence denotes Vital signs Patient Normal range for age
T31 3406-3440 Sentence denotes Temperature 102.7° F 95-100.3° F
T32 3441-3498 Sentence denotes Heart rate 172 beats per minute 80-130 beats per minute
T33 3499-3550 Sentence denotes Respiratory rate 32 breaths/min 40-60 breaths/min
T34 3551-3784 Sentence denotes Oxygen saturation on room air 98% 94-100% Laboratory findings showed a negative respiratory viral panel, a normal complete blood count (CBC) with lymphocytic predominance (Table 2), elevated C-reactive protein (CRP) of 25.81 mg/dL.
T35 3785-3916 Sentence denotes The comprehensive metabolic panel (CMP) revealed metabolic acidosis with a normal anion gap with ketones present in the urinalysis.
T36 3917-4062 Sentence denotes We obtained blood and urine cultures, and the patient was admitted and started empirically on ceftriaxone, antipyretics, and intravenous fluids. 
T37 4063-4107 Sentence denotes Table 2 Complete blood count of the patient
T38 4108-4341 Sentence denotes WBC - white blood cells; RBC - red blood cells; Hgb - hemoglobin; Hct - hematocrit; MCV - mean corpuscular volume; MCH - mean corpuscular hemoglobin; MCHC - mean corpuscular hemoglobin concentration; RDW - red cell distribution width
T39 4342-4411 Sentence denotes Complete blood count Result Reference range (for patient age) Unit
T40 4412-4439 Sentence denotes WBC 7.7 6.0-17.5 x 109/L
T41 4440-4468 Sentence denotes RBC 4.46 3.8-5.4 x 10¹²/L
T42 4469-4494 Sentence denotes Hgb 11.4 13.1-15.5 g/L
T43 4495-4514 Sentence denotes Hct 35 39-47 L/L
T44 4515-4537 Sentence denotes MCV 77 72.0-88.0 fL
T45 4538-4556 Sentence denotes MCH 26 26-34 ρg
T46 4557-4580 Sentence denotes MCHC 329 320-360 g/L
T47 4581-4604 Sentence denotes RDW 12.9 11.5-16.0 %
T48 4605-4636 Sentence denotes Platelet 357 130-400 x 109/L
T49 4637-4670 Sentence denotes Neutrophil 2.5 1.5-8.5 x 109/L
T50 4671-4704 Sentence denotes Lymphocytes 3.9 3-13.0 x 109/L
T51 4705-4737 Sentence denotes Monocytes 1.1 0.1-1.9 x 109/L
T52 4738-4770 Sentence denotes Basophils 0.2 0.0-0.3 x 109/L
T53 4771-5007 Sentence denotes Eosinophils 0 0.0-1.5 x 109/L Due to persistent fever, a chest X-ray (CXR) was ordered, which showed bilateral interstitial infiltrates more prominent on the right peri-hilar area, which could represent atypical pneumonia (Figure 1).
T54 5008-5047 Sentence denotes Urine and blood cultures were negative.
T55 5048-5208 Sentence denotes However, the severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) polymerase chain reaction (PCR) was positive 24 hours after admission to the hospital.
T56 5209-5362 Sentence denotes The patient was subsequently started on azithromycin for clinical suspicion of atypical pneumonia related to COVID-19, correlating with the CXR findings.
T57 5363-5466 Sentence denotes The fever subsided after the first day of antibiotics, and the cheilitis improved during the admission.
T58 5467-5641 Sentence denotes The patient was discharged home with isolation guidelines and completed five days of azithromycin and seven days of amoxicillin clavulanate for suspected clinical pneumonia. 
T59 5642-5785 Sentence denotes Figure 1 Portable CXR: bilateral interstitial infiltrates more prominent on the right perihilar area, which could represent atypical pneumonia
T60 5786-5803 Sentence denotes CXR - chest X-ray
T61 5805-5815 Sentence denotes Discussion
T62 5816-5931 Sentence denotes COVID-19 is a novel viral illness caused via close contact, respiratory droplets, and aerosolized particles [4, 5].
T63 5932-6081 Sentence denotes In the review of the current literature, children appear to display milder clinical manifestations for COVID-19 compared to the adult population [6].
T64 6082-6276 Sentence denotes More recently, SARS-CoV-2 virus infections have been associated with Kawasaki like illness with a hyperimmune state and described as a multisystem inflammatory syndrome of children (MIS-C) [7]. 
T65 6277-6465 Sentence denotes The Centers for Disease Control and Prevention (CDC) noted that 56% of laboratory-confirmed COVID-19 pediatric cases presented with fever, 54% with cough, and 13% with shortness of breath.
T66 6466-6590 Sentence denotes Other associated findings are gastrointestinal symptoms, including abdominal discomfort, nausea, vomiting, and diarrhea [8].
T67 6591-6836 Sentence denotes Laboratory COVID-19 confirmed pediatric cases can show normal total white blood cell counts with lymphopenia, elevated liver enzymes, lactate dehydrogenase, C-reactive protein, erythrocyte sedimentation rates, and pro-calcitonin levels [9, 10]. 
T68 6837-6936 Sentence denotes Pediatric cases of persistent fever and cheilitis often coincide in children with Kawasaki disease.
T69 6937-7132 Sentence denotes Other associated signs and symptoms are bilateral non-exudative conjunctivitis, cervical lymphadenopathy, mucositis, polymorphous rash, and edema of the hands and feet, all absent in our patient.
T70 7133-7321 Sentence denotes At the time of our literature review, there have been 15 reported cases of atypical, typical, and incomplete Kawasaki like disease in children in the New York State as of April 29th, 2020.
T71 7322-7458 Sentence denotes Over 50% of these patients with MIS-C presented in shock and required blood pressure support, while 33% required mechanical ventilation.
T72 7459-7523 Sentence denotes As of the date of this article, no fatalities were reported [7].
T73 7524-7630 Sentence denotes The exact mechanism of COVID-19 infection and this new multisystem inflammatory syndrome remains unclear. 
T74 7631-7882 Sentence denotes As of April 2020, the World Health Organization (WHO) noted that 80% of confirmed COVID-19 positive pediatric patients displayed mild symptoms such as fever, non-productive cough, and fatigue and often recovered without requiring hospitalization [11].
T75 7883-7982 Sentence denotes This patient presented with fever without an apparent source prompting a partial workup for sepsis.
T76 7983-8074 Sentence denotes The patient required hospitalization for continued diagnostic workup and empiric treatment.
T77 8075-8162 Sentence denotes This patient did not develop any respiratory complications from his COVID-19 infection.
T78 8163-8372 Sentence denotes It is important to now consider COVID-19 as a potential differential diagnosis in addition to routine sepsis workup in pediatric patients presenting with persistent fever without a defined source of infection.
T79 8373-8523 Sentence denotes Occult infectious etiologies such as bacteremia, urinary tract infection, and meningitis, should not be discounted for patients with persistent fever.
T80 8524-8677 Sentence denotes Acute cheilitis may be another manifestation of COVID-19, and the occurrence of this finding in febrile children should raise the suspicion of COVID- 19.
T81 8678-8788 Sentence denotes We suggest testing for COVID-19 for febrile children presenting with cheilitis that is otherwise unexplained. 
T82 8790-8801 Sentence denotes Conclusions
T83 8802-9002 Sentence denotes New evidence suggests that more severe presentations associated with COVID-19 are emerging in pediatric patients, MIS-C, which can present with a prolonged history of fever, along with other criteria.
T84 9003-9194 Sentence denotes In cases where children present with prolonged fever of unknown origin, they should continue to receive a workup for sepsis in addition to considering COVID-19 infection during this pandemic.
T85 9195-9247 Sentence denotes MIS-C should be also be considered as a possibility.
T86 9248-9314 Sentence denotes Cheilitis may be a new sign or clinical manifestation of COVID-19.
T87 9315-9469 Sentence denotes Although the occurrence of cheilitis has not been well described in the current COVID-19 literature, more research is needed to investigate this finding. 
T88 9471-9531 Sentence denotes The authors have declared that no competing interests exist.
T89 9532-9544 Sentence denotes Human Ethics
T90 9545-9600 Sentence denotes Consent was obtained by all participants in this study.
T91 9601-9648 Sentence denotes Institutional Review Board issued approval n/a.
T92 9649-9685 Sentence denotes Project Title: [1596595-1] COVID-19:
T93 9686-9762 Sentence denotes An unusual cause of fever and cheilitis in an infant Principal Investigator:
T94 9763-9796 Sentence denotes Adebayo Adeyinka Submission Type:
T95 9797-9824 Sentence denotes Publication Date Submitted:
T96 9825-9854 Sentence denotes April 21, 2020 Document Type:
T97 9855-9899 Sentence denotes Acknowledgement Letter Document Description:
T98 9900-9936 Sentence denotes Acknowledgement Letter Publish Date:
T99 9937-10010 Sentence denotes May 1, 2020 Should you have any questions you may contact Twyla Tate at .