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01-12-2021 | Shock | Research article

The severity and atypical presentations of COVID-19 infection in pediatrics

Authors: Nagwan Y. Saleh, Hesham M. Aboelghar, Sherif S. Salem, Reda A. Ibrahem, Fatma O. Khalil, Ahmed S. Abdelgawad, Asmaa A. Mahmoud

Published in: BMC Pediatrics | Issue 1/2021

Abstract

Background

Emergence of 2019-nCoV attracted global attention and WHO declared COVID-19 a public health emergency of international concern. Therefore we aimed to explore the severity and atypical manifestations of COVID-19 among children.

Methods

This is an observational cohort study conducted on 398 children with confirmed COVID-19 by using real-time reverse transcriptase polymerase chain reaction assay for detection of 2019-nCoV nucleic acid during the period from March to November 2020. Patients were subdivided regarding the severity of COVID-19 presentation into Group I (Non-severe COVID-19) was admitted into wards and Group II (Severe COVID-19) admitted into the PICU.

Results

Non- severe cases were 295cases (74.1%) and 103cases (25.9%) of severe cases. There was a significant difference between age groups of the affected children (P < 0.001) with a median (0–15 years). Boys (52%) are more affected than girls (48%) with significant differences (P < 0.001). 68.6%of confirmed cases had contact history to family members infected with COVID-19. 41.7% of severe patients needed mechanical ventilation. Death of 20.4% of severe cases. In COVID-19 patients, fever, headache, fatigue and shock were the most prominent presentations (95, 60.3, 57.8, and 21.8% respectively). 3.5% of children were manifested with atypical presentations; 1.25% manifested by pictures of acute pancreatitis, 1.25% presented by manifestations of deep venous thrombosis and 1.0% had multisystem inflammatory syndrome (MIS-C). Multivariate regression analysis showed that COVID-19 severity in children was significantly higher among children with higher levels of D-dimer, hypoxia, shock and mechanical ventilation.

Conclusion

Most children had a non-severe type of COVID-19 and children with severe type had higher levels of D-dimer, hypoxia, shock and mechanical ventilation.

Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med. 2020;382(13):1199–207. https://doi.org/10.1056/NEJMoa2001316.CrossRefPubMedPubMedCentral

Shi ZL, Guo D, Rottier PJ. Coronavirus: epidemiology, genome replication and the interactions with their hosts. Virol Sin. 2016;31(1):1–2 https://doi.org/10.1007/s12250-016-3746-0.CrossRefPubMedPubMedCentral

Lu R, Zhao X, Li J, Niu P, Yang B, Wu H, et al. Genomic characterization and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding. Lancet. 2020;395(10224):565–74 https://doi.org/10.1016/S0140-6736(20)30251-8.CrossRefPubMedPubMedCentral

Yuen KS, Ye ZW, Fung SY, Chan CP, Jin DY. SARS-CoV-2 and COVID-19: the most important research questions. Cell Biosci. 2020;10(1):40. https://doi.org/10.1186/s13578-020-00404-4.CrossRefPubMedPubMedCentral

Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. Coronavirus investigating, and research team. N Engl J Med. 2020;382(8):727–33. https://doi.org/10.1056/NEJMoa2001017.CrossRefPubMedPubMedCentral

Cucinotta D, Vanelli M. WHO declares covid19 a pandemic. Acta Biomed. 2020;91:157–60. https://doi.org/10.23750/abm.v91i1.9397.CrossRefPubMedPubMedCentral

Seyedi SJ, Shojaeian R, Hiradfar M, Mohammadipour A, Alamdaran SA. Coronavirus disease 2019 (COVID-19) outbreak in pediatrics and the role of pediatricians: a systematic review. Iran J Pediatr. 2020;30(2):e102784 https://doi.org/10.5812/ijp.102784.CrossRef

Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020;395(10223):507–13 https://doi.org/10.1016/S0140-6736(20)30211-7.CrossRefPubMedPubMedCentral

Wang D, Ju XL, Xie F, Lu Y, Li FY, Huang HH, et al. Clinical analysis of 31 cases of 2019 novel coronavirus infection in children from six provinces (autonomous region) of northern China. Zhonghua Er Ke Za Zhi. 2020;58(4):269–74. PMID: 32118389. https://doi.org/10.3760/cma.j.cn112140-20200225-00138.CrossRefPubMed

10.

Sun D, Li H, Lu XX, Xiao H, Ren J, Zhang FR, et al. Clinical features of severe pediatric patients with coronavirus disease 2019 in Wuhan: a single center’s observational study. World J Pediatr. 2020;16(3):251–9. https://doi.org/10.1007/s12519-020-00354-4.CrossRefPubMed

11.

Dong Y, Mo X, Hu Y, Qi X, Jiang F, Jiang Z, et al. Epidemiology of COVID-19 among children in China. Pediatrics. 2020;145(6):e20200702 https://doi.org/10.1542/peds.2020-0702.CrossRefPubMed

12.

Xia W, Shao J, Guo Y, Peng X, Li Z, Hu D. Clinical and CT features in pediatric patients with COVID-19 infection: different points from adults. Pediatr Pulmonol. 2020;55(5):1169–74. https://doi.org/10.1002/ppul.24718.CrossRefPubMedPubMedCentral

13.

Li W, Cui H, Li K, Fang Y, Li S. Chest computed tomography in children with COVID-19 respiratory infection. Pediatr Radiol. 2020;50:796–9 https://doi.org/10.1007/s00247-020-04656-7.CrossRefPubMed

14.

WHO. Coronavirus disease 2019 (COVID- 19): situation report – 42. Available at: https://www.who.int/docs/defaultsource/coronaviruse/20200302-sitrep-42-covid-19.pdf?Sfvrsn=d863e045_2. Accessed 3 Mar 2020.

15.

Fang F, Chen Y, Zhao D, Liu T, Huang Y, Qiu L, et al. Recommendations for the diagnosis, prevention, and control of coronavirus disease-19 in children—the Chinese perspectives. Front Pediatr. 2020; https://doi.org/10.3389/fped.2020.553394.

16.

Bradley JS, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C, et al. The management of community-acquired Pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011;53:617–30. PMID: 21880587 PMCID: PMC7107838. https://doi.org/10.1093/cid/cir531.CrossRefPubMedPubMedCentral

17.

Goldstein B, Giroir B, Randolph A. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med. 2005;6(1):2–8. https://doi.org/10.1097/01.PCC.0000149131.72248.E6.CrossRefPubMed

18.

World Health Organization. Hypoxemia and hypoxia in “oxygen therapy for children: a manual for health workers”. Geneva: WHO; 2016. p. 4. Available From: http://apps.who.int/iris/handle/10665/204584

19.

Kleinman ME, Chameides L, Schexnayder SM, Samson RA, Hazinski MF, Atkins DL, et al. 2010 American heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Part 14: pediatric advanced life support. Circulation. 2010;122(18_suppl_3):S876–908. https://doi.org/10.1161/CIRCULATIONAHA.110.971101.CrossRefPubMed

20.

Riou J, Althaus CL. Pattern of early human-to-human transmission of Wuhan 2019 novel coronavirus (2019-nCoV), December 2019 to January 2020. Euro Surveill. 2020;25(4):7–11. https://doi.org/10.2807/1560-7917.ES.2020.25.4.2000058.CrossRef

21.

The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. The epidemiological characteristics of an outbreak of 2019 Novel coronavirus diseases (COVID-19) in China. Zhonghua Liu Xing Bing Xue Za Zhi. 41(2):2020, 145–151. PMID: 32064853. https://doi.org/10.3760/cma.j.issn.0254-6450.2020.02.003.

22.

Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. China Medical Treatment Expert Group for COVID19. Clinical characteristics of coronavirus disease 2019 in China [published online ahead of print February 28, 2020]. N Engl J Med. 382(18):1708–20. https://doi.org/10.1056/NEJMoa2002032.

23.

Ding Y, Yan H, Wenbin GW. Clinical characteristics of children with COVID-19: a meta-analysis. Front Pediatr. 2020;8:431. https://doi.org/10.3389/fped.2020.00431.CrossRefPubMedPubMedCentral

24.

Hoang A, Chorath K, Moreira A, Evans M, Burmeister-Morton F, Naqvi R, et al. COVID-19 in 7780 pediatric patients: a systematic review. E Clin Med. 2020). https://doi.org/10.1016/j.eclinm.2020.100433;24:100433.

25.

Mantovani A, Rinaldi E, Zusi C, Beatrice G, Saccomani MD, Dalbeni A. Coronavirus disease 2019 (COVID-19) in children and/or adolescents: a meta-analysis: International Pediatric Research Foundation, Inc; 2020. https://doi.org/10.1038/s41390-020-1015-2

26.

Bialek S, Gierke R, Hughes M, Lucy A. Coronavirus disease 2019 in children United States, 2020. MMWR Morb Mortal Wkly Rep. 2020;69:422–6. https://doi.org/10.15585/mmwr.mm6914e4.CrossRefPubMedCentral

27.

Wang J, Wang D, Chen GC, TaoX W, Zeng LK. SARS-CoV-2 infection with gastrointestinal symptoms as the first manifestation in a neonate. Zhongguo Dang Dai ErKe ZaZhi. 2020;22(3):211–4. https://doi.org/10.7499/j.issn.1008-8830.2020.03.006.CrossRef

28.

Zeng L, Xia S, Yuan W, Yan K, Xiao F, Shaoet J, et al. Neonatal early-onset infection with SARS-CoV-2 in 33 neonates born to mothers with COVID 19 in Wuhan, China. Pediatr. 2020;174(7):722–5. https://doi.org/10.1001/jamapediatrics.2020.0878.CrossRef

29.

Alloway BC, Yaeger SK, Mazzaccaro RJ, Mazzaccaro RJ, Villalobos T, Hardy SG. Suspected case of COVID-19- associated pancreatitis in a child. Radiol Case Rep. 2020;15(8):1309–12. https://doi.org/10.1016/j.radcr.2020.06.009.CrossRefPubMedPubMedCentral

30.

Samies NL, Yarbrough A, Boppana S. Pancreatitis in pediatric patients with COVID-19. J Pediatr Infect Dis Soc. 2020. https://doi.org/10.1093/jpids/piaa125.

31.

Liu F, Long X, Zhang B, Zhang W, Chen X, Zhang Z. ACE2 expression in pancreas may cause pancreatic damage after SARS-CoV-2 infection. Clin Gastroenterol Hepatol. 2020;18:2128–30.e2. https://doi.org/10.1016/j.cgh.2020.04.040.CrossRefPubMedPubMedCentral

32.

Aloysius MM, Thatti A, Gupta A, Sharma N, Bansal P, Goyala H. COVID-19 presenting as acute pancreatitis. Pancreatology. 2020;20(5):1026–7. https://doi.org/10.1016/j.pan.2020.05.003.CrossRefPubMed

33.

Visveswaran GK, Morparia K, Narang S, Sturt C, Divita M, Vogit B, et al. Severe acute respiratory syndrome coronavirus 2 infection and thrombosis: phlegmasia cerulea dolens presenting with venous gangrene in a child. J Pediatr. 2020;226:281–4 https://doi.org/10.1016/j.jpeds.2020.07.032.CrossRefPubMedPubMedCentral

34.

Demelo-Rodríguez P, Cervilla-Muñoz E, Ordieres-Ortega L, Parra-Virto A, Toledano-Macías M, Toledo-Samaniego N, et al. Incidence of asymptomatic deep vein thrombosis in patients with COVID-19 pneumonia and elevated D-dimer levels. Thromb Res. 2020;192:23–6 https://doi.org/10.1016/j.thromres.2020.05.018.CrossRefPubMedPubMedCentral

35.

Licciardi F, Pruccoli G, Denina M, Parodi E, Taglietto M, Rosati S, et al. SARS-CoV-2-induced Kawasaki-like hyperinflammatory syndrome: a novel COVID phenotype in children. Pediatrics. 2020;146:e20201711. https://doi.org/10.1542/peds.2020-1711.CrossRefPubMed

36.

Bozzani A, Arici V, Franciscone MM, Danesino V, Cascina A, Ticozzelli G, et al. Severe acute respiratory syndrome coronavirus 2 infection and the upper limb deep vein thrombosis risk. Ann Vasc Surg. 2020;66:11e13.CrossRef

37.

Verdoni L, Mazza A, Gervasoni A, Martelli L, Ruggeri M, Ciuffreda M, et al. An outbreak of severe Kawasaki-like disease at the Italian epicentre of the SARS-CoV-2 epidemic: an observational cohort study. Lancet. 2020;395:1771–8 https://doi.org/10.1016/S0140-6736(20)31103-X.CrossRefPubMedPubMedCentral

38.

Bhumbra S, Malin S, Kirkpatrick L, Khaitan A, John CC, Rowan CM, et al. Clinical features of critical coronavirus disease 2019 in children. Pediatr Crit Care Med. 2020. https://doi.org/10.1097/PCC.0000000000002511.

39.

Chen ZM, Fu JF, Shu Q, Chen YH, Hua CZ, Li FB, et al. Diagnosis and treatment recommendations for pediatric respiratory infection caused by the 2019 novel coronavirus. World J Pediatr. 2020. https://doi.org/10.1007/s12519-020-00345-5;16(3):240–6.CrossRefPubMed

40.

Shekerdemian LS, Mahmood NR, Wolfe KK, Riggs BJ, Ross CE, McKiernan CA, et al. International COVID-19 PICU collaborative: characteristics and outcomes of children with coronavirus disease 2019 (COVID-19) infection admitted to US and Canadian pediatric intensive care units. JAMA Pediatr. 2020;174(9):868–73. https://doi.org/10.1001/jamapediatrics.2020.1948.CrossRefPubMed

41.

DeBiasi RL, Song X, Delaney M, Bell M, Smith K, Pershad J, et al. Severe COVID-19 in children and young adults in the Washington, DC metropolitan region. J Pediatr. 2020;223:199–203.e1. https://doi.org/10.1016/j.jpeds.2020.05.007.CrossRefPubMedPubMedCentral

42.

Grasselli G, Zangrillo A, Zanella A, Antonelli M, Cabrini L, Castelli A, et al. Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy Region, Italy. JAMA. 2020;323:1574–81. PMID: 32250385 PMCID: PMC7136855. https://doi.org/10.1001/jama.2020.5394.CrossRefPubMedPubMedCentral

43.

Fan BE, Chong VCL, Chan SSW, Lim GH, Lim KGE, Tan GB, et al. Hematologic parameters in patients with COVID-19 infection. Am J Hematol. 2020;95(6):E131–4. https://doi.org/10.1002/ajh.25774.PubMed

44.

Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223):497–506 https://doi.org/10.1016/S0140-6736(20)30183-5.CrossRefPubMedPubMedCentral

45.

Kosmeri C, Koumpis E, Tsabouri S, Siomou E, Makis A. Hematological manifestations of SARS-CoV-2 in children. Pediatr Blood Cancer. 2020;67(12):ee28745 https://doi.org/10.1002/pbc.28745.CrossRef

46.

Raba AA, Abobaker A, Elgenaidi IS, Daoud A. Novel coronavirus infection (COVID-19) in children younger than one year: a systematic review of symptoms, management and outcomes. Acta Paediatr. 2020;109(10):1948–55. https://doi.org/10.1111/apa.15422.CrossRefPubMed

47.

Guan WJ, Ni ZY, Hu Y, Liang W, Ou C, He J, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med. 2020;382(18):1708–20. https://doi.org/10.1056/NEJMoa2002032.CrossRefPubMed

48.

Standage SW, Wong HR. Biomarkers for pediatric sepsis and septic shock. Expert Rev Anti-Infect Ther. 2011;9(1):71–9. https://doi.org/10.1586/eri.10.154.CrossRefPubMedPubMedCentral

49.

Razavi A, Davoodi L, Shojaei L, Jafarpour H. COVID-19 in children: a narrative review. Open Access Maced J Med Sci. 2020;8(T1):23–31 https://doi.org/10.3889/oamjms.2020.4714.CrossRef

50.

Momtazmanesh S, Shobeiri P, Hanaei S, Mahmoud-ElSayed H, Dalvi B, Rad E, et al. Cardiovascular disease in COVID-19: a systematic review and meta-analysis of 10,898 patients and proposal of a triage risk stratification tool. Egypt Heart J. 2020;72(1):41. https://doi.org/10.1186/s43044-020-00075-z.CrossRefPubMedPubMedCentral

51.

Zhou P, Yang XL, Wang XG, Hu B, Zhang L, Zhang W, et al. A pneumonia outbreak associated with a new coronavirus of probable bat origin. Nature. 2020;579(7798):270–3 https://doi.org/10.1038/s41586.020.2012.7.CrossRefPubMedPubMedCentral

52.

Li G, Fan Y, Lai Y, Han T, Li Z, Zhou P, et al. Coronavirus infections and immune responses. J Med Virol. 2020;92(4):424–32. PMID: 31981224 PMCID: PMC7166547. https://doi.org/10.1002/jmv.25685.CrossRefPubMedPubMedCentral

53.

Terpos E, Ntanasis-Stathopoulos I, Elalamy I, Kastritis E, Sergentanis TN, Politou M, et al. Hematological findings and complications of COVID-19. Am J Hematol. 2020). PMID: 32282949 PMCID: PMC7262337. https://doi.org/10.1002/ajh.25829.

54.

Liguoro L, Pilotto C, Bonanni M, Ferrari ME, Pusiol A, Nocerino A, et al. SARS-COV-2 infection in children and newborns: a systematic review. Eur J Pediatr. 2020;179(7):1029. https://doi.org/10.1007/s00431-020-03684-7–46.CrossRefPubMed

Title: The severity and atypical presentations of COVID-19 infection in pediatrics
Authors: Nagwan Y. Saleh
Hesham M. Aboelghar
Sherif S. Salem
Reda A. Ibrahem
Fatma O. Khalil
Ahmed S. Abdelgawad
Asmaa A. Mahmoud
Publication date: 01-12-2021
Publisher: BioMed Central
Keywords: Shock
Shock
COVID-19
Published in: BMC Pediatrics / Issue 1/2021
Electronic ISSN: 1471-2431
DOI: https://doi.org/10.1186/s12887-021-02614-2

Keynote webinar | Spotlight on medication adherence

Springer Medicine

The severity and atypical presentations of COVID-19 infection in pediatrics

Abstract

Background

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

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