Clinical characteristics and outcomes of children with COVID-19 in Saudi Arabia

Prevalence of invasive bacterial infection in febrile infants ≤90 days with a COVID-19 positive test: a systematic review and meta-analysis

BACKGROUND

Febrile infants with an infection by influenza or enterovirus are at low risk of invasive bacterial infection (IBI).

OBJECTIVE

To determine the prevalence of IBI among febrile infants ≤90 days old with a positive COVID-19 test.

METHODS

MEDLINE, Embase, Cochrane Central Register databases, Web of Science, ClinicalTrials.gov and grey literature were searched for articles published from February 2020 to May 2023.

INCLUSION CRITERIA

researches reporting on infants ≤90 days of age with fever and a positive test for SARS-CoV-2 (antigen test/PCR). Case reports with <3 patients, articles written in a language other than English, French or Spanish, editorials and other narrative studies were excluded. Preferred Reposting Items for Systematic Reviews and Meta-analysis guidelines were followed, and the National Institutes of Health Quality Assessment Tool was used to assess study quality. The main outcome was the prevalence of IBI (a pathogen bacterium identified in blood and/or cerebrospinal fluid (CSF)). Forest plots of prevalence estimates were constructed for each study. Heterogeneity was assessed and data were pooled by meta-analysis using a random effects model. A fixed continuity correction of 0.01 was added when a study had zero events.

RESULTS

From the 1023 studies and 3 databases provided by the literature search, 33 were included in the meta-analysis, reporting 3943 febrile infants with a COVID-19 positive test and blood or CSF culture obtained. The pooled prevalence of IBI was 0.14% (95% CI, 0.02% to 0.27%). By age, the prevalence of IBI was 0.56% (95% CI, 0.0% to 1.27%) in those 0-21 days old, 0.53% (95% CI, 0.0% to 1.22%) in those 22-28 days old and 0.11% (95% CI, 0.0% to 0.24%) in those 29-60 days old.

CONCLUSION

COVID-19-positive febrile infants ≤90 days old are at low risk of IBI, especially infants >28 days old, suggesting this subgroup of patients can be managed without blood tests.

PROSPERO REGISTRATION NUMBER

CRD42022356507.

Neurological Manifestations of Coronavirus Disease 2019 and Monkeypox in Pediatric Patients and Their Management: A State-of-the-Art Systematic Review

BACKGROUND

There is an increasing number of cases being reported of neurological manifestations of Coronavirus disease 2019 (COVID-19) infection and monkeypox, both during the course of the infection and as a presenting symptom. We aim to review the neurological manifestations of COVID-19 and monkeypox in pediatric patients and their management.

METHODS

We conducted a systematic review that included cohort studies and case series or reports involving a pediatric population of patients with a confirmed COVID-19 or monkeypox infection and their neurological manifestations. We searched the following electronic databases: PubMed, EMBASE, and Scopus.

RESULTS

From 1136 articles identified, 127 studies were included. Headache, stroke, Guillain-Barré syndrome, seizure, nerve palsies, and multisystem inflammatory syndrome in children were the most common neurological symptoms caused by COVID-19, whereas encephalitis was commonly seen in patients with monkeypox. Rare neurological manifestations of COVID-19 included cerebral venous sinus thrombosis, plexopathies, demyelinating disorders, encephalitis, etc., and rare neurological manifestations of monkeypox included headache.

CONCLUSIONS

Our review highlights the importance of investigating possible neurological manifestations and closely monitoring these patients to develop a better understanding of the treatment strategies that can be adopted.

Prognosis of COVID-19 in the middle eastern population, knowns and unknowns

Since its emergence in China in 2019, the SARS-CoV-2 virus has affected all countries worldwide. The virus is easily transmitted from one person to another via infected aerosols or contaminated surfaces. Unlike its counterparts, the prognosis of COVID-19 ranges from asymptomatic to critical disease or death. Several factors play a role in determining the severity of the disease in infected patients. Among others, is the pre-existence of an underlying medical condition such as diabetes, cancer, and others. Furthermore, although children are less prone to the severe form of the COVID-19 disease, they require attention due to the report of many atypical presentations of the infection, post-asymptomatic exposure. In the Middle East, little is known about the prognosis of the SARS-CoV-2 infection in high-risk categories, notably patients with diabetes, cancer, and pregnant women. The aim of this review is to summarize the current knowledge about this group of population in the middle eastern region as well as to highlight the gap in the literature. We have found that the majority of the papers were from the Gulf countries. Although, few studies were conducted; high-risk patients appear to have an increased risk of morbidity and mortality from COVID-19 compared to their counterparts. Higher levels of inflammatory markers, C-reactive protein, erythrocyte sedimentation rate, D-dimer, and ferritin levels were also observed. Children are often asymptomatic or present with atypical presentations. More studies should be conducted to determine the clinical biomarkers of COVID-19 in high-risk categories to help in patient risk stratification and management in the middle eastern population.

A Case Report of Postinfectious Bronchiolitis Obliterans After Coronavirus Disease 2019 in a 10-Year-Old Child

Coronavirus disease 2019 (COVID-19) is usually less severe in children and adolescents than in adults. However, it can cause severe respiratory illness in a small proportion of children with risk factors. Here, we report a rare case of a 10-year-old boy with postinfectious bronchiolitis obliterans that developed after pneumonia caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). This patient was previously healthy apart from a high body mass index (BMI, 30.13; 99.6th percentile for the age bracket), history of preterm birth (35 weeks), and low birth weight (1,850 g). He had persistent exertional dyspnea after recovering from SARS-CoV-2-related pneumonia. Spirometry revealed obstructive lung disease with the following results: predicted forced vital capacity (FVC%_pred), 71%; forced expiratory volume in 1 second (FEV₁%_pred), 63%; FEV₁/FVC, 0.81; and forced expiratory flow_25-75%_pred, 55%. Chest computed tomography showed multifocal areas of parenchymal hyperlucency and mosaic attenuation in both lungs. This case suggests that careful observation of children with obesity and low birth weight is necessary after recovery from SARS-CoV-2-related pneumonia.

A systematic review and meta-analysis of otorhinolaryngological manifestations of coronavirus disease 2019 in paediatric patients

BACKGROUND

This meta-analysis provides a quantitative measure of the otorhinolaryngological manifestations of coronavirus disease 2019 in children.

METHODS

A structured literature review was carried out using PubMed, Embase and Cochrane Central, employing pertinent search terms. The statistical analysis was performed using Stata version 14.2 software, and the analysed data were expressed as the pooled prevalence of the symptoms with 95 per cent confidence intervals.

RESULTS

The commonest symptoms noted were cough (38 per cent (95 per cent confidence interval = 33-42; I² = 97.5 per cent)), sore throat (12 per cent (95 per cent confidence interval =10-14; I² = 93.7 per cent)), and nasal discharge (15 per cent (95 per cent confidence interval = 12-19; I² = 96.9 per cent)). Anosmia and taste disturbances showed a pooled prevalence of 8 per cent each. Hearing loss, vertigo and hoarseness were rarely reported.

CONCLUSION

Cough, sore throat and nasal discharge were the commonest otorhinolaryngological symptoms in paediatric patients with coronavirus disease 2019. Compared with adults, anosmia and taste disturbances were infrequently reported in children.

Symptoms of COVID-19 in children

The aim of this study was to review the symptomatic manifestations of COVID-19 in children in the scientific literature. An integrative review of studies published between December 2019 and September 5, 2021, from the Medical Literature Analysis and Retrieval System Online, Web of Science, Scopus, Literatura Latino-Americana em Ciência de Saúde, and Base de Dados de Enfermagem databases, was carried out to answer the following research question: What symptomatic manifestations does COVID-19 cause in children?". Twenty articles were included. The main symptoms described were fever, cough, diarrhea, vomiting, sore throat, dyspnea, headache, abdominal pain, malaise, and weakness or tiredness. The findings of this review can contribute to the diagnosis and clinical decision-making of the health team by providing information that facilitates the identification of COVID-19 in the target population, favoring early identification, better care, and consequently a better prognosis.

Clinical profile, risk factors and outcomes of ric COVID-19: a retrospective cohort multicentre study in Saudi Arabia

OBJECTIVE

To describe the risk factors, clinical profile and outcomes of COVID-19 in the paediatric population.

DESIGN

Multicentre, retrospective observational study.

SETTING

Four tertiary hospitals in Saudi Arabia.

PATIENTS

We recruited 390 paediatric patients aged 0-18 years who presented from March to December 2020 and tested positive for COVID-19 on PCR.

MAIN OUTCOME MEASURES

We retrospectively analysed medical records for sociodemographics, health indicators, clinical presentations, laboratory findings, clinical complications, and outcomes.

RESULTS

The mean participant age was 5.66±4.90 years, and the mean hospital stay was 2.17±3.48 days. Forty patients, mostly school-aged children (16, 40.00%; p=0.005) and children with comorbidities (25, 62.50%; p<0.001), received more than just supportive care. Complications were seen in 15 (3.9%) patients, bacterial infection being the most common (6, 40.00%). Patients presented with dyspnoea (OR 6.89; 95% CI 2.89 to 20.72), abnormal chest radiographs (OR 6.11; 95% CI 1.26 to 29.38), lethargy (OR 9.04; 95% CI 2.91 to 28.06) and elevated ferritin (OR 14.21; 95% CI 4.18 to 48.37) and D-dimer (OR 48.40; 95% CI 14.32 to 163.62), with higher odds of developing complications. The odds of paediatric intensive care unit (ICU) admission were higher for patients with dyspnoea (adjusted OR 4.66; 95% CI 1.24 to 17.50) and elevated white blood cell count (adjusted OR 3.54; 95% CI 1.02 to 12.30).

CONCLUSIONS

COVID-19 complications were limited among our patients. However, dyspnoea, abnormal chest radiographs, lethargy and elevated ferritin and D-dimer were associated with an increased risk of complications. Dyspnoea, leucocytosis, comorbidities and abnormal chest radiographs at presentation increased the risk of ICU admission.

Clinical and Laboratory Features of PCR-Confirmed and Clinically Suspected COVID-19 Pediatric Patients: A Single Hospital-Based Experience During the First COVID-19 Wave in the United Arab Emirates

OBJECTIVE

This study investigated clinical and laboratory differences between confirmed (RT-PCR-positive) and clinically suspected (RT-PCR-negative) COVID-19 pediatric patients, and explored factors associated with disease severity at presentation and duration of hospitalization.

METHODS

Medical charts of COVID-19-confirmed and clinically suspected pediatric patients admitted to a tertiary hospital in Abu Dhabi were reviewed. Sociodemographic information and clinical and laboratory outcomes were retrieved and analyzed.

RESULTS

Between 1 April to 30 June, 2020, 173 patients (mean age: 3.6 ± SD 3.2 years) presented with respiratory symptoms. Of them, 18.0% had confirmed contact with COVID-19 cases, 66.5% had symptoms for ≤3 days, and 86.7% were with moderate to severe disease. Twenty-eight (16.1%) patients tested positive while the rest (83.8%) tested negative in RT-PCR. COVID-19-confirmed and clinically suspected patients were statistically similar (p > 0.05) in all sociodemographic data, disease severity, and vital signs except residence status (89.3% vs. 58.6% were residents, respectively, p = 0.002) and contact with confirmed COVID-19 cases (82.1% vs. 5.5%, respectively, p < 0.001). Fever (100 and 91.0%) and cough (100 and 95.9%) were the most common symptoms in both confirmed and clinically suspected COVID-19 patients. All patients were statistically comparable in mean white blood cell and platelet counts and hemoglobin concentration, except in mean concentration of neutrophils (higher in clinically suspected, p = 0.019). C-reactive protein was two times higher in clinically suspected compared to confirmed patients (p = 0.043). Lymphocyte (OR: 1.31, p < 0.001), LDH (OR: 1.01, p = 0.001), D-dimer (OR: 1.92, p < 0.001), and ferritin levels after 24-36 h (OR: 9.25, p < 0.05), and SGPT (OR: 1.04, p < 0.05) were all associated with disease severity. Elevated ferritin (>300 μg/L) after 24-36 h was the only correlated factor with disease severity (aOR: 17.38, p < 0.05). Confirmed compared with clinically suspected patients (aOR: 4.00, 95% CI: 2.92-5.10) and children with moderate compared with mild disease (aOR: 5.87, 95% CI: 1.08-32.06) had longer hospitalization.

CONCLUSION

In pediatric patients with negative RT-PCR, COVID-19 is still suspected based on clinical symptoms and epidemiological data. A tentative diagnosis can be made based on a thorough examination, and proper medical management can be initiated promptly.

Clinical Characteristics, Laboratory Findings, Management, and Outcome of Severe Coronavirus Disease 2019 in Children at a Tertiary Care Center in Riyadh, Saudi Arabia: A Retrospective Study

BACKGROUND

Numerous studies worldwide have reported COVID-19 in children; however, the clinical symptoms and consequences of COVID-19 in children have only been reported in a few studies in Saudi and gulf region. Therefore, we aimed to investigate the clinical features and outcomes of COVID-19 infection in children and the therapeutic interventions used.

METHODS

This retrospective cohort study included 96 patients with confirmed severe acute respiratory syndrome coronavirus 2 infection aged ≤14 years who were admitted to a tertiary governmental care hospital in Riyadh, Saudi Arabia between March 2020 and November 2020. Data on children with COVID-19, including demographics, comorbidities, symptoms, imaging and laboratory results, therapies, and clinical outcomes, were analyzed.

RESULTS

Of 96 children admitted with a confirmed diagnosis of COVID-19, 63.8% were aged ≤ 3 years, 52.1% were male, 56.2% had an unknown source of infection, and 51% had no comorbidities. Most cases had severe infection (71.88%) as they required oxygen, 10.42% of whom were critical. The most common symptoms were respiratory-related (98%), and the common physical sign was fever (49%). High D-dimer (90.7%) and C-reactive protein (72.09%) levels were found in most cases. Oxygen (71.88%) was the most commonly used treatment. Most patients were discharged home and fully recovered (97.92%). We reported two deaths (2.08%).

CONCLUSIONS

Our findings showed that the majority of the admitted children with COVID-19 were ≤3 years of age (52.1%) and infected with an unknown source (56.2%). Moreover, the majority of the cases had severe COVID-19 infection as they required oxygen (71.88%), although they had favorable outcomes. However, some cases were critical and resulted in death. Future studies will be crucial to better understand the disease spectrum and potential therapeutic options for COVID-19 in children.

Epidemiology and clinical evolution of non-multisystem inflammatory syndrome (MIS-C) dermatological lesions in pediatric patients affected by SARS-CoV-2 infection: A systematic review of the literature

COVID-19 can present with a range of skin manifestations, some of which specific of the pediatric age. The aim of this systematic literature review was to determine the type, prevalence, time of onset, and evolution of cutaneous manifestations associated with COVID-19 in newborns, children, and adolescents, after excluding multisystem inflammatory syndrome in children (MIS-C). PubMed, Tripdatabase, ClinicalTrials, and Cochrane Library databases were searched using an ad hoc string for case reports/series and observational studies, published between December 2019 and February 2022. Study quality was assessed using the STROBE and CARE tools. Seventy-three (49 case reports/series and 24 studies) out of 26,545 identified articles were included in the analysis. Dermatological lesions were highly heterogeneous for clinical presentation, time of onset, and association with other COVID-19 manifestations. Overall, they mainly affected the acral portions, and typically presented a favorable outcome. Pseudo-chilblains were the most common.

CONCLUSIONS

Mucocutaneous manifestations could be the only/predominant and early manifestation of COVID-19 that could precede other more severe manifestations by days or weeks. Therefore, physicians of all disciplines should be familiar with them.

WHAT IS KNOWN

• A variety of cutaneous manifestations have been reported in association with COVID-19. • Urticaria, maculopapular, or vesicular rashes can occur at any age, while chilblains and erythema multiforme are more common in children and young patients.

WHAT IS NEW

• Skin lesions related to SARS-CoV-2 infection often show a peculiar acral distribution. • Mucocutaneous lesions of various type may be the only/predominant manifestation of COVID-19; they could present in paucisymptomatic and severely ill patients and occur at different stages of the disease.

Worldwide epidemiology of neuro-coronavirus disease in children: lessons for the next pandemic

PURPOSE OF REVIEW

The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic has overwhelmed the global community, negatively impacting patient health and research efforts; associated neurological manifestations are a significant cause of morbidity. This review outlines the worldwide epidemiology of neurologic manifestations of different SARS-CoV-2 clinical pediatric phenotypes, including acute coronavirus disease 2019 (COVID-19), multisystem inflammatory syndrome in children (MIS-C) and postacute sequelae of COVID-19 (PASC). We discuss strategies to develop adaptive global research platforms for future investigation into emerging pediatric neurologic conditions.

RECENT FINDINGS

Multicenter, multinational studies show that neurological manifestations of acute COVID-19, such as smell/taste disorders, headache, and stroke, are common in hospitalized adults (82%) and children (22%), associated with increased mortality in adults. Neurological manifestations of MIS-C are reported in up to 20% of children, including headache, irritability, and encephalopathy. Data on PASC are emerging and include fatigue, cognitive changes, and headache. Reports of neurological manifestations in each phenotype are limited by lack of pediatric-informed case definitions, common data elements, and resources.

SUMMARY

Coordinated, well resourced, multinational investigation into SARS-CoV-2-related neurological manifestations in children is critical to rapid identification of global and region-specific risk factors, and developing treatment and mitigation strategies for the current pandemic and future health neurologic emergencies.

Urgent Neurosurgical Interventions in the COVID-19-Positive Pediatric Population

BACKGROUND

Urgent neurosurgical interventions for pediatric patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are rare. These cases pose additional stress on a potentially vulnerable dysregulated inflammatory response that can place the child at risk of further clinical deterioration. Our aim was to describe the perioperative course of SARS-CoV-2-positive pediatric patients who had required an urgent neurosurgical intervention.

METHODS

We retrospectively analyzed pediatric patients aged ≤18 years who had been admitted to a quaternary children's hospital with a positive polymerase chain reaction test result for SARS-CoV-2 virus from March 2020 to October 2021. The clinical characteristics, anesthetic and neurosurgical operative details, surgical outcomes, and non-neurological symptoms were collected and analyzed.

RESULTS

We identified 8 SARS-CoV-2-positive patients with a mean age of 8.83 years (median, 8.5 years; range, 0.58-18 years). Of the 8 patients, 6 were male. All children had had mild or asymptomatic coronavirus disease 2109. The anesthetic and surgical courses for these patients were, overall, uncomplicated. All the patients had been admitted to a specialized isolation unit in the pediatric intensive care unit for cardiopulmonary and neurological monitoring. The use of increased protective personal equipment during anesthesia and surgery did not impede a successful neurosurgical operation.

CONCLUSIONS

SARS-CoV-2-positive pediatric patients with minimal coronavirus disease 2019-related symptoms who require urgent neurosurgical interventions face unique challenges regarding their anesthetic status, operative delays due to SARS-CoV-2 polymerase chain reaction testing, and requirements for additional protective personal equipment. Despite these clinical challenges, the patients in our study had not experienced adverse postoperative consequences, and no healthcare professional involved in their care had contracted the virus.

Outcome of COVID19 in Patients With Osteogenesis Imperfecta: A Retrospective Multicenter Study in Saudi Arabia

BACKGROUND

Although genetic diseases are rare, children with such conditions who get infected with COVID-19 tend to have a severe illness requiring hospitalization. Osteogenesis imperfecta (OI) is a rare genetic disorder of collagen resulting in fractures and skeletal deformities. Kyphoscoliosis, restrictive lung disease, and pneumonia worsen the prognosis of patients with OI. The use of bisphosphonate improves bone mineral density (BMD) and reduces fractures in OI. There is no literature describing the impact of COVID-19 in patients with OI.

METHODOLOGY

A retrospective multi-center study was performed in three hospitals in Jeddah and Riyadh, Saudi Arabia, from March 1st, 2020, until August 31st, 2021, aiming to evaluate the outcome of COVID-19 in patients with OI. Demographics, vaccination status, underlying kyphoscoliosis, functional status, use of bisphosphonate, BMD, and COVID-19 severity, and course were recorded for all patients.

RESULTS

Twelve cases of confirmed COVID-19 were identified among 146 patients with OI. 9 (75%) of patients were less than 18 years, 6 (50%) were male, 5 (41%) had kyphoscoliosis, and 5 (41%) were wheelchair-bound. 6 (50%) received bisphosphonate, and 7(58%) had normal BMD. All patients had mild disease and did not require hospitalization. None of OI the patients with COVID-19 were fully vaccinated before the infection, and some were ineligible for vaccination.

CONCLUSION

Patients with OI and COVID-19 in our study recovered without complications, unlike patients with other genetic diseases. Young age and mild illness contributed to the favorable outcome. Half of the patients received bisphosphonate and had normal BMD.