Discussion
Children can carry the heaviest burden of viral respiratory diseases. However, corona virus related infections also vary widely among pediatric individuals. Studies from China and America recommend, that children with COVID-19 might be less serious than in adults and that pediatric cases might knowledge various symptoms than do adults (19, 20); nevertheless, disease characteristics among pediatric patients in the Turkey have not been described. The aim of this study was to determine the epidemiological characteristics of pediatric COVID-19 patients during the first 3 months (April - June) of the disease that occur in Turkey.
Our study included positive pediatric cases confirmed with the RT-PCR method. The male/female ratio in COVID-19 varies between studies. In previous reports from China and America, boy outnumbered girls (11, 19- 21). The present study showed a male (51.4%) predominance, similar to what has been described in the Chinese and American populations (22-24). In previous studies, ages ranged between 1 day and 18 years (19, 20, 22). In our study, the mean age of the patients was 108.64±65.61 months and the age range of patients is between 45 days to 18 years. These results suggests that all ages of childhood were sensitive to COVID-19.
In a Chinese study, the most common symptoms in children with COVID-19 were reported as fever and dry cough (36%, 19%, respectively) (22). Also in an another previous large-scale study, fever and cough were reported more frequently in pediatric COVID-19 cases (56%, 54%, respectively), too. In our study, the most common symptoms on admission were cough (16.2%), fever (15.2%), lassitude and fatigue (13.3%). In American study the frequency of sore throat, headache, and diarrhea have been found to be quite less in pediatric patients (20). The present study found the symptoms including; sore throat, headache, diarrhea, loss of taste, anosmia and vomiting (8%, 20%, 4%, 2%, 3% and 6% respectively). These findings are in line with other studies from other countries. These results suggests that children do not always have fever or cough as reported signs and symptoms.
Comorbidities were present in 3.8% of the patients. The comorbidities were as follows: diabetes mellitus, beta thalasemia major, chronic respiratory disease, Down syndrome, acute lymphoblastic leukemia and epilepsy (25).
A 17-year-old girl with insulin-dependent type one diabetes (HbA1C: 8.6) and bone marrow transplantation due to beta thalassemia major and who developed bronchiolitis obliterans presented to the emergency department with shortness of breath and two weeks of a cough. On physical examination, there was tachycardia and high fever. Also, there was bilateral crepitan ral and roncus in auscultation. Laboratory workup was significant for white blood count (WBC) of 7.74 × 103/μL with 0.99 % eosinophils, blood glucose of 220 mg/dL, elevated C-reactive protein, and normal venous blood gas. Initial blood and sputum cultures with gram stain were negative. Computed tomography (CT) of the chest showed ground glass, peribronchial consolidation areas and mosaic pattern in both lungs (Fig. 3 ). Despite initial treatment with oseltamivir, azithromycin and hydroxychloroquine treatment, the patient developed respiratory distress, so that lopinavir–ritonavir and favipiravir were added to the treatment. The PCR tests for SARS-COV-2 on the 9th and 11th days of treatment were negative. The patient was discharged on the 17th day with healin.
A 6-month-old male patient infected with COVID-19 in April 2020, while receiving Hemophagocytic Lymphohistiocytosis (HLH) 2004 chemotherapy protocol with the diagnosis of familial (Genetic / Primary) HLH. In our patient, which was accompanied by defective perforin gene defect in primary HLH pathogenesis, COVID-19 infection with the presence of fever and hyperferritinemia, was evaluated in favor of reactivation and the patient was given both the HLH-2004 chemotherapy protocol treatment and COVID-19 therapy as recommended by the guidelines. Our patient improved clinically and in terms of laboratory test results at the end of the 15-day hospitalization period and was discharged. It should be remembered that COVID-19 can be seen with different clinical manifestations in the pediatric age group, and COVID-19 test should be recommended, especially in children with immunosuppression and fever.
In a previous report covering 2135 pediatric patients with COVID-19, the disease followed an asymptomatic, mild, moderate, severe and critical. Regarding the severity, 4.4%, 51.0%, and 38.7% cases were diagnosed as asymptomatic, mild, or moderate, respectively (totally 94.1% of all cases) (19). In another study found that children with COVID-19 had milder clinical manifestations and nearly half of pediatric patients were asymptomatic (22). In our study, 56.2 % of the cases were asymptomatic, 30.5% were mild, 10.5% were moderate, 2.9 % were severe and none of our patients were critical. The percentage of the patients requiring ICU admission was 2.9%.
Laboratory findings in pediatric COVID-19 patients are generally similar to those in other coronavirus infections. The number of white cells is often normal or low; neutropenia and / or lymphopenia may accompany. Thrombocytopenia may develop. C reactive protein and procalcitonin values are generally normal. In severe cases, liver enzymes and lactate dehydrogenase may increase, and abnormal coagulation and high D-dimer levels have been reported in these cases (26). In our study, we found the elevated level of lactate dehydrogenase and D-dimer in 3 cases with severe disease.
Thoracic tomography findings in children are bilateral multiple patchy, nodular ground glass opacities and / or infiltrations in the middle and outer zones of the lung or under the pleura. In the present study, pulmonary ground glass opacities (n = 11, 10.4%) were found as the most common finding in chest tomography. Other common findings were; local patchy shadow (n=5, 4.7%) and bilateral patchy shadow (n=4, 3.8%), respectively. In one of our patients, pleural effusion was seen. These results are consistent with other reports (11, 21, 27). The radiological findings are non-specific and milder than adults (17, 21, 27, 28).
To date, there are no published controlled clinical trials on pediatric COVID-19 specific drug therapy. As with other age groups, there is insufficient evidence for any drug that can be used in the treatment of COVID-19 in children. Therefore, suggested treatments for COVID-19 in child patients should be evaluated in accordance with the studies on adults and should be planned in specific to a child patient. World Health Organization and the American Center for Disease Control and Prevention does not recommend a specific drug for the treatment of children with COVID-19 (29, 30). In our country, the management of pediatric patients with COVID-19 is also evaluated by the Scientific Board of Ministry of Health at frequent intervals and revisions are made (31, 32). Probable adverse effects of drugs must be taken into consideration in the decision for treatment in child patients. Treatment should be evaluated in specific to each child patient, and medication may be planned for patients with probable severe pneumonia and mild cases with risk factor. Medicines used in the treatment of patients, respectively; azithromycin (n = 42, 40%), hydroxychloroquin (n = 21, 20%), empirical antibiotic (n=10, 9.5%), oseltamivir (n = 8, 7.6%), lopinavir-ritonavir (n = 4, 3.8%) and Favipiravir (n = 1, 0.9%). Only 3 patients needed oxygen therapy. High flow humidified oxygen was applied to a patient who was followed up in the intensive care unit.
There were some limitations to our study. First, this study was hospital-based, second it is possible the data may be incomplete and incorrect due to the retrospective study design.