Implications of COVID-19 in pediatric rheumatology

Blood pH and COVID-19

The coronavirus disease 2019 (COVID-19) pandemic is a worldwide war. Raising the blood pH might be a crucial strategy to chase COVID-19. The human blood is slightly alkaline, which is essential for cell metabolism, normal physiology, and balanced immunity since all of these biological processes are pH-dependent. Varieties of physiologic derangements occur when the blood pH is disrupted. Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) proliferates in acidic blood that magnifies the severity of COVID-19. On the other side, blood acidemia is linked to increased morbidity and mortality because of its complications on immunity, especially in the elderly and in critical diseases such as cancer, musculoskeletal degradation, renal, cardiac, and pulmonary disorders, which result in many pathological disorders such as osteomalacia, and disturbing the hematopoiesis. Additionally, acidemia of the blood facilitates viral infection and progression. Thus, correcting the acid-base balance might be a crucial strategy for the treatment of COVID-19, which might be attributed to the distraction of the viral spike protein to its cognate receptor angiotensin-converting enzyme 2 and supporting the over-taxed immunity.

Patients Without a Rheumatic Disease Diagnosis in a Pediatric Rheumatology Unit: Retrospective Analysis and Comparison Between Pre-pandemic and Pandemic Periods

OBJECTIVE

Children with suspicious complaints of rheumatic diseases are generally referred to a pediatric rheumatologist. We aimed to evaluate the profile of patients referred to the pediatric rheumatology unit and were not diagnosed with a rheumatic disease and to assess the impact of the coronavirus disease-2019 pandemic on referral complaints.

MATERIALS AND METHODS

All new outpatients who applied to the pediatric rheumatology department between March 2019 and February 2021 and were not diagnosed with rheumatic disease were included. We also compared the frequency of admission symptoms during the pre-pandemic (March 2019-February 2020) and pandemic periods (March 2020-February 2021).

RESULTS

A total of 1089 patients without a rheumatic disease diagnosis (568 female, 52.2%; median age 10.0 years) were included in this study. The most common complaint for referral was prolonged or recurrent fevers (13.4%) followed by anti-nuclear antibody positivity (13.1%), arthralgia (13.0%), skin findings (7.5%), and the presence of heterozygous mutations in the Mediterranean fever gene (6.9%). During the pandemic year, the number of patients referred for back pain increased significantly (P = .028). A total of 682 of 1089 patients were consulted from other departments in our center (62.6%). Of these, the most frequent consultation request was from general pediatrics (43.6%). The rheumatic disease was excluded in 11.3% of the patients.

CONCLUSION

Prolonged or recurrent fever and anti-nuclear antibody positivity were the most frequent complaints of referrals to a pediatric rheumatology unit in patients who did not have a rheumatic disease. The rate of back pain was more common in children during the pandemic period.

Critical roles of cytokine storm and bacterial infection in patients with COVID-19: therapeutic potential of mesenchymal stem cells

The severe acute respiratory syndrome coronavirus 2 has been a shocking disaster for healthcare systems worldwide since December 2019. This virus can affect all systems of the body and its symptoms vary from a simple upper respiratory infection to fatal complications including end-organ damage. On the other hand, the normal immune system plays a pivotal role in the recovery of infectious diseases such as COVID-19. However, occasionally, exaggerated immune system inflammation and an excessive synthesis of cytokines, known as a "cytokine storm," can deteriorate the patient's clinical condition. Secondary bacterial co-infection is another problem in COVID-19 which affects the prognosis of patients. Although there are a few studies about this complication, they suggest not using antibiotics commonly, especially broad-spectrum ones. During this pandemic, various approaches and therapeutics were introduced for treating COVID-19 patients. However, available treatments are not helpful enough, especially for complicated cases. Hence, in this era, cell therapy and regenerative medicine will create new opportunities. Therefore, the therapeutic benefits of mesenchymal stem cells, especially their antimicrobial activity, will help us understand how to treat COVID-19. Herein, mesenchymal stem cells may stop the immune system from becoming overactive in COVID-19 patients. On the other side, the stem cells' capacity for repair could encourage natural healing processes.

Clinical impact and disease evolution of SARS-CoV-2 infection in familial Mediterranean fever

The innate immune system is critically involved in the pathogenesis of familial Mediterranean fever (FMF), characterized by dysregulated inflammasome activity and recurrent inflammatory attacks: this is the most common among monogenic autoinflammatory diseases, which shares some biochemical pathways with the severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) infection. In this short review we explore the overlap in the pathophysiology of FMF and SARS-CoV-2 infection, discussing how to understand better the interaction between the two diseases and optimize management. A poorer outcome of SARS-CoV-2 infection seems not to be present in infected FMF patients in terms of hospitalization time, need for oxygen support, need for intensive care, rate of complications and exitus. Long-term surveillance will confirm the relatively low risk of a worse prognosis observed so far in SARS-CoV-2-infected people with FMF. In these patients COVID-19 vaccines are recommended and their safety profile is expected to be similar to the general population.

Multisystemic inflammatory syndrome related to COVID-19, with latent tuberculosis in bone marrow, and satisfactory response to tocilizumab, in a 7-year-old boy

Paediatric inflammatory multisystem syndrome temporally associated with COVID-19 (PIMS-TS) or multisystem inflammatory syndrome in children (MIS-C) is a new acute-onset systemic inflammatory disease, which mainly affects children. Latent tuberculosis infection (LTBI) is characterized by the presence of immune sensitization to Mycobacterium tuberculosis (MTB) in the absence of any clinical or radiological evidence of active disease. We present a child with MIS-C related to COVID-19, with latent TB in the bone marrow, and satisfactory response to tocilizumab. It is important to pay attention in the investigation of TB cases in countries with a high prevalence of tuberculosis, especially when opting for immunusuppression.

Different Course of SARS-CoV-2 Infection in Two Adolescents With Other Immunosuppressive Factors

Even after two years of the Coronavirus Disease 2019 (COVID-19) pandemic, despite known risk factors, we are still unable to predict the severity of the infection in specific patients. Due to the contradictory data, the protective role of immunosuppression in preventing the severe course of the infection remains uncertain. Therefore, we want to discuss the influence of several immunosuppressive factors on the COVID-19 pattern in children, based on two case reports regarding 17-year-old boys with other immunosuppressive factors and a completely different course of the disease. The first patient suffered from AIDS, syphilis and primary central nervous system B-cell lymphoma, treated with radiotherapy. He experienced a light path of the infection, presenting only periodically appearing cough with no X-ray inflammatory changes. Nevertheless, due to the risk of severe COVID-19 and transient hypoxia, remdesivir was administered. He remained in a generally good condition and his follow-up did not reveal any noticeable complications. The second patient was characterised by Down syndrome, obesity, polyarteritis nodosa and chronic immunosuppressive therapy. He developed massive pneumonia, required treatment in the intensive care unit with the use of mechanical ventilation, remdesivir and anakinra. Despite the initial improvement of his general condition, including the degree of lung involvement and respiratory function, he developed an intracerebral haemorrhage, leading to brain herniation and ultimately death. In conclusion, HIV infection, oncological and immunosuppressive treatment do not seem to predispose to the severe course of COVID-19, whereas Down syndrome and obesity do.

Therapeutic Strategies for COVID-19 Lung Disease in Children

The novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection has milder presentation in children than in adults, mostly requiring only supportive therapy. The immunopathogenic course of COVID-19 can be divided in two distinct but overlapping phases: the first triggered by the virus itself and the second one by the host immune response (cytokine storm). Respiratory failure or systemic involvement as Multisystem Inflammatory Syndrome in Children (MIS-C) requiring intensive care are described only in a small portion of infected children. Less severe lung injury in children could be explained by qualitative and quantitative differences in age-related immune response. Evidence on the best therapeutic approach for COVID-19 lung disease in children is lacking. Currently, the approach is mainly conservative and based on supportive therapy. However, in hospitalized children with critical illness and worsening lung function, antiviral therapy with remdesivir and immunomodulant treatment could be considered the "therapeutic pillars."

Interleukin-1 in COVID-19 Infection: Immunopathogenesis and Possible Therapeutic Perspective

The newfound coronavirus disease 2019 (COVID-19), initiated by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is an international public health concern, threatening the lives of millions of people worldwide. The virus seems to have a propensity to infect older males, especially those with underlying diseases. The cytokine storm following hyperactivated immune responses due to SARS-CoV-2 infection is probably the crucial source of severe pneumonia that leads to acute lung injury, systemic inflammatory response syndrome, or acute respiratory distress syndrome, and finally multiple organ dysfunction syndromes, as well as death in many cases. Several studies revealed that interleukin (IL)-1β levels were elevated during COVID-19 infection. In addition, the IL-1 cytokine family has a pivotal role in the induction of cytokine storm due to uncontrolled immune responses in COVID-19 infection. This article reviews the role of IL-1 in inflammation and utilization of IL-1 inhibitor agents in controlling the inflammatory outcomes initiated by SARS-CoV-2 infection.

Current Take on Systemic Sclerosis Patients' Vaccination Recommendations

Systemic sclerosis (SSc) is a rare autoimmune inflammatory rheumatic disease. The prevalence of SSc ranges from 7 to 700 cases per million worldwide. Due to multiple organ involvement and constant inflammatory state, this group of patients presents an increased risk of infectious diseases. This paper aimed to gather the up-to-date evidence on vaccination strategies for patients with SSc and to be a useful tool for the prevention and management of infectious diseases. The authors conducted a scoping review in which each paragraph presents data on a specific vaccine’s safety, immunogenicity, and efficacy. The work deals with the following topics: SARS-CoV-2, seasonal influenza, S. pneumoniae, HAV, HBV, HZV, N. meningitidis, H. influenzae, HPV, and diphtheria-tetanus-pertussis.

Impact of COVID-19 on Pediatric Immunocompromised Patients

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Rheumatology university faculty opinion on coronavirus disease-19 (COVID-19) vaccines: the vaXurvey study from Egypt

OBJECTIVES

The aim of the present work was to explore the perspectives of Egyptian Rheumatology staff members as regards the coronavirus disease-19 (COVID-19) vaccine.

METHODS

The survey is composed of 25 questions. Some questions were adapted from the global rheumatology alliance COVID-19 survey for patients.

RESULTS

187 rheumatology staff members across Egypt from 18 universities and authorizations actively participated with a valid response. The mean time needed to complete the survey was 17.7 ± 13 min. Participants were 159 (85%) females (F:M 5.7:1). One-third agreed that they will be vaccinated once available, 24.6% have already received at least one dose, 29.4% are unsure while 16% will not take it. Furthermore, 70.1% agreed that they will recommend it to the rheumatic diseases (RD) patients once available, 24.1% are not sure while 5.9% will not recommend it. RD priority to be vaccinated against COVID-19 in descending order include SLE (82.9%), RA (55.1%), vasculitis (51.3%), systemic sclerosis (39.6%), MCTD (31.6%), Behcet's disease (28.3%). The most common drugs to be avoided before vaccination included biologics (71.7%), DMARDs (44.4%), biosimilars (26.7%), IVIg (17.1%) and NSAIDs (9.1%).

CONCLUSIONS

The results of the study and specifically the low rate of acceptability are alarming to Egyptian health authorities and should stir further interventions to reduce the levels of vaccine hesitancy. As rheumatic disease patients in Egypt were not systematically provided with the vaccine till present, making the vaccine available could as well enhance vaccine acceptance. Further studies to investigate any possible side effects, on a large scale of RD patients are warranted.

Current Understanding of Multisystem Inflammatory Syndrome (MIS-C) Following COVID-19 and Its Distinction from Kawasaki Disease

PURPOSE OF REVIEW

In this article, I have reviewed current reports that explore differences and similarities between multisystem inflammatory syndrome in children (MIS-C) and other known multisystem inflammatory diseases seen in children, particularly Kawasaki disease.

RECENT FINDINGS

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a human coronavirus causing the COVID-19 disease which emerged in China in December 2019 and spread rapidly to the entire country and quickly to other countries. Currently, there is a pandemic of SARS-CoV-2 infection that results in 20% of patients admitted to hospital with illness, with 3% developing intractable acute respiratory distress syndrome (ARDS) with high mortality. However, pediatric COVID-19 is still reported to be a mild disease, affecting only 8% of children. Pathogenesis in children is comparable to adults. There are suggested impaired activation of IFN-alpha and IFN regulator 3, decreased cell response causing impaired viral defense, yet the clinical course is mild, and almost all children recover from the infection without major complications. Interestingly, there is a subset of patients that develop a late but marked immunogenic response to COVID-19 and develop MIS-C. Clinical features of MIS-C resemble certain pediatric rheumatologic diseases, such as Kawasaki disease (mucocutaneous lymph node syndrome) which affects small-medium vessels. Other features of MIS-C resemble those of macrophage activation syndrome (MAS). However, recent research suggests distinct clinical and laboratory differences between MIS-C, Kawasaki disease, and MAS. Since the start of the SARS-CoV-2 pandemic, MIS-C has become the candidate for the most common cause of acquired heart disease in children.

COVID-19 in the Context of Inborn Errors of Immunity: a Case Series of 31 Patients from Mexico

INTRODUCTION

Patients with inborn errors of immunity (IEI) have a compromised or inappropriate immune response. Although they might be considered a high-risk group for severe SARS-CoV-2 infection, the reported impact of COVID-19 in these patients has been reassuring, while the differential susceptibility of distinct types of IEI remains unclear.

OBJECTIVE

We aimed to describe the findings and outcomes of our known patients with IEI who were diagnosed with COVID-19.

METHODS

In a retrospective study from March 2020 to February 2021, four centers in Mexico collected clinical, laboratory, and genetic data from pediatric and adult patients with known diagnoses of IEI who presented with COVID-19, based on compatible symptoms and positive SARS-CoV-2 testing or known household exposure.

RESULTS

We report 31 patients with known IEI from Mexico who presented with SARS-CoV-2 infection. Seventy-four percent were male, 52% were pediatric, and 81% survived. Their ages ranged from 5 months to 56 years, with a median of 17 years. Sixty-five percent had predominant antibody deficiencies, 48% were hospitalized, and 26% required ICU. Pediatric patients had a higher hospital admission rate than adults. Inpatient mortality was 40%, and ICU mortality rate was 63%. Forty-eight percent developed pneumonia, while 36% had evidence of hyperinflammation (4 adults and 7 children). Predominant laboratory features were lymphopenia and thrombocytopenia, seen in 70 and 44% of patients, respectively. The serum D-dimer median value was 2.6 (0.5-20.6) μg/mL, and the median highest ferritin value was 1015 (32-10,303) ng/mL. Intravenous immunoglobulin was used in 80% of patients. Other treatments included macrolides (39%) and corticosteroids (29%). Six patients died from secondary infection or uncontrolled systemic inflammation.

DISCUSSION

Although impaired immunity due to IEI may be a predisposing factor for severe COVID-19, most of our patients with IEI who acquired the SARS-CoV-2 infection developed a well-tolerated infection and survived, as have more than 80% of worldwide reported patients to date. An impaired immune or inflammatory response may be a predisposing factor for some and a protective factor for others. A systematic review of the literature could help identify those patients at risk of severe disease and complications. Healthcare-associated infections should be aggressively prevented.

Postdischarge rheumatic and musculoskeletal symptoms following hospitalization for COVID-19: prospective follow-up by phone interviews

To describe the rheumatic and musculoskeletal symptoms at hospitalization as well as their persistence/severity after discharge with coronavirus disease 2019 (COVID-19) and to identify whether age, sex, body mass index (BMI), and length of hospital stay are associated with persistence of these symptoms. In this single-center cohort study, comprising 300 participants, two phone interviews were conducted (2-week and 1-month after hospitalization) and symptoms were queried with a standardized form. This form included musculoskeletal symptoms and other COVID-19 symptoms. Considering all symptoms (musculoskeletal and other), 100.0%, 86.7%, and 72.0% of patients reported one or more symptoms, at hospitalization, 2-week, and 1-month, respectively. Considering only musculoskeletal symptoms, 92.3%, 72.7%, and 56.3% of patients reported any musculoskeletal symptom at hospitalization, 2-week, and 1-month, respectively. The musculoskeletal symptoms were fatigue (44.3% of patients reported), back pain (22.7%), arthralgia (22.0%), myalgia (21.0%), low back pain (16.3%), and neck pain (10.3%); the other symptoms were shortness of breath (26.3%), loss of taste (15.0%), cough (14.0%), loss of smell (12.3%), loss of appetite (10.3%), headache (8.7%), sore throat (3.0%), diarrhea (1.3%), dizziness (1.3%), and fever (0.3%) at 1-month. Increasing BMI was associated with higher odds of persistence of fatigue (OR: 1.08, 1.03 to 1.13), myalgia (OR: 1.08, 1.01 to 1.14), and arthralgia (OR: 1.07, 1.02 to 1.14, p = 0.012) at 1-month. Nearly three-quarters reported one or more symptoms, with more than half of patients reported any musculoskeletal symptom at 1 month. The most common musculoskeletal symptom was fatigue, followed by back pain, arthralgia, myalgia, low back pain, and neck pain. The persistence of fatigue, myalgia, and arthralgia was related to BMI. The study results increase our understanding of the spectrum of COVID-19, which, in turn, may lead to more efficient and better care for COVID-19 survivors.

Seroprevalence of Antibodies against SARS-CoV-2 in Children with Juvenile Idiopathic Arthritis a Case-Control Study

There is limited data on the effect of the novel coronavirus disease (COVID-19) caused by severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) on pediatric rheumatology. We examined the prevalence of antibodies against SARS-CoV-2 in children with juvenile idiopathic arthritis (JIA) and a negative history of COVID-19 and the correlation of the presence of these antibodies with disease activity measured by juvenile arthritis disease activity score (JADAS). In total, 62 patients diagnosed with JIA, under treatment with various antirheumatic drugs, and 32 healthy children (control group) were included. Serum samples were analyzed for inflammatory markers and antibodies and their state evaluated with the juvenile arthritis disease activity score (JADAS). JIA patients do not have a higher seroprevalence of anti-SARS-CoV-2 antibodies than healthy subjects. We found anti-SARS-CoV-2 antibodies in JIA patients who did not have a history of COVID-19. The study showed no unequivocal correlation between the presence of SARS-CoV-2 antibodies and JIA activity; therefore, this relationship requires further observation. We also identified a possible link between patients’ humoral immune response and disease-modifying antirheumatic treatment, which will be confirmed in follow-up studies.

SIMILARITIES AND DIFFERENCES BETWEEN FAMILIAL MEDITERRANEAN FEVER AND BEHÇET’S DISEASE

Familial Mediterranean Fever (FMF) is the most common monogenic autoinflammatory disease, mainly affecting populations originating from the Eastern Mediterranean region. Behçet’s Disease (BD) is grouped in polygenic autoinflammatory diseases. It is a systemic vasculitis that affects all types and sizes of blood vessels. The aim of this article is to shed light on similarities and differences between FMF and BD. BD is frequently reported along the ancient Silk Road, extending from the Far East to the Mediterranean basin. Several studies have searched for the association between FMF and BD. FMF is caused by mutations of the MEditerranean FeVer (MEFV) gene while an increased frequency of MEFV mutations is reported in BD patients. Although BD and FMF share some epidemiological and pathophysiological features, there are distinct clinical characteristics of these nosological entities. Mucocutaneous manifestations, especially recurrent oral ulcers, are the most common symptom in BD patients whereas fever accompanied by serosal inflammation is the main clinical presentation in FMF patients.

Therapeutic approaches to pediatric COVID-19: an online survey of pediatric rheumatologists

Data on therapy of COVID-19 in immunocompetent and immunosuppressed children are scarce. We aimed to explore management strategies of pediatric rheumatologists. All subscribers to international Pediatric Rheumatology Bulletin Board were invited to take part in an online survey on therapeutic approaches to COVID-19 in healthy children and children with autoimmune/inflammatory diseases (AID). Off-label therapies would be considered by 90.3% of the 93 participating respondents. In stable patients with COVID-19 on oxygen supply (stage I), use of remdesivir (48.3%), azithromycin (26.6%), oral corticosteroids (25.4%) and/or hydroxychloroquine (21.9%) would be recommended. In case of early signs of “cytokine storm” (stage II) or in critically ill patients (stage III) (a) anakinra (79.5% stage II; 83.6% stage III) or tocilizumab (58.0% and 87.0%, respectively); (b) corticosteroids (oral 67.2% stage II, intravenously 81.7% stage III); (c) intravenous immunoglobulins (both stages 56.5%); or (d) remdesivir (both stages 46.7%) were considered. In AID, > 94.2% of the respondents would not support a preventive adaptation of the immunomodulating therapy. In case of mild COVID-19, more than 50% of the respondents would continue pre-existing treatment with immunoglobulins (100%), hydroxychloroquine (94.2%), anakinra (79.2%) or canakinumab (72.5%), or tocilizumab (69.8%). Long-term corticosteroids would be reduced by 26.9% (< = 2 mg/kg/d) and 50.0% (> 2 mg/kg/day), respectively, with only 5.8% of respondents voting to discontinue the therapy. Conversely, more than 75% of respondents would refrain from administering cyclophosphamide and anti-CD20-antibodies. As evidence on management of pediatric COVID-19 is incomplete, continuous and critical expert opinion and knowledge exchange is helpful.

COVID-19 outcomes in patients with familial Mediterranean fever: a retrospective cohort study

Aim of this study is to investigate the course of coronavirus disease 2019 (COVID-19), in our cohort of familial Mediterranean fever (FMF) patients in means of mortality, admission to hospital and/or intensive care unit and length of hospital stay.A retrospective cohort was formed from patients who have previously been followed with a diagnosis of FMF. Patients of this cohort were retrospectively evaluated for a positive severe acute respiratory syndrome-coronavirus 2 (SARS-CoV 2) polymerized chain reaction (PCR) test result and information regarding hospitalisation, intensive care unit admission and mortality were collected from medical records.Out of a total 496 FMF patients, 34 were detected to have a positive SARS-CoV 2 PCR test. Eighty-five point three percent of these patients were under colchicine treatment and 17.6% were under interleukin (IL)—1 inhibitor treatment. Eight of the 34 patients (23.9%) were found to be hospitalized, one of them was admitted to the intensive care unit and died thereafter (2.9%). An increasing trend in the frequency of comorbid diseases (presence of at least one comorbidity 64.7% in all patients vs 75.0% in hospitalized patients) and IL-1 inhibitor usage (17.6% in all patients vs 50.0% in hospitalized patients) was observed in hospitalized patients.Rates of comorbid diseases and IL-1 inhibitor use for FMF were observed to be increased in FMF patients hospitalized for COVID-19.

Covid-19 in Cartagena and the Bolívar Department, Colombia. Current status, perspectives and challenges until the arrival of the vaccine

COVID-19, caused by SARS-CoV-2, a new coronavirus, was first observed in Wuhan (China) in November 2019. In a short time, SARS-CoV-2 spread across the world, creating a pandemic. There is a need to know the current situation of each country and region and to generate strategies to contain and mitigate the impact on global health and the economy. To control COVID-19 in Cartagena and the Department of Bolívar, Colombia, a strategic network involving public health entities and higher education institutions has emerged. The network has been in place for six months, and 77,122 subjects have been tested in Cartagena and Bolívar Department, of whom 8,260 (10.71%) tested positive (RT-qPCR). Of those who tested positive, 51.4% were male (p>0.05), and 13.1% were health personnel (9.43% female, p < 0.05). The mortality rate was relatively low, 1.22%, with males being the most affected, accounting for 0.9% of deaths (p > 0.05). The daily case report showed upward and downward fluctuations by the mobility restrictions applied to the population, and from day 120 of the start of the pandemic, the epidemiological curve stabilized, and a logarithmic plateau was reached. COVID-19 spread in 39/46 municipalities of Bolívar; however, Bolívar and Cartagena had a low number of cases and deaths compared to other departments and city in Colombia. Cartagena and Bolívar have been given an economic opening with restrictions on crowding and mandatory use of a mouth cover until a vaccine is available. UNIMOL was the first laboratory in Cartagena, Bolívar and Colombia to receive approval from the National Institute of Health to process COVID-19 samples; thanks to the timely diagnosis of cases by UNIMOL, intensive care unit (ICU) occupancy did not exceed capacity, and population confinement was appropriately initiated.

Public interest in rheumatic diseases and rheumatologist in the United States during the COVID-19 pandemic: evidence from Google Trends

To evaluate the public interest in rheumatic diseases during the coronavirus disease 2019 (COVID-19) pandemic. Google Trends was queried to analyze search trends in the United States for numerous rheumatic diseases and also the interest in a rheumatologist. Three 8-week periods in 2020 ((March 15-May 9), (May 10-July 4), and (July 5-August 29)) were compared to similar periods of the prior 4 years (2016-2019). Compared to a similar time period between 2016 and 2019, a significant decrease was found in the relative search volume for more than half of the search terms during the initial March 15-May 9, 2020 period. However, this trend appeared to reverse during the July 5-August 29, 2020 period where the relative volume for nearly half of the search terms were not statistically significant compared to similar periods of the prior 4 years. In addition, this period showed a significant increase in relative volume for the terms: Axial spondyloarthritis, ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis, Sjögren's syndrome, antiphospholipid syndrome, scleroderma, Kawasaki disease, Anti-Neutrophil Cytoplasmic Antibody (ANCA)-associated vasculitis, and rheumatologist. There was a significant decrease in relative search volume for many rheumatic diseases between March 15 and May 9, 2020 when compared to similar periods during the prior 4 years. However, the trends reversed after the initial period ended. There was an increase in relative search for the term "rheumatologist" between July and August 2020 suggesting the need for rheumatologists during the COVID-19 pandemic. Policymakers and healthcare providers should address the informational demands on rheumatic diseases and needs for rheumatologists by the general public during pandemics like COVID-19.

Bell's palsy in a pediatric patient with hyper IgM syndrome and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)

Bell's palsy is an acute facial paralysis with known association to viral infections. We describe a medically complex 6-year-old male with hyper IgM syndrome who presented with unilateral facial droop and positive SARS-CoV-2 RT-PCR. This is the first reported pediatric case of Bell's palsy in the setting of SARS-CoV-2 infection.

Acute respiratory distress syndrome and COVID-19 in a child with systemic lupus erythematosus

We report a case of COVID-19 in a pediatric patient with systemic lupus erythematosus (SLE), who presented with respiratory distress marked by increased work of breathing and low oxygen saturation. Lab tests confirmed COVID-19, and showed lymphocytopenia and elevated markers of inflammation and coagulopathy. Chest X-ray showed bilateral mid-lung opacities, and the patient required intubation early in his disease course. Imaging and clinical findings were consistent with acute respiratory distress syndrome (ARDS) with inflammation. The patient was treated with different combinations of antivirals (hydroxychloroquine and remdesivir), cytokine inhibitors (anakinra and tocilizumab), glucocorticoids (hydrocortisone and methylprednisolone), and an anticoagulant (enoxaparin). Inflammatory markers decreased before clinical improvement in lung aeration. This case highlights the potential for pediatric patients with SLE to present with COVID-19 similar to the clinical presentation described in adults.

Comorbidities in rheumatic diseases need special consideration during the COVID-19 pandemic

Comorbidities in rheumatic and musculoskeletal diseases (RMDs) not only increase morbidity and mortality but also confound disease activity, limit drug usage and increase chances of severe infections or drug-associated adverse effects. Most RMDs lead to accelerated atherosclerosis and variable manifestations of the metabolic syndrome. Literature on COVID-19 in patients with RMDs, and the effects of various comorbidities on COVID-19 was reviewed. The initial data of COVID-19 infections in RMDs have not shown an increased risk for severe disease or the use of different immunosuppression. However, there are some emerging data that patients with RMDs and comorbidities may fare worse. Various meta-analyses have reiterated that pre-existing hypertension, cardiovascular disease, stroke, diabetes, chronic kidney disease, heart failure, lung disease or obesity predispose to increased COVID-19 mortality. All these comorbidities are commonly encountered in the various RMDs. Presence of comorbidities in RMDs pose a greater risk than the RMDs themselves. A risk score based on comorbidities in RMDs should be developed to predict severe COVID-19 and death. Additionally, there should be active management of such comorbidities to mitigate these risks. The pandemic must draw our attention towards, and not away from, comorbidities.

How the COVID-19 pandemic has influenced pediatric rheumatology practice: Results of a global, cross-sectional, online survey

OBJECTIVES

The COVID-19 pandemic is a global health problem. We, as the EMERGE (EMErging RheumatoloGists and rEsearchers) group of PReS (Pediatric Rheumatology European Society) analyzed how the pandemic has affected pediatric rheumatology practice.

METHODS

An online survey was developed to assess changes in pediatric rheumatology practice due to the pandemic. Results were analyzed using descriptive statistics.

RESULTS

From 70 countries, 493 pediatric rheumatologists (80.3% in pediatric rheumatology practice for ≥5 years) responded to the survey. Around 70% disagreed that the pandemic led to reduced prescription of nonsteroidal anti-inflammatory drugs, conventional synthetic and biologic disease-modifying antirheumatic drugs. Almost half were more likely to taper corticosteroids faster. One-fifth hesitated to switch the major immunosuppressant during a flare. Patients encountering difficulties obtaining hydroxychloroquine and tocilizumab due to shortages were noted by 192 (38.9%) and 44 (8.9%), respectively. Twenty to 30% indicated that their patients had experienced a flare or delay in diagnosis/intervention due to postponed appointments.53% mentioned use of phone calls/smartphone applications while 47% shifted towards video consultations for patient care. Respondents indicated an increased number of patients with Kawasaki disease (30%), macrophage activation syndrome (15.6%), unusual vasculitic rashes (31.4%), and hyperinflammation (33.5%) during the pandemic.

CONCLUSION

This is the largest survey to date addressing changes in pediatric rheumatology practice due to the COVID-19 pandemic. Primary changes were due to delays in clinic appointments, increase in use of virtual technologies, and concerns about the use of immunosuppressive therapies. An increased number of patients with Kawasaki disease/hyperinflammation mentioned by the respondents is noteworthy.

[Features of neurological manifestations of the COVID-19 in children and adults]

The number of COVID-19 patients is increasing worldwide and the number of patients with neurological manifestations of a new coronavirus infection is increasing as well. Pathognomonic for COVID-19 is the presence of cephalgic syndrome, infectious-toxic encephalopathy, hypo- and anosmia and ageusia. Inducing of pathological autoimmune response contributes to the development of Miller Fischer and Guillain-Barré syndrome. Hyperergic reaction with the generation of the so-called «cytokine storm» provokes multisystem hemorrhagic complications such as Kawasaki disease and acute necrotizing hemorrhagic encephalopathy. There is also a special form of COVID-19-associated stroke. Almost all post-COVID-19 patients complain of severe fatigue, emotional lability, and sometimes have features of asthenic-neurotic, anxiety-phobic disorders and apato-abulic syndromes, which require rehabilitation measures, as well as courses of restorative neurotrophic and nootropic therapy.

Comparison of Efficacy of Dexamethasone and Methylprednisolone in Improving PaO2/FiO2 Ratio Among COVID-19 Patients

Introduction Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the reason for the global pandemic that started from Wuhan, China, in December 2019, known as coronavirus diseases 2019 (COVID-19). Acute respiratory distress syndrome happened in COVID-19 not just because of uncontrolled viral replication but also because of an uncontrolled immune reaction from the host. That's why antiviral and anti-inflammatory treatments have become an increasing concern for clinicians. Methods A retrospective quasi-experimental study design was used to assess the effectiveness of methylprednisolone and dexamethasone in the improvement of PaO2/FiO2 (P/F) ratio in COVID-19 patients. We included 60 participants for this study by using a convenient sampling technique and divided them into two groups with 30 patients in each group. Group 1 was given dexamethasone 8 mg twice daily, and group 1 given methylprednisolone 40 mg twice daily for eight days. We recorded C-reactive protein (CRP), serum ferritin level, and P/F ratio before administration of both drugs and after administration of drugs for eight days. We used the paired t-test to assess the effect of both drugs on the P/F ratio of participants. Results The initial mean CRP in group 1 was 110.34, which reduced to 19.45 after administration of dexamethasone; similarly, the CRP in group 2 was 108.65, which reduced to 43.82 after administering methylprednisolone for eight days. In P/F ratio improvement, the calculated significance value for dexamethasone (p=0.000) was less than the table value at 0.05 in all sections, p-value for methylprednisolone (p=0.009) was also less than the table value at 0.05, which shows that both dexamethasone and methylprednisolone were effective in improving P/F ratio. Calculated p-value for dexamethasone (p=0.000) was lower than the calculated p-value for methylprednisolone (p=0.009), which shows that dexamethasone is more effective as compare to methylprednisolone. Conclusions Steroid therapy is effective in controlling inflammation markers, and especially dexamethasone is significantly effective in improving the P/F ratio in COVID-19 patients.

Does immunosuppressive treatment entail an additional risk for children with rheumatic diseases? A survey-based study in the era of COVID-19

The aim of the research was to further extend current knowledge of whether severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) disease 2019 (COVID-19) entails a risk for children with various rheumatic diseases under immunosuppressive treatment. Telephone survey was administered by conducting interviews with the parents from May 1, 2020 to May 20, 2020. A message containing a link to the actual questionnaire was sent to their phones simultaneously. The medical records of the patients were reviewed for gathering information about demographic data, clinical follow-up, and treatments. Patients who were followed-up under immunosuppressive treatment (n = 439) were attempted to be contacted. The diagnostic distribution of patients (n = 414) eligible for the study was as follows: juvenile idiopathic arthritis (JIA) (n = 243, 58.7%), autoinflammatory diseases (n = 109, 26.3%), connective tissue diseases (n = 51, 12.3%), and vasculitis (n = 11, 2.7%). In the entire cohort, the mean age was 12 ± 4.7 years, and 54.1% (n = 224) were female. Nine patients have attended the hospital for COVID-19 evaluation, 6 of whom were in close contact with confirmed cases. One patient with seronegative polyarticular JIA, previously prescribed methotrexate and receiving leflunomide during pandemic was identified to be diagnosed with COVID-19. None, including the confirmed case, had any severe symptoms. More than half of the patients with household exposure did not require hospitalization as they were asymptomatic. Although circumstances such as compliance in social distancing policy, transmission patterns, attitude following contact may have influenced the results, immunosuppressive treatment does not seem to pose an additional risk in terms of COVID-19.

Kawasaki-like disease in children with COVID-19

Children with Coronavirus disease 2019 (COVID-19) are being reported to have manifestations of hyperinflammatory states and/or Kawasaki-like disease. In this study, we investigated children with typical and atypical Kawasaki disease (KD) likely to be associated with COVID-19. We have reported four children with Kawasaki-like disease probably associated with COVID-19. The clinical features were consistent with incomplete KD in three patients. SARS-CoV-2 RT-PCR was positive in one and the serology was positive in one patient with negative RT-PCR. Corticosteroids, anakinra, intravenous immunoglobulin (IVIG), and acetylsalicylic acid were used in the treatment. Three patients recovered after the treatment while one patient died. The literature review revealed 36 articles describing 320 children with Kawasaki-like disease associated with COVID-19. SARS-CoV-2 RT-PCR was negative in 120 (65.5%) of 183 patients while the serology was positive in 130 (83.8%) of 155 patients. The therapeutic options have included IVIG, acetylsalicylic acid, tocilizumab, anakinra, enoxaparin, and methylprednisolone. Pediatric COVID-19 cases may present with atypical/incomplete Kawasaki-like disease. Thus, pediatricians need to be aware of such atypical presentations resembling KD for early diagnosis of COVID-19.

Management of childhood-onset autoinflammatory diseases during the COVID-19 pandemic

Concerns regarding the comorbidity as a significant risk factor for Coronavirus Disease-2019 (COVID-19), gave rise to an urgent need for studies evaluating patients with chronic conditions such as autoinflammatory diseases (AIDs). We prepared a web-based survey investigating the clinical findings and contact histories among pediatric patients with AIDs. Confirmed COVID-19 cases, patients with contact history and those with symptoms which were highly suggestive of COVID-19 were called via phone or recruited to a video or face to face appointment. Data of AIDs were obtained from their medical records, retrospectively. Laboratory and screening findings were confirmed by our national health registry website. There were 404 patients (217 female) eligible for the enrollment. During pandemic, 375 (93%) were on colchicine treatment and 48 (11.8%) were receiving biologic treatment. Twenty-four out of 404 patients were admitted to hospital due to COVID-19 suspicion. Severe acute respiratory syndrome coronavirus-2 (SARS CoV-2) was identified through rhinopharyngeal swabs in seven patients, six of whom were only on colchicine treatment. Only one patient with no finding of any severe respiratory complications was hospitalized. All of seven patients recovered completely. Among patients on biologic drugs, neither a symptom nor a positive polymerase chain reaction test for COVID 19 was detected. In conclusion, pediatric patients with AIDs, those receiving biologic treatment and/or colchicine, may not be at increased risk for neither being infected nor the severe disease course.

Salient Conclusive Remarks on Epidemiology and Clinical Manifestations of Pediatric COVID-19: Narrative Review

The ongoing pandemic of COVID-19, which is caused by the novel coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), constituted significant public health concerns and impacted the human populations with massive economic and social burdens worldwide. The disease is known to infect people of all ages, including children, adults, and the elderly. Although several reports about pediatric COVID-19 were seen in the literature, we believe that the epidemiology and pathology of the infection described in these reports are not conclusive. Therefore, in this scientific communication, a narrative review study was performed to shed some light on the characteristic epidemiological features and clinical phenotypes of pediatric COVID-19. In this report, we had compiled and presented the different epidemiological features of the disease related to the age of infection, virus acquisition, explanations of the low infectivity rates, and consequences of infections. The discriminatory clinical manifestations of the disease in children were also addressed and discussed in this review. The search included the data published from the date of the start of the pandemic in December 2019 up to October 2020. Our literature search revealed that children of all ages, including neonates, had been infected by the virus. Despite the fact that pediatric COVID-19 is less common to occur, as compared to the disease in adults, the infected children usually manifest the disease symptomatology in benign form. Asymptomatic and symptomatic adult patients are the primary source of the virus to the children. Intrauterine transmission of the virus and breastfeeding infections to the neonates were hypothesized in some studies but ruled out since they were not confirmed. Intensive review and discussion warranting the low infection rates and benign conditions of COVID-19 in children were also made in this study. As documented in many studies, the infectivity, morbidity, and mortality rates of the disease among the children populations are much lower than those in adults. They also seem to be lower than those observed during SARS-CoV and MERS-CoV epidemics. The described clinical phenotypes of COVID-19 in children do not differ much from those of adults, and complications of the disease seem to be associated with comorbidities.