Novel coronavirus disease 2019 (COVID-19) outbreak in children in Iran: Atypical CT manifestations and mortality risk of severe COVID-19 infection

Predictive factors for COVID-19 severity and mortality in hospitalized children

BACKGROUND

Understanding the factors influencing disease progression and severity in pediatric COVID-19 cases is essential for effective management and intervention strategies. This study aimed to evaluate the discriminative ability of clinical and laboratory parameters to identify predictors of COVID-19 severity and mortality in hospitalized children.

METHODS

In this multicenter retrospective cohort study, we included 468 pediatric patients with COVID-19. We developed a predictive model using their demographic, clinical, and laboratory data. The performance of the model was assessed using various metrics including sensitivity, specificity, positive predictive value rates, and receiver operating characteristics (ROC).

RESULTS

Our findings demonstrated strong discriminatory power, with an area under the curve (AUC) of 0.818 for severity and 0.873 for mortality prediction. Key risk factors for severe COVID-19 in children include low albumin levels, elevated C-reactive protein (CRP), lactate dehydrogenase (LDH), and underlying medical conditions. Furthermore, ROC curve analysis highlights the predictive value of CRP, LDH, and albumin, with AUC values of 0.789, 0.752, and 0.758, respectively.

CONCLUSION

Our study indicates that laboratory values are valuable in predicting COVID-19 severity in children. Various factors, including CRP, LDH, and albumin levels, demonstrated statistically significant differences between patient groups, suggesting their potential as predictive markers for disease severity. Implementing predictive analyses based on these markers could aid clinicians in making informed decisions regarding patient management.

The effects of Annual SZ drug on dynamic changes in lymphocytes and cytokines of COVID-19 patients: A randomized clinical trial

BACKGROUND

The search for a potent anti-coronavirus therapy has remained an overwhelming task since the outbreak of COVID-19. Annual SZ is a novel formulation of artemisinin and its derivatives. We aim to investigate the effect of Annual SZ on clinical outcomes, cellular immune responses, and cytokine changes in COVID-19 patients.

METHODS

This study included 80 COVID-19 hospitalized patients, which were randomly allocated into two groups (intervention and control). Both groups received standard supportive treatment. In addition, the intervention group (n = 40) received Annual SZ syrup, and the control group (n = 40) received a placebo. Dynamic changes in lymphocytes, cytokines, and clinical status were evaluated since hospital admission to 7 and 14 days after treatment.

RESULTS

The dynamic count of total T lymphocytes and T lymphocyte subsets (CD4+ and CD8+) in the Annual SZ group was significantly higher than the placebo group (p < 0.05). In addition, Programmed Death 1 (PD-1) was significantly increased in the CD4+ and CD8+ T cells in the placebo group compared with the Annual SZ group (p < 0.05). Also, the CD4+/CD8+ ratio was not significantly different between the groups (p > 0.9). Moreover, IL-6 levels were significantly reduced (p < 0.05), while IL-4 and IFN-γ levels were not statistically different between the two groups (p > 0.05).

CONCLUSION

This research indicated that the Annual SZ syrup significantly improved clinical status and lymphocyte frequency with less exhaustion of T lymphocytes and a reduction of inflammatory responses, which seems to be beneficial in the treatment process of COVID-19 patients.

The nosocomial infection survey among patients suffering from the Coronavirus disease-2019 hospitalized in Ayatollah Rouhani Hospital, Babol

Background

Having a weakened immune system can make patients easily get nosocomial infection (NI) with multi-drug resistant (MDR) bacteria and put them in a dangerous situation. It causes long hospital stays, disability, economic burden, and even death. The present study aimed to determine the prevalence of NI in patients suffering from COVID-19.

Methods

In this retrospective study, the information on 250 patients suffering from COVID-19 in the intensive care unit (ICU) (2020 to 2021) was considered. For statistical analysis, analysis of variance (ANOVA), paired samples t-test, and chi-square using SPSS-23 software were used (p<0.05).

Results

Two hundred and fifty hospitalized (107 females and 143 males, mean ± standard deviation (SD) of age; 56.50 ± 17.20) patients were considered. The most (97.60%) medicine prescribed was remdesivir. Candida spp. (two females), Escherichia coli (two females), Acinetobacter spp. (one female), Citrobacter spp. (one female), Pseudomonas spp. (one male), Sphingomonas spp. (one male), Stenotrophomonas spp. (one male) and Enterobacter spp. (one male) were isolated from the patient's specimens. Four of seven bacterial isolates were positive for MDR. NI was diagnosed in six patients. There was no significant relationship between the age with the isolated microbes (P=0.154) and MDR (P=0.987) and also between gender with common microbes (P=0.576) and MDR (P=0.143).

Conclusion

The coexistence of bacteria and NI was observed in patients. Remdesivir was prescribed for most patients. Most bacteria were resistant to antibiotics, especially, β-lactams.

Risk perception and avoidance of preventive behavior on the COVID-19 among cancer patients

Background and Aims

Willingness to engage in preventive behaviors against coronavirus disease 2019 (COVID-19) depends on people's risk perception. This is especially important in cancer patients who are at risk of complications from the disease. Therefore, this study was conducted to investigate avoidance of COVID-19 preventive behavior of in cancer patients.

Methods

This cross-sectional analytical study was done with 200 cancer patients who were selected by convenience sampling method. The study was conducted in Imam Khomeini Hospital of Ardabil, Iran from July to August 2020. A researcher-made questionnaire was used to investigate the risk perception of cancer patients towards COVID-19 with seven subscales according to the Extended Parallel Process Model. Data were analyzed by SPSS 20 using Pearson correlation and linear regression tests.

Results

The mean and standard deviation of the age of 200 participants (including 109 men and 91 women) was 48 ± 17. Results showed that the response efficacy (12.6 ± 2.2) had the highest mean and defensive avoidance (8 ± 2.8) had the lowest mean score among EPPM constructs. Linear regression results showed that fear (β = 0.242, p > 0.001), and perceived severity (β = 0.191, p = 0.008) were significant predictors of defensive avoidance.

Conclusion

Perceived severity and fear were significant predictors of defensive avoidance, and providing accurate and reliable news and information can be effective in reducing fear and promoting preventive behaviors.

Ocular manifestations of COVID-19 in pediatric patients

The coronavirus disease-19 (COVID-19) infection may remain asymptomatic or may have several different presentations. Although this disease primarily affects the respiratory system, systemic manifestations affecting the gastrointestinal, cardiovascular, neurological, otorhinolaryngologic, and ophthalmic systems have been reported. Ophthalmic signs may be the first and only sign of COVID-19 infection in children. In the current narrative review, we report the ophthalmic manifestations of COVID-19 in the pediatric age cohort. We performed a comprehensive literature search for the publications on ophthalmic manifestations of COVID-19 in children between 1 March 2020 and 1 January 2022 and compiled the ophthalmic manifestations of this entity among the pediatric population. Conjunctivitis is the most common ophthalmic manifestation in children and can develop at any stage of the disease. Ophthalmic manifestations are seen more commonly in children with severe systemic disease. Long-term and indirect consequence of the COVID-19 disease is the rise of myopia among children. Ophthalmic signs may be the first and only sign of COVID-19 infection in children. Pediatricians, as well as ophthalmologists, must keep observing all children with COVID-19 closely for ophthalmic signs.

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 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.

Cavitary lung lesions in a neonate: Potential manifestation of COVID-19 related multisystem inflammatory syndrome

BACKGROUND

The hyperinflammatory state of multisystem inflammatory syndrome in children (MIS-C) predisposes to thromboembolic complications. We report a neonate with multiple cavitary lesions in lung, which we suspect could be a manifestation of multisystem inflammatory syndrome in neonate (MIS-N) following maternal COVID-19 infection during pregnancy.

CASE REPORT

Eight-day-old neonate was referred with fever and fast breathing. Mother was positive for COVID-19 in 29th week. COVID-19 reverse-transcription polymerase chain reaction was negative, however, antibodies were positive. He had increased leucocyte count, and elevated levels of C-reactive protein (CRP), procalcitonin, ferritin, lactate dehydrogenase, and d-dimer along with bilateral reticulonodular opacities on chest radiograph and multiple nodules with evidence of cavitation in both lungs on chest tomography. All cultures were negative. A possible diagnosis of MIS was made. Infant was treated with intravenous immunoglobulin (IVIG) which he responded to with resolution of symptoms.

CONCLUSION

Neonates exposed to COVID-19 should be evaluated for thromboembolic complications and IVIG can be one of the treatment modalities.

Gastrointestinal viral shedding in children with SARS-CoV-2: a systematic review and meta-analysis

BACKGROUND

Coronavirus disease 2019 (COVID-19) has different manifestations in pediatric cases. It is assumed that they might present more gastrointestinal symptoms with a different viral shedding pattern in gastrointestinal samples. In this systematic review and meta-analysis, we aimed to evaluate the viral shedding pattern in gastrointestinal specimens of children with COVID-19.

METHODS

We searched all published studies in English language in PubMed, Web of Science, and Scopus, up to date as of October 2021. Our search included the term "severe acute respiratory syndrome coronavirus 2, COVID-19, SARS-CoV-2, novel coronavirus, or coronavirus; and shed, excrete, secret, or carriage; and stool or rectal; and children or pediatrics". We included studies evaluating SARS-CoV-2 shedding in gastrointestinal specimens, including rectal swabs and stool samples of children with COVID-19 infection. We excluded duplicated data, case reports, and studies without original data.

RESULTS

Twelve studies met the eligibility criteria for the qualitative synthesis, 10 of which were included in the meta-analysis. The pooled prevalence of gastrointestinal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA in children with COVID-19 was 86% (95% confidence interval 73%-96%, I² = 62.28%). After respiratory specimen had become negative, 72% (43/60) had persistent shedding in gastrointestinal specimens. The gastrointestinal RNA had a positive test result for more than 70 days after symptoms onset.

CONCLUSIONS

Gastrointestinal shedding of SARS-CoV-2 might occur in a substantial portion of children and might persist long after negative respiratory testing. Further research is recommended to find the role of SARS-CoV-2 gastrointestinal shedding in transmission in children.

Evaluation of human coronavirus OC43 and SARS-COV-2 in children with respiratory tract infection during the COVID-19 pandemic

The coronavirus disease 2019 (COVID‐19) pandemic is an overwhelming crisis across the world. Human Coronavirus OC43 (HCoV‐OC43) is a Betacoronavirus responsible mostly for mild respiratory symptoms. Since the presentations of HCoV‐OC43 and severe acute respiratory syndrome coronavirus 2 (SARS‐COV‐2) are believed to resemble a lot, the aim of this study was to evaluate the frequency and characteristics of HCoV‐OC43 in the current pandemic and the rate of coinfection for the two viruses. One hundred and seventeen patients referred to Children's Medical Center, Tehran, Iran with respiratory symptoms were included. Real‐time reverse transcription‐polymerase chain reaction (RT‐PCR) methods were performed for the detection of HCoV‐OC43 and SARS‐COV‐2. Totally, 23 (20%) had a positive RT‐PCR for HCoV‐OC43 and 25 (21%) were positive for SARS‐COV‐2. Two patients (2%) had a positive PCR for both HCoV‐OC43 and SARS‐COV‐2. The two groups showed significant differences in having contact with family members with suspected or confirmed COVID‐19 (p = 0.017), fever (p =  0.02), edema (p = 0.036), vomiting (p < 0.001), abdominal complaints (p = 0.005), and myalgia (p = 0.02). The median level of lymphocyte count in patients with HCoV‐OC43 was significantly lower than patients with SARS‐COV‐2 infection (p =  0.039). The same frequency of SARS‐COV‐2 and HCoV‐OC43 was found in children with respiratory symptoms during the COVID‐19 pandemic. The rate of coinfection of SARS‐COV‐2 with HCoV‐OC43 in our study was 0.08. Further research into the cocirculation of endemic coronaviruses, such as HCoV‐OC43 and SARS‐CoV2, in different regions, is highly recommended. Attempts to determine the geographic distribution and recruit more flexible test panel designs are also highly recommended.

The same frequency of SARS‐COV‐2 and HCoV‐OC43 was found in children with respiratory symptoms during the COVID‐19 pandemic.

The rate of co‐infection of SARS‐COV‐2 with HCoV‐OC43 was 0.08. The frequency of fever, headache, edema, vomiting, abdominal complaints and myalgia was significantly higher in the HCoV‐OC43 group compared with the SARS‐COV‐2 group.

Computed tomography findings in 3,557 COVID-19 infected children: a systematic review

Background

Although it was assumed in the early stages of the coronavirus disease 2019 (COVID-19) outbreak that the novel coronavirus infection was uncommon among children, the number of infected children has since been increasing significantly. Real-time polymerase chain reaction (RT-PCR) is the gold standard modality for the diagnosis of COVID-19 infection. In adults, chest CT is performed as an adjunct for identifying suspected COVID-19 cases along with patients' management and follow-up. However, CT findings in COVID-19 children studies have shown a diverse incidence of abnormal CT and finding patterns that made CT scan necessity to have remained controversial. The aim of the present review was to comprehensively determine the imaging findings of chest CT scans of confirmed COVID-19-infected pediatric patients through a systematic review of the available published studies.

Methods

A systematic literature search was performed in the PubMed, Embase, Scopus, and Web of Science core collection databases (four databases including SSCI, SCIE, AHCI, and ESCI) to find original articles containing chest CT findings in children with COVID-19 through May 7, 2021. This review included 81 articles published in English that in total included 3,557 pediatric patients.

Results

This review included 81 articles published in English that in total included 3,557 pediatric patients. Among the total confirmed coronavirus-infected cases (via RT-PCR test), two-thirds had abnormal chest CT findings; among these patients, 549 (37.8%) had bilateral lung involvement, and 475 (32.7%) had unilateral disease. Regarding the types of lung lesions, ground glass opacities were observed in 794 (54.7%) of patients, and consolidation was observed in 10.2%; moreover, halo sign, discrete pulmonary nodules, interstitial abnormalities or reticulations, and vascular thickening shadows were reported in 7.4%, 2.6%, 9.7% and 1.7% of the patients, respectively.

Discussion

This review revealed that chest CT scan manifestations in majority of COVID-19 positive children are mild, so regarding the risk of radiation exposure, it is reasonable to confine CT scan to individual cases that its benefits outweigh the risks.

SARS-CoV-2 transmission among health care workers in Iran: an urgent need for early identification and management

INTRODUCTION

By increasing the rate of COVID-19, particularly in developing countries such as Iran, high numbers of frontline service providers, including doctors and nurses, die and makes frontline healthcare workers (HCWs) more vulnerable to the psychological disorders, fear and anxiety of secondary transmission to others, especially their family members. In this study, we aimed to report the incidence of COVID-19 infection among HCWs in an Iranian referral pediatrics hospital between April 2020 and July 2020.

MATERIAL AND METHODS

In this retrospective cross-sectional study, HCWs and hospital staff working at Children's Medical Center, Tehran, Iran with positive SARS-CoV-2 RT-PCR test results were evaluated between April 2020 and July 2020.

RESULTS

Sixty-one out of the 1085 personnel (5.6%) including 14 pediatricians (23%), 24 nurses (39%), 9 paramedics (15%), and 14 HCWs without direct patient contact (23%) had a nasopharyngeal specimen positive SARS-CoV-2 RT-PCR test. The mean age was 39.8±10.6 years. Eleven cases (18%) had underlying diseases such as hypertension and asthma. The most common symptoms were fatigue (67%, n=41), dry cough (61%, n=37), fever (52%, n=32), headache (46%, n=28), dyspnea (43%, n=24), anosmia (28%, n=17), chills (26%, n=16), sore throat (26%, n=16), gastrointestinal symptoms (23%, n=14), and productive cough (3%, n=2). Eleven cases (18%) showed lung involvement in their chest X-rays and/or CT scans. Eighteen cases (29.5%) had lymphopenia, and 20 individuals (33%) had a high level of C-reactive protein.

CONCLUSION

In conclusion, in the early phase of the COVID-19 outbreak, a substantial proportion of HCWs with fever, respiratory, and other prevalent symptoms including fatigue and headache were infected with SARS-CoV-2. Therefore, implementation of infection prevention measures, isolation of confirmed HCWs, disinfection of the environment, and regular COVID-19 prevention training for HCWs are strongly recommended for the wellbeing of health workers and minimizing the spread of infection.

COVID-19 infection in children with underlying malignancies in Iran

OBJECTIVES

Although coronavirus disease 2019 (COVID-19) prognosis is mostly good in pediatric patients with no underlying diseases, there are a few reports on children with oncological underlying malignancies. This study aimed to describe the clinical and laboratory features of 20 children with COVID-19 who had underlying malignancies in an Iranian referral pediatrics hospital.

METHODS

All children under 15-year-old of age with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive real-time polymerase chain reaction (PCR) and presence of an underlying malignancy were included in the study.

RESULTS

In this study, among 20 patients, 11 were male (55%). The mean age of the patients was 6.0 ± 4.1 years. Twelve patients (60%) had acute lymphocytic leukemia, two had acute myeloid leukemia (10%), and six had solid organ tumors (30%). The most common symptoms were fever (65%) and cough (65%). We reported severe pneumonia in seven hospitalized patients (35%) and three patients (20%) required intensive care unit admission and mechanical ventilation. Procalcitonin was normal in 73% of the cases (11 out of 15), but it was highly elevated in four cases (27%). Five patients (25%) had positive blood cultures and a mortality of 20% was reported.

CONCLUSIONS

This is the largest study on SARS-CoV-2 infected pediatric patients with underlying malignancies in Iran. Since the risk of exposure to SARS-CoV-2 and even death in children with malignancy, either in the hospital or community setting during the pandemic is high, special precautions to reduce the risk of transmission are highly suggested.

Gastrointestinal Manifestations of Pediatric Coronavirus Disease and Their Relationship with a Severe Clinical Course: A Systematic Review and Meta-analysis

BACKGROUND

Data on the gastrointestinal (GI) manifestations of Pediatric Corona Virus Disease (COVID-19) are conflicting and the relationship between GI involvement and the severity of COVID-19 disease has not been evaluated. The objectives of this systematic review were to determine the GI manifestations of pediatric COVID-19 and to evaluate their role as risk factors for a severe clinical course.

METHODS

: A systematic literature search was carried out in PubMed and Scopus for studies published before 31 December 2020 with information about the GI manifestations of pediatric COVID-19. Patients with a severe and nonsevere clinical course were compared using the inverse variance heterogeneity model and odds ratio (OR) as the effect size. A sensitivity analysis was performed if the heterogeneity was high among studies.

RESULTS

A total of 811 studies were identified through a systematic search of which 55 studies (4369 patients) were included in this systematic review. The commonest GI symptoms were diarrhea-19.08% [95% confidence interval (CI) 10.6-28.2], nausea/vomiting 19.7% (95% CI 7.8-33.2) and abdominal pain 20.3% (95% CI 3.7-40.4). The presence of diarrhea was significantly associated with a severe clinical course with a pooled OR of 3.97 (95% CI 1.80-8.73; p < 0.01). Abdominal pain and nausea/vomiting were not associated with disease severity.

CONCLUSIONS

Diarrhea, nausea/vomiting or abdominal pain are present in nearly one-fifth of all children with COVID-19. The presence of diarrhea portends a severe clinical course.

COVID-19 in transplant recipient children: An Iranian referral hospital-based study

To our knowledge, there is still very limited information on the severity, mortality, laboratory, and radiologic findings of COVID-19 infection in transplant patients, particularly children. In this study, we reported 7 transplant recipients with laboratory-confirmed COVID-19 infection. The median age was 7.5 years (IQR: 31month-10 years), and 71% of the patients were male. All cases presented with a fever. The median duration of fever before admission was 2 days (IQR:1-8 days). Five patients (71%) experienced cough and dyspnea. Lymphocytopenia (Median of 0.6 (IQR: 0.14-2.0 × 10⁹ cells per L) and thrombocytopenia (Median of 65 (IQR: 49-201 × 10⁹ cells per L) were the most common CBC findings (both seen in 5 out of the 7 patients. Among 4 of the patients who underwent CT scans, 2 had ground glass opacity and consolidations. The mean number of lobe involvement in our patients was 3 (0-5), and 75% of the cases showed bilateral lung involvement in the imaging. In 4 patients (51%) the disease course manifested severely, and 2 patients are now deceased (28.6%). In conclusion, immunocompromised pediatric subgroups may experience higher rates of disease severity and mortality in comparison with the immunocompetent pediatric population. (www.actabiomedica.it)

Giant intracardiac thrombosis in an infant with leukaemia and prolonged COVID-19 viral RNA shedding: a case report

Background

COVID-19 can induce thrombotic disease both in the venous and arterial circulations, as a result of inflammation, platelet activation, endothelial dysfunction, and stasis. Although several studies have described the coagulation abnormalities and thrombosis in adult patients with COVID-19, there is limited data in children. Here, we present an 18-month-old boy with a prolonged SARS-CoV‐2 RNA shedding and chronic right atrial and superior vena cava (SVC) thrombosis.

Case presentation

An 18-month-old boy with acute lymphoblastic leukemia (ALL) (pre-B cell ALL) and a history of chemotherapy was referred to our center due to intermittent fever with unknown origin. a positive nasopharyngeal PCR for COVID-19 was reported and stayed positive for eight consecutive weeks The high-resolution computed tomography (HRCT) showed no sign of pulmonary embolism. Initial echocardiography indicated a semilunar thrombotic mass extending from right SVC into the right atrium without coronary or myocardial involvement. Enoxaparin was administered with continuous monitoring of the level of anti-Xa activity. The serial echocardiographic studies found a slow but continuous reduction in the mass size.

Conclusions

Our case shows that, as already described in adult patients, clinically relevant thrombosis can complicate the course of pediatric patients as well. In view of the specific and milder manifestations of COVID-19 in children, these complications may pose considerable diagnostic and therapeutic challenges.

Clinical evaluation of SARS-CoV-2 lung HRCT and RT-PCR Techniques: Towards risk factor based diagnosis of infectious diseases

This study uses image analysis techniques for comparative analysis of the lung HRCT features and RT-PCR of 325 suspected patients to COVID-19 pneumonia. Our findings propose more caution in the interpretation of RT-PCR data, promoting, instead, also the quantification of age and sex-based risk factors using HRCT images. Statistical analysis of our methodology reveals a direct relation between intensity, skewness and kurtosis of the radiological features and the gender of patients. Moreover, we investigate the effect of the age of patients on the appearance of COVID-19 pneumonia in the HRCT images. We have also applied our methodology to investigate the effect of time on the severity of COVID-19 pneumonia within the lungs. Subsequently, we find a strong relationship between image analysis and the informed medical diagnosis asserted by the radiologists. Additionally, our results also indicate increase in the severity of lung infection in the first and second week after the onset of the SARS-CoV-2 symptoms. Thereafter, a gradual decrease in the lung damage is observed during the third week. The proposed image analysis methodology can be used as a simple complementary tool for infectious disease diagnostics as demonstrated in this study with an example of SARS-CoV-2 to provide better understanding of the disease for drug and vaccine development.

Clinical, laboratory, and imaging features of pediatric COVID-19: A systematic review and meta-analysis

Pediatric cases of coronavirus disease 2019 (COVID-19) have been reported. This meta-analysis was aimed at describing the clinical, laboratory, and imaging characteristics of children with COVID-19 based on published data of pediatric COVID-19 cases.Search of PubMed, Embase, Web of Sciences, Science Direct, and Google Scholar for articles published until December 14, 2020, that described the clinical, laboratory, and imaging features of children with COVID-19. Data were extracted independently by 2 authors. Random-effects meta-analysis models were used to report pooled results.Clinical data from 2874 children with COVID-19 from 37 articles were finally included for quantitative analyses. Fever (48.5%, 95% CI: 41.4%-55.6%) and cough (40.6%, 95% CI: 33.9%-47.5%) were the most common symptoms; asymptomatic infection and severe cases, respectively, accounted for 27.7% (95% CI: 19.7%-36.4%) patients and 1.1% of the 1933 patients included. Laboratory tests showed 5.5% (95% CI: 2.8%-8.9%) of the patients had lymphopenia. The pooled prevalence of leukopenia was 7.3% (95% CI: 3.4%-12.2%), and the C-reactive protein level was high in 14.0% (95% CI: 6.8%-22.8%). Chest computed tomography showed unilateral and bilateral lesions, and ground-glass opacity in 29.4% (95% CI: 24.8%-34.3%) and 24.7% (95% CI: 18.2%-31.6%), and 32.9% (95% CI: 25.3%-40.9%), respectively, and normal in approximately 36.0% (95% CI: 27.7%-44.7%).We found that children with COVID-19 had relatively mild disease, with quite a lot of asymptomatic infections and low rate of severe illness. Data from more regions are needed to determine the prevention and treatment strategies for children with COVID-19.

Effects of Coronavirus Disease 2019 (COVID-19) on Peripheral Blood Lymphocytes and Their Subsets in Children: Imbalanced CD4+/CD8+ T Cell Ratio and Disease Severity

Introduction: While pathogenesis in COVID-19 is not fully known and the effects between SARS-CoV-2 and the immune system are complicated, it is known that lymphopenia, hyper-inflammatory responses, and cytokines play an important role in the pathology of COVID-19. While some hematological abnormalities have been described among the laboratory features of COVID-19, there have not been studies reported on lymphocyte subset analyses in children. The aim of this study was to describe lymphocyte subsets in pediatric patients with mild/moderate or severe COVID-19. Methods: The subjects in the study were children with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia confirmed with the real-time RT-PCR. The subjects were admitted to the Children's Medical Center, affiliated with the Tehran University of Medical Sciences, between March 7th and June 10th of 2020. The complete blood counts and lymphocyte subpopulations were analyzed for each patient. Results: The study included 55 hospitalized patients with confirmed SARS-CoV-2 infection (34 patients (62%) with an observed mild/moderate case of the disease and 21 patients (38%) with severedisease). Lymphocyte counts were found to be lower in patients with a severe case (mean ± SD 1.6 ± 0.9 in the severe group vs. 2.3 ± 2.2 in the mild group). Compared to the group with mild/moderate pneumonia, children with severe pneumonia had an increased count of CD8+ T cell and a lower percentage of CD4+ T cell. However, the differences between the groups were negligible. Interestingly, the severe group had a lower CD4+/CD8+ T cell ratio compared to the mild group (1.1 ± 0.47 vs. 1.4 ± 0.8, p-value: 0.063). CD4+/CD8+ T cell ratio <2, 1.5, and 1 was found in 48 (87%), 40 (73%), and 19 cases (35%). All of the seven cases in which the subject passed (13%) had CD4+/CD8+ T cell ratio of <2, 86% had CD4+/CD8+ T cell ratio of <1.5, and 29% had CD4+/CD8+ T cell ratio of <1. Conclusion: The CD4+/CD8+ T cell ratio was lower in patients with severe COVID-19 compared to those with mild/moderate form of disease. However, although a decline in CD4+/CD8+ ratio may serve as a useful metric in analyzing of the derangement in immune responses in patients with severe COVID-19, further study with larger sample sizes is highly recommended.

Prevention, Diagnosis, and Treatment of COVID-19 in Infants and Children: A Systematic Review Study of Performed Protocols

Context: Coronavirus disease 2019 (COVID-19) is one of the most dangerous viral diseases that started spreading in China in 2019 and has caused many deaths so far. Therefore, this study aimed to systematically review studies on the prevention, diagnosis, and treatment of coronavirus in infants and children. Evidence Acquisition: This is a systematic review study conducted in PubMed/Medline, Scopus, Embase, Cochrane Library, Science Direct, and Web of Science (ISI) databases on October 8 2020. Also, we searched Google Scholar to find all in-press articles. To extract data, a checklist was used, which included the author’s name, year of publication, purpose, age group of patients under study, and the protocol applied for coronavirus prevention, diagnosis, and treatment. The search was done with AND, OR, NOT strategies. The results of the study were reported in a descriptive manner using Endnote version 8 software. Results: According to the results of the basic search, 120 articles were extracted on the management of coronavirus. Of the articles extracted, 30 were articles related to children, of which only eight developed protocols for prevention, diagnosis, and treatment in infants and children. Of the studies extracted, six were from China, one from Iran, and one from Australia. It should be noted that the protocols for infants were extracted from two studies on infants and four studies on the pediatric group. Conclusions: It is proposed to consider and study this systematic review of coronavirus management in infants and children.

The JANUS of chronic inflammatory and autoimmune diseases onset during COVID-19 - A systematic review of the literature

The diverse clinical manifestations of COVID-19 is emerging as a hallmark of the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection. While the initial target of SARS-CoV-2 is the respiratory tract, it is becoming increasingly clear that there is a complex interaction between the virus and the immune system ranging from mild to controlling responses to exuberant and dysfunctional multi-tissue directed autoimmune responses. The immune system plays a dual role in COVID-19, being implicated in both the anti-viral response and in the acute progression of the disease, with a dysregulated response represented by the marked cytokine release syndrome, macrophage activation, and systemic hyperinflammation. It has been speculated that these immunological changes may induce the loss of tolerance and/or trigger chronic inflammation. In particular, molecular mimicry, bystander activation and epitope spreading are well-established proposed mechanisms to explain this correlation with the likely contribution of HLA alleles. We performed a systematic literature review to evaluate the COVID-19-related autoimmune/rheumatic disorders reported between January and September 2020. In particular, we investigated the cases of incident hematological autoimmune manifestations, connective tissue diseases, antiphospholipid syndrome/antibodies, vasculitis, Kawasaki-like syndromes, acute arthritis, autoimmune-like skin lesions, and neurologic autoimmune conditions such as Guillain-Barré syndrome. We screened 6263 articles and report herein the findings of 382 select reports which allow us to conclude that there are 2 faces of the immune response against SARS-CoV-2, that include a benign virus controlling immune response and a many faceted range of dysregulated multi-tissue and organ directed autoimmune responses that provides a major challenge in the management of this viral disease. The number of cases for each disease varied significantly while there were no reported cases of adult onset Still disease, systemic sclerosis, or inflammatory myositis.

Dynamic Changes of Lymphocyte Subsets in the Course of COVID-19

Background

Although the pathophysiology of coronavirus disease 2019 (COVID-19) is not clearly defined, among the proposed mechanisms, immune system dysfunction is more likely than others. The aim of this study was to clarify the characteristics and clinical significance of dynamic changes of lymphocyte subsets in the course of COVID-19.

Methods

In this prospective study, the levels of peripheral lymphocyte subsets including CD4⁺, CD8⁺, CD4⁺CD25⁺FOXP3⁺, CD38⁺, CD3⁺HLA-DR⁺, CD19⁺, CD20⁺, and CD16⁺CD56⁺ cells were measured by flow cytometry in 52 confirmed hospitalized patients with COVID-19 at the day of admission and after 7 days of care. Clinical response was defined as improvement in symptoms (fever, dyspnea, and cough as well as blood oxygen saturation), and patients who met these criteria after 1 week of admission were classified as early responders; others who survived and finally discharged from the hospital were classified as late responders and patients who died were categorized as nonresponders. Immunophenotyping of studied cell changes on the first day of admission and 7 days after treatment were compared. Besides, the correlation between cellular subset variation and clinical response and outcome were analyzed.

Results

Total counts of white blood cell, T cells, CD4⁺ T cells, CD8⁺ T cells, CD38⁺ lymphocytes, and CD3⁺HLA-DR⁺ lymphocytes were significantly increased in both early and late responders. No statistically significant difference was observed in CD4⁺/CD8⁺ ratio, B cells, FOXP3⁺T_reg lymphocytes, and FOXP3 median fluorescence intensity among studied groups. According to the multivariate analysis, an increase in CD4⁺ T cells (p = 0.019), CD8⁺ T cells (p = 0.001), and administration of interferon (p < 0.001) were independent predictors of clinical response.

Conclusion

We found an increasing trend in total T cells, T helpers, cytotoxic T cells, activated lymphocytes, and natural killer cells among responders. This trend was not statistically significant among nonresponders. The findings of this study may enhance our knowledge about the pathogenesis of COVID-19.

Fulminant hepatic failure: A rare and devastating manifestation of Coronavirus disease 2019 in an 11-year-old boy

Although several typical manifestation of novel coronavirus disease 2019 (COVID-19) including respiratory symptoms, weakness, fever, and fatigue have been reported, some rare and novel manifestations have also been observed, particularly in children. We report a pediatric case of fulminant hepatic failure associated with COVID-19. Although the patient was treated for acute fulminant hepatic failure in the context of COVID-19, he died following the progression of the disease to stage 4 hepatic failure with encephalopathy and brain death.

Multisystem inflammatory syndrome associated with SARS-CoV-2 infection in 45 children: a first report from Iran

During the coronavirus disease 2019 (COVID-19) pandemic, a new phenomenon manifesting as a multisystem inflammatory syndrome in children (MIS-C) which has a similar clinical presentation to Kawasaki disease, toxic shock syndrome and severe sepsis has emerged. Although the number of MIS-C reports is increasing, rare reports in Asia is still available. To our knowledge, this study is the largest series of published MIS-C cases in Iran. We performed a retrospective study of all patients with case definition for MIS-C admitted to the three paediatric hospitals in Iran. All of these hospitals are located within the most active COVID-19 pandemic areas (Tehran, Qom and Mazandaran) in Iran. Demographic characteristics, clinical data, laboratory findings, imaging and echocardiographic findings, treatment and outcomes were collected. Between 7 March and 23 June 2020, 45 children were included in the study. The median age of children was 7 years (range between 10 months and 17 years). Common presenting symptoms include fever (91%), abdominal pain (58%), nausea/vomiting (51%), mucocutaneous rash (53%), conjunctivitis (51%) and hands and feet oedema (40%) with median duration of symptoms prior to presentation of 5 (interquartile range (IQR) 3, 7) days. Fifty-three percent of children showed lymphopaenia. Overall, the majority of cases at admission had markedly elevated inflammatory markers erythrocyte sedimentation rate (ESR) (95.5%) and C-reactive protein (CRP) (97%). Ferritin was abnormal in 11 out of 14 tested patients (73%), and it was highly elevated (>500 ng/ml) in 47% of cases. Median fibrinogen level was 210 (IQR 165, 291) mg/dl, D-dimer was 3909 (IQR 848, 4528) ng/ml and troponin was 0.6 (IQR 0.1, 26) ng/ml, respectively. Twenty out of 31 patients (64.5%) had hypoalbuminaemia. In addition, hyponatraemia was found in 64% of cases. Twenty-five patients (56%) presented with cardiac involvement and acute renal failure was observed in 13 cases (29%). Pleural, ascitic, ileitis and pericardial effusions were found in 18%, 11%, 4% and 2% of cases, respectively. In conclusion, this is a first large case series of hospitalised children who met criteria for MIS-C in Iran. There was a wide spectrum of presenting signs and symptoms; evidence of inflammation with abnormal values of CRP, ESR, D-dimer, ferritin and albumin; and multi-organ involvement.