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Pei YY, Wang HL, Yin GQ, Xu Y, Tan JH, Liang XH, Wu HY, Yin XT, Fang CX, Peng JZ, Wu ZY, Sun Y, Dang R, Liang YF, Tang HM, Li YY, Qiao ZX, Liang ZC, Tang JP, Zeng FS, Zheng KL, Zeng YR, Cao XJ, Xia HM, Wei JR, Tang JL, Gong ST. Specific convulsions and brain damage in children hospitalized for Omicron BA.5 infection: an observational study using two cohorts. World J Pediatr 2024; 20:1079-1089. [PMID: 38713366 PMCID: PMC11502579 DOI: 10.1007/s12519-024-00808-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 03/22/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND SARS-CoV-2 continues to mutate over time, and reports on children infected with Omicron BA.5 are limited. We aimed to analyze the specific symptoms of Omicron-infected children and to improve patient care. METHODS We selected 315 consecutively hospitalized children with Omicron BA.5 and 16,744 non-Omicron-infected febrile children visiting the fever clinic at our hospital between December 8 and 30, 2022. Specific convulsions and body temperatures were compared between the two cohorts. We analyzed potential associations between convulsions and vaccination, and additionally evaluated the brain damage among severe Omicron-infected children. RESULTS Convulsion rates (97.5% vs. 4.3%, P < 0.001) and frequencies (median: 2.0 vs. 1.6, P < 0.001) significantly differed between Omicron-infected and non-Omicron-infected febrile children. The body temperatures of Omicron-infected children were significantly higher during convulsions than when they were not convulsing and those of non-Omicron-infected febrile children during convulsions (median: 39.5 vs. 38.2 and 38.6 °C, both P < 0.001). In the three Omicron-subgroups, the temperature during convulsions was proportional to the percentage of patients and significantly differed ( P < 0.001), while not in the three non-Omicron-subgroups ( P = 0.244). The convulsion frequency was lower in the 55 vaccinated children compared to the 260 non-vaccinated children (average: 1.8 vs. 2.1, P < 0.001). The vaccination dose and convulsion frequency in Omicron-infected children were significantly correlated ( P < 0.001). Fifteen of the 112 severe Omicron cases had brain damage. CONCLUSIONS Omicron-infected children experience higher body temperatures and frequencies during convulsions than those of non-Omicron-infected febrile children. We additionally found evidence of brain damage caused by infection with omicron BA.5. Vaccination and prompt fever reduction may relieve symptoms.
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Affiliation(s)
- Yuan-Yuan Pei
- Clinical Data Center, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - Hong-Li Wang
- Department of Gastroenterology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - Gen-Quan Yin
- Department of Internal Medicine, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - Yi Xu
- Department of Infectious Diseases, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - Jian-Hao Tan
- Information Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - Xin-Hua Liang
- School of Pediatrics, Guangzhou Medical University, Guangzhou, 510623, China
| | - Hui-Ying Wu
- Imaging Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - Xun-Tao Yin
- Imaging Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - Chun-Xiao Fang
- Department of Infectious Diseases, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - Jun-Zheng Peng
- Respiratory Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - Zhi-Yuan Wu
- Pediatric Intensive Care Unit, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - Yi Sun
- Neonatal Intensive Care Unit, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - Run Dang
- Pediatric Intensive Care Unit, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - Yu-Feng Liang
- Pediatric Intensive Care Unit, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - Hong-Mei Tang
- Rehabilitation Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - You-Yi Li
- General Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - Zhong-Xiang Qiao
- Rehabilitation Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - Zhi-Cheng Liang
- Emergency Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - Jian-Ping Tang
- Neonatal Intensive Care Unit, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - Fan-Sen Zeng
- Department of Infectious Diseases, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - Ke-Lu Zheng
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - Yi-Ru Zeng
- Department of Neurology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - Xiao-Jun Cao
- Information Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - Hui-Min Xia
- Key Laboratory of Structural Birth Defects Research in Guangdong Province, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - Jian-Rui Wei
- Cardiovascular Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China
| | - Jin-Ling Tang
- Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China.
| | - Si-Tang Gong
- General Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, China.
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Jin Q, Ma W, Zhang W, Wang H, Geng Y, Geng Y, Zhang Y, Gao D, Zhou J, Li L, Gou Y, Zhong B, Li J, Hou W, Lu S. Clinical and hematological characteristics of children infected with the omicron variant of SARS-CoV-2: role of the combination of the neutrophil: lymphocyte ratio and eosinophil count in distinguishing severe COVID-19. Front Pediatr 2024; 12:1305639. [PMID: 38978839 PMCID: PMC11228319 DOI: 10.3389/fped.2024.1305639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 05/30/2024] [Indexed: 07/10/2024] Open
Abstract
Purpose Investigate the clinical/hematological characteristics of children infected with the Omicron variant of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) and identify an effective indicator to distinguish coronavirus disease 2019 (COVID-19) severity in children. Methods A retrospective study was conducted through electronic medical records from pediatric patients. The demographic, clinical, and routine blood test (RBT) features of children diagnosed by real-time PCR for SARS-CoV-2 were collected. Results Data of 261 patients were analyzed. The most common abnormality shown by RBTs was increased monocyte count (68%). Children had "mild-moderate" or "severe" forms of COVID-19. Prevalence of abnormal neutrophil count (p = 0.048), eosinophil count (p = 0.006), mean corpuscular volume (p = 0.033), mean platelet volume (p = 0.006), platelet-large cell ratio (p = 0.043), and red blood cell distribution width-standard deviation (p = 0.031) were significantly different in the two types. A combination of the neutrophil: lymphocyte ratio (NLR) and eosinophil count for diagnosing severe COVID-19 presented the largest AUC (0.688, 95% CI = 0.599-0.777; p < 0.001), and the AUC increased with a decrease in age. Conclusions Combination of the NLR and eosinophil count might be a promising indicator for identifying severe COVID-19 in children at infection onset.
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Affiliation(s)
- Qiaoyan Jin
- Department of Pediatrics, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- Department of Biochemistry and Molecular Biology, Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Wenxian Ma
- Department of Biochemistry and Molecular Biology, Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Wei Zhang
- Xijing 986 Hospital Department, Air Force Medical University, Xi’an, China
| | - Huiyuan Wang
- Department of Pediatrics, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Yiongxiang Geng
- Department of Pediatrics, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Yan Geng
- Department of Pediatrics, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Yang Zhang
- Department of Pediatrics, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Dan Gao
- Department of Pediatrics, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Jing Zhou
- Department of Pediatrics, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Lin Li
- Xijing 986 Hospital Department, Air Force Medical University, Xi’an, China
| | - Yaping Gou
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Shaanxi University of Traditional Chinese Medicine, Xi’an, China
| | - Bo Zhong
- Department of Pediatrics, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Jing Li
- Department of Pediatrics, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Wei Hou
- Department of Pediatrics, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Shemin Lu
- Department of Biochemistry and Molecular Biology, Xi’an Jiaotong University Health Science Center, Xi’an, China
- National Joint Engineering Research Center of Biodiagnostics and Biotherapy, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi’an, China
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Kovacs M, Makszin L, Nyul Z, Hollody K. Has the Incidence of Febrile Convulsions in Childhood Changed During the SARS-CoV-2 Pandemic? J Child Neurol 2024; 39:190-194. [PMID: 38698642 PMCID: PMC11179305 DOI: 10.1177/08830738241249630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 03/08/2024] [Accepted: 04/05/2024] [Indexed: 05/05/2024]
Abstract
Introduction: SARS-CoV-2 infection in children is usually asymptomatic or only mild symptoms are typical. The aim of our study was to assess the incidence of febrile convulsions in our own patients with COVID-19. Patients and Methods: In our retrospective study, we reviewed the data of children who presented at our University Hospital from March 2020 to March 2022 with febrile convulsion. The control group were children admitted to the hospital because of febrile convulsions from January 2018 to January 2020. Results: During the coronavirus pandemic, 51 patients were examined with febrile convulsions. The majority (86.3%) of children had their first febrile convulsion during this period. We diagnosed simple febrile convulsions in 40 cases and complicated ones in 11 cases. The family history of febrile convulsion or epilepsy was present in 12 (23.5%) patients. In addition to febrile convulsion, SARS-CoV-2 infection was confirmed by laboratory testing in 4 cases (7.8%). Three of them had febrile convulsion during the Omicron variant period. Conclusions: During the coronavirus pandemic, the number of children examined because of having febrile convulsions was not higher than in the control period. The coronavirus is unlikely to increase the risk of febrile convulsions.
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Affiliation(s)
- Monika Kovacs
- Faculty of Medicine, Department of Pediatrics, University of Pecs, Pecs, Hungary
| | - Lilla Makszin
- Faculty of Medicine, Institute of Bioanalysis, University of Pecs, Pecs, Hungary
| | - Zoltan Nyul
- Faculty of Medicine, Department of Pediatrics, University of Pecs, Pecs, Hungary
| | - Katalin Hollody
- Faculty of Medicine, Department of Pediatrics, University of Pecs, Pecs, Hungary
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Jiang J, Shen Z, Cao J. Seizures in febrile children with SARS-CoV-2 infection: clinical features, short-term follow-up. BMC Pediatr 2024; 24:257. [PMID: 38627666 PMCID: PMC11022318 DOI: 10.1186/s12887-024-04691-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 03/04/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND As the Omicron variant of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) emerges, the neurological manifestations correlated with this epidemic have garnered increasing attention. This study was primarily intended to compare seizures in febrile children with and without SARS-CoV-2 infection and to conduct short-term follow-up of the SARS-CoV-2-infected patients. METHODS Retrospective analysis of patients admitted to the Children's Hospital of Chongqing Medical University for fever and seizures between October 1 and December 30, 2022. Based on the results of SARS-CoV-2 Reverse Transcription-Polymerase Chain Reaction(RT-PCR) at the time of admission, the patients were divided into a Coronavirus disease 2019(COVID-19) positive group and a COVID-19 negative group. Aside from that, we followed up COVID-19-positive patients for 3 months after their discharge from the hospital. The follow-up included monitoring for post-discharge seizures. RESULTS Compared with the COVID-19-negative group, the COVID-19-positive group had a higher proportion of seizure duration ≥ 15 min(18.7%VS5.1%;P = 0.001), seizure ≥ 2 time(54.4%VS41.0%; P = 0.024), status epilepticus(15.4%VS5.1%; P = 0.005), and Electroencephalogram (EEG) abnormalities(29.4%VS13.6%; P = 0.016). Among the 161 individuals under follow-up, 21 (13.0%)experienced a recurrence of seizures. CONCLUSIONS Although the incidence of seizure duration ≥ 15 min, number of seizures ≥ 2 time, and status epilepticus was higher in the COVID-19-positive group, the majority of patients had a favorable prognosis. Nonetheless, patients with COVID-19 who present with seizures and persistent impaired consciousness need to be alerted to serious neurological disorders such as acute necrotizing encephalopathy. Owing to the consideration that some patients may experience a recurrence of seizures within a short period of time, it is paramount to provide guardians with education about the emergency management of seizures and to follow up with patients over time.
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Affiliation(s)
- Jipeng Jiang
- Department of General Medicine, Nation Clinical Research Center for Child Health and Disorders, Ministry of Education Key Labiratory of Child Development and Disorders, Childrens Hospital of Chongqing Medical University, No.136 Zhongshan 2nd Road, Yuzhong District, Chongqing, China
- China International Science and Technology Cooperation base of Child development and Critical Disorders, No.136 Zhongshan 2nd Road, Yuzhong District, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, No.136 Zhongshan 2nd Road, Yuzhong District, Chongqing, China
| | - Zhengsong Shen
- Department of General Medicine, Nation Clinical Research Center for Child Health and Disorders, Ministry of Education Key Labiratory of Child Development and Disorders, Childrens Hospital of Chongqing Medical University, No.136 Zhongshan 2nd Road, Yuzhong District, Chongqing, China
| | - Jie Cao
- Department of General Medicine, Nation Clinical Research Center for Child Health and Disorders, Ministry of Education Key Labiratory of Child Development and Disorders, Childrens Hospital of Chongqing Medical University, No.136 Zhongshan 2nd Road, Yuzhong District, Chongqing, China.
- China International Science and Technology Cooperation base of Child development and Critical Disorders, No.136 Zhongshan 2nd Road, Yuzhong District, Chongqing, China.
- Chongqing Key Laboratory of Pediatrics, No.136 Zhongshan 2nd Road, Yuzhong District, Chongqing, China.
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Kasai M, Sakuma H, Abe Y, Kuki I, Maegaki Y, Murayama K, Murofushi Y, Nagase H, Nishiyama M, Okumura A, Sakai Y, Tada H, Mizuguchi M, Takanashi JI. Clinical characteristics of SARS-CoV-2-associated encephalopathy in children: Nationwide epidemiological study. J Neurol Sci 2024; 457:122867. [PMID: 38199023 DOI: 10.1016/j.jns.2024.122867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 11/29/2023] [Accepted: 01/01/2024] [Indexed: 01/12/2024]
Abstract
OBJECTIVE Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) sometimes triggers acute encephalopathy as a serious neurological complication in children. We previously reported the clinico-radiological findings of SARS-CoV-2-associated encephalopathy. The advent of the SARS-CoV-2 omicron variant led to a marked increase in pediatric patients with coronavirus disease 2019 (COVID-19); however, epidemiological changes with acute encephalopathy according to the emergence of SARS-CoV-2 have not yet been documented. Therefore, the present study investigated epidemiological differences in SARS-CoV-2-associated encephalopathy during the BA.1/BA.2 and BA.5 predominant periods and also between SARS-CoV-2-associated and non-SARS-CoV-2-associated encephalopathy. METHODS We conducted a nationwide survey of SARS-CoV-2-associated encephalopathy in Japanese children between June and November 2022. We compared the present results during the BA.5 predominant period and previous findings during the BA.1/BA.2 predominant period. We also compared the clinico-radiological syndromes of encephalopathy between SARS-CoV-2-associated and non-SARS-CoV-2-associated encephalopathy. RESULTS Although many patients with SARS-CoV-2-associated encephalopathy in the BA.5 predominant period had seizures as their initial symptoms, no significant differences were observed in the clinical features. Patients with SARS-CoV-2-associated encephalopathy had worse outcomes than those with non-SARS-CoV-2-associated encephalopathy (p-value = 0.003). Among 103 patients with SARS-CoV-2-associated encephalopathy, 14 (13.6%) had severe types of acute encephalopathy, namely, encephalopathy with acute fulminant cerebral edema (AFCE) and hemorrhagic shock and encephalopathy syndrome (HSES). Also, 28 (27.2%) patients with SARS-CoV-2-associated encephalopathy had poor outcome: severe neurological sequelae or death. Ninety-five patients (92.2%) were not vaccinated against SARS-CoV-2. CONCLUSIONS In SARS-CoV-2-associated encephalopathy, high percentages of AFCE and HSES can result in poor outcomes.
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Affiliation(s)
- Mariko Kasai
- Department of Brain and Neurosciences, Tokyo Metropolitan Institute of Medical Science, 2-1-6 Kamikitazawa, Setagaya-ku, Tokyo, Japan.
| | - Hiroshi Sakuma
- Department of Brain and Neurosciences, Tokyo Metropolitan Institute of Medical Science, 2-1-6 Kamikitazawa, Setagaya-ku, Tokyo, Japan.
| | - Yuichi Abe
- Division of Neurology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, Japan.
| | - Ichiro Kuki
- Department of Pediatric Neurology, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka, Japan.
| | - Yoshihiro Maegaki
- Division of Child Neurology, Institute of Neurological Sciences, Faculty of Medicine, Tottori University, 86 Nishi-cho, Yonago-shi, Tottori, Japan.
| | - Kei Murayama
- Center for Medical Genetics, Department of Metabolism, Chiba Children's Hospital, 579-1 Heta-cho, Midori-ku, Chiba-shi, Chiba, Japan..
| | - Yuka Murofushi
- Department of Pediatrics and Pediatric Neurology, Tokyo Women's Medical University Yachiyo Medical Center, 477-96 Owada Shinden, Yachiyo-shi, Chiba, Japan.
| | - Hiroaki Nagase
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe City, Hyogo, Japan.
| | - Masahiro Nishiyama
- Department of Neurology, Hyogo Prefectural Kobe Children's Hospital, 1-6-7, Minatojima-minamimachi, Chuo-ku, Kobe-shi, Hyogo, Japan
| | - Akihisa Okumura
- Department of Pediatrics, Aichi Medical University School of Medicine, 1-1 Yazakokarimata, Nagakute, Aichi, Japan.
| | - Yasunari Sakai
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, Japan
| | - Hiroko Tada
- Division of Pediatrics, Chibaken Saiseikai Narashino Hospital, 2-1-1 Miyama, Narashino-shi, Chiba, Japan
| | - Masashi Mizuguchi
- Department of Pediatrics, National Rehabilitation Center for Children with Disabilities, 1-1-10 Komone, Itabashi-ku, Tokyo, Japan.
| | - Jun-Ichi Takanashi
- Department of Pediatrics and Pediatric Neurology, Tokyo Women's Medical University Yachiyo Medical Center, 477-96 Owada Shinden, Yachiyo-shi, Chiba, Japan.
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Anastasopoulou S, Svensson E, Wickström R, Hertting O, Rinder MR, Bennet R, Eriksson M. Seizures in hospitalised paediatric patients with SARS-CoV-2 and comparison of severity with seizures in hospitalised paediatric patients with other respiratory viruses during the COVID-19 pandemic: a population-based cohort study. Arch Dis Child 2024; 109:152-157. [PMID: 37798081 PMCID: PMC10850622 DOI: 10.1136/archdischild-2023-325974] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 09/20/2023] [Indexed: 10/07/2023]
Abstract
OBJECTIVE To study seizures in patients hospitalised due to SARS-CoV-2 infection, and compare their severity with seizures in patients hospitalised due to other viral respiratory tract infections (RTIs). DESIGN Observational population-based cohort study. SETTING Northern Stockholm. PATIENTS Patients aged 1 month-18 years hospitalised due to SARS-CoV-2 with and without seizures, and patients of the same age hospitalised due to other viral RTIs with seizures, between 1 March 2020 and 30 June 2022. MAIN OUTCOME MEASURES The prevalence of seizures in hospitalised patients due to SARS-CoV-2, the evaluation of assumed predictors of seizures and the comparison of severity markers in patients with SARS-CoV-2 versus other RTIs. RESULTS 32 of 239 included patients (13.4%) admitted due to SARS-CoV-2 infection had seizures. Central nervous system (CNS) disease and the omicron period had significantly increased OR for seizures (OR: 5.12; CI: 2.06 to 12.72 and OR: 3.01; CI: 1.15 to 7.88, respectively). Seizures in patients with SARS-CoV-2 were more common in children older than 5 years (p=0.001), even in the absence of fever (p=0.007), as compared with other viral RTIs. The duration of hospitalisation was longer in patients with seizures due to other viral RTIs (p=0.023). There was no significant difference regarding severity markers of seizures between the two groups. CONCLUSIONS CNS disease and the omicron period were risk factors for seizures in patients with SARS-CoV-2, who were older than patients with other RTIs. The severity of seizures was comparable between the two groups; hospitalisation was however longer in patients with other RTIs.
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Affiliation(s)
- Stavroula Anastasopoulou
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Neurology Department, Karolinska University Hospital, Stockholm, Sweden
| | - Eva Svensson
- Pediatric Neurology Department, Karolinska University Hospital, Stockholm, Sweden
| | - Ronny Wickström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Neurology Department, Karolinska University Hospital, Stockholm, Sweden
- Paediatric Neurology, Karolinska Institute, Stockholm, Sweden
| | - Olof Hertting
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Emergencies and Infections Department, Karolinska University Hospital, Stockholm, Sweden
| | - Malin Ryd Rinder
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Emergencies and Infections Department, Karolinska University Hospital, Stockholm, Sweden
| | - Rutger Bennet
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Emergencies and Infections Department, Karolinska University Hospital, Stockholm, Sweden
| | - Margareta Eriksson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Emergencies and Infections Department, Karolinska University Hospital, Stockholm, Sweden
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Ohta K, Okanishi T, Arai Y, Kanai S, Nakamura Y, Namba N, Maegaki Y. Febrile seizure in children with COVID-19 during the Omicron variant-predominant era: A single-center study. Brain Dev 2024; 46:28-34. [PMID: 37661526 DOI: 10.1016/j.braindev.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/28/2023] [Accepted: 08/21/2023] [Indexed: 09/05/2023]
Abstract
OBJECTIVE Coronavirus disease 2019 (COVID-19) has significantly impacted medical services worldwide. During the Omicron variant-predominant era, febrile seizure (FS) in patients with COVID-19 increased compared to that in the pre-Omicron variant era. Therefore, this study aimed to demonstrate the clinical characteristics of FS in patients with COVID-19. METHODS We surveyed patients aged < 16 years who presented with FS to the emergency room of Tottori University Hospital. The patients were divided into two groups: FS patients with COVID-19 (FS with COVID-19 group) and FS patients without COVID-19 (FS without COVID-19 group) as per the results of the respiratory multiplex array test. Patients with positive results for both SARS-CoV-2 and other microorganisms were excluded. We obtained data on the patients' clinical backgrounds, symptoms, seizure duration, type of FS (simple or complex), diagnostic examinations, laboratory test results, and treatment. We compared the data between the FS with and without COVID-19 groups. RESULT A total of 128 patients with FS met the inclusion criteria. Of these, 18 patients and 110 patients were included in the FS with COVID-19 group and without COVID-19 group, respectively. The late FS onset (>60 months) were significantly more common in the FS with COVID-19 group than that in the FS without COVID-19 group. Moreover, patients in the FS with COVID-19 group had significantly longer seizure durations than those in the FS without COVID-19 group. A diazepam (DZP) suppository was administered to 72% of FS patients with COVID-19 after the first seizure during a febrile episode. CONCLUSION FS patients with COVID-19 had different distributions of age at onset and seizure duration than those without COVID-19. The use of DZP suppositories was more frequent in FS patients with COVID-19 compared to those without COVID-19.
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Affiliation(s)
- Kento Ohta
- Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Tohru Okanishi
- Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Japan.
| | - Yuto Arai
- Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Sotaro Kanai
- Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Yuko Nakamura
- Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Noriyuki Namba
- Division of Perinatology and Pediatrics, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Yoshihiro Maegaki
- Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Japan
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Shi T, Bian Y, Wu J, Li X, Deng J, Feng T, Huang L, Kong X, Tian J. Decreased NK cell count is a high-risk factor for convulsion in children with COVID-19. BMC Infect Dis 2023; 23:856. [PMID: 38057734 DOI: 10.1186/s12879-023-08556-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 08/22/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND The neurological symptoms caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are of increasing concern. Convulsions are among the main neurological manifestations reported in children with coronavirus disease-2019 (COVID-19), and cause serious harm to physical and mental health. This study aimed to investigate the risk factors for convulsion in children with COVID-19. METHODS This prospective study was conducted at the Children's Hospital of Soochow University. In total, 102 COVID-19 patients with convulsion, 172 COVID-19 patients without convulsion, and 50 healthy controls were enrolled in the study. The children's clinical and laboratory data were analyzed to assess the risk factors for convulsion in COVID-19 patients. RESULTS Convulsions occurred in 37.2% of children, mostly those aged 1-3 years, who were hospitalized with the Omicron variant. The neutrophil count, neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), and mean platelet volume-to-platelet ratio (MPR) were significantly higher in the convulsion group than those in the non-convulsion and control groups (P < 0.01). However, the counts of lymphocytes, eosinophils, platelets, lymphocyte subsets, CD3+ T cells, CD4+ T cells, CD8+ T cells, and NK cells were lower in the convulsion group than those in the non-convulsion and control groups (P < 0.01). Multivariate regression analysis indicated that NK cell count (OR = 0.081, 95% CI: 0.010-0.652) and a history of febrile seizure (OR = 10.359, 95% CI: 2.115-50.746) were independent risk factors for the appearance of convulsions in COVID-19. CONCLUSIONS History of febrile seizure and decreased NK cell count were high-risk factors for convulsions in COVID-19 patients.
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Affiliation(s)
- Ting Shi
- Department of Infectious Diseases & Pediatric Intensive Care Unit, Children's Hospital of Soochow University, 303 Jingde Road, Suzhou, 215000, Jiangsu, China
| | - Yuanxi Bian
- Department of Infectious Diseases & Pediatric Intensive Care Unit, Children's Hospital of Soochow University, 303 Jingde Road, Suzhou, 215000, Jiangsu, China
| | - Jiahui Wu
- Department of Infectious Diseases & Pediatric Intensive Care Unit, Children's Hospital of Soochow University, 303 Jingde Road, Suzhou, 215000, Jiangsu, China
| | - Xiaohong Li
- Department of Infectious Diseases & Pediatric Intensive Care Unit, Children's Hospital of Soochow University, 303 Jingde Road, Suzhou, 215000, Jiangsu, China
| | - Jianping Deng
- Department of Infectious Diseases & Pediatric Intensive Care Unit, Children's Hospital of Soochow University, 303 Jingde Road, Suzhou, 215000, Jiangsu, China
| | - Tao Feng
- Department of Infectious Diseases & Pediatric Intensive Care Unit, Children's Hospital of Soochow University, 303 Jingde Road, Suzhou, 215000, Jiangsu, China
| | - Linlin Huang
- Department of Infectious Diseases & Pediatric Intensive Care Unit, Children's Hospital of Soochow University, 303 Jingde Road, Suzhou, 215000, Jiangsu, China.
| | - Xiaoxing Kong
- Department of Infectious Diseases & Pediatric Intensive Care Unit, Children's Hospital of Soochow University, 303 Jingde Road, Suzhou, 215000, Jiangsu, China
| | - Jianmei Tian
- Department of Infectious Diseases & Pediatric Intensive Care Unit, Children's Hospital of Soochow University, 303 Jingde Road, Suzhou, 215000, Jiangsu, China.
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Zhang X, Hu R, Zhao F. Clinical and radiological features of a case of primary encephalitis induced by SARS-CoV-2 omicron variant infection: A case report. Medicine (Baltimore) 2023; 102:e35229. [PMID: 37713824 PMCID: PMC10508470 DOI: 10.1097/md.0000000000035229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/24/2023] [Indexed: 09/17/2023] Open
Abstract
RATIONALE In 2022, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Omicron spread widely around the world. In the context of most literature reporting weakened virulence of the virus, immunocompromised patients who have not been vaccinated should be vigilant for the development of encephalitis following SARS-CoV-2 infection. PATIENT CONCERNS A 58-year-old male patient with immunodeficiency presented with respiratory and psychiatric symptoms after contracting SARS-CoV-2 Omicron variant. DIAGNOSES The patient was diagnosed with coronavirus disease 2019 infection and associated acute primary encephalitis. INTERVENTIONS The patient was received comprehensive treatment including Azvudine antiviral therapy, immunoglobulin infusion, and methylprednisolone anti-inflammatory therapy. OUTCOMES The patient's condition improved and he was discharged smoothly. One month after discharge, the patient returned for follow-up, and the occipital lobe still had a few slow waves on electroencephalogram, but the patient reported no seizure events since discharge. LESSONS During the prevalence of the SARS-CoV-2 Omicron variant, we believe that it is still necessary to be vigilant about immunocompromised patients developing encephalitis. Early use of cranial magnetic resonance imaging as a diagnostic assistance is conducive to early diagnosis and treatment of patients.
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Affiliation(s)
- Xiong Zhang
- Department of Radiology, Minzu Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Ruiting Hu
- Department of Radiology, Minzu Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Fanyu Zhao
- Department of Radiology, Minzu Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
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Mohamed ZA, Tang C, Thokerunga E, Deng Y, Fan J. Pediatric infection with the Omicron variant increases the risks of febrile seizures among COVID-19 infected children. Front Pediatr 2023; 11:1226403. [PMID: 37664550 PMCID: PMC10469930 DOI: 10.3389/fped.2023.1226403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 08/07/2023] [Indexed: 09/05/2023] Open
Abstract
Background The Omicron variant of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is less likely to cause severe disease in children than the other variants but has become an increasing cause of febrile seizures (FS) among children. In this case-control study, we aimed to examine the risk factors associated with FS in children infected with the COVID-19 Omicron variant and related treatment modalities. Methods This retrospective case-control study includes 113 subjects infected with the COVID-19 Omicron variant, grouped into 45 cases (those with FS) and 68 controls (those without FS). Data on clinical features, laboratory parameters, and treatment modalities were collected and analyzed. Results Approximately 5.74% of COVID-19 infected children developed COVID-19-associated FS. Children with COVID-19 and high body temperatures [RR 1.474; (95% CI: 1.196-1.818), p < 0.001], previous history of FS [RR 1.421; (95% CI: 1.088-1.855), p = 0.010], high procalcitonin levels [RR 1.140; (95% CI: 1.043-1.246), p = 0.048] and high neutrophil counts [RR 1.015; (95% CI: 1.000-1.029), p = 0.048] were more likely to experience FS than the controls. In contrast, children with COVID-19 and low eosinophil counts, low hemoglobin levels, and cough had a lower risk of developing FS [RR 0.494; (95% CI: 0.311-0.783), p = 0.003], [RR 0.979; (95% CI: 0.959-0.999), p = 0.044]; and [RR 0.473 (95% CI 0.252-0.890), p = 0.020]; respectively. Children with FS received more anti-flu medications than those without. Conclusion A significant increase in FS was observed in children with Omicron SARS-CoV-2 infection. A higher body temperature, a history of FS, a higher procalcitonin level, and a high neutrophil count were all associated with an increased risk of FS in children with COVID-19. The risk of developing FS was lower in children with COVID-19 and low eosinophil counts and hemoglobin levels than in those without.
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Affiliation(s)
| | - Chunjiao Tang
- Department of Pediatrics, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Erick Thokerunga
- Department of Clinical Laboratory Medicine, Center for Gene Diagnosis, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Youping Deng
- Department of Pediatrics, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jingyi Fan
- Department of Pediatrics, Zhongnan Hospital of Wuhan University, Wuhan, China
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11
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Jeon J, Park J, Choi MH, Choi H, Kim MH. Unequal burdens of COVID-19 infection: a nationwide cohort study of COVID-19-related health inequalities in Korea. Epidemiol Health 2023; 45:e2023068. [PMID: 37536718 PMCID: PMC10667578 DOI: 10.4178/epih.e2023068] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 07/18/2023] [Indexed: 08/05/2023] Open
Abstract
OBJECTIVES While the Korean government's response to the coronavirus disease 2019 (COVID-19) pandemic is considered effective given the relatively low mortality rate, issues of inequality have been insufficiently addressed. This study explored COVID-19-related health inequalities in Korea. METHODS Age standardization for various health inequality indices was derived using data from the Korean National Health Insurance Service, the Korea Disease Control and Prevention Agency, and the Microdata Integrated Service of Statistics Korea. The slope index of inequality (SII) and relative index of inequality (RII) were calculated for socioeconomic variables, while absolute difference (AD) and relative difference (RD) were used for gender and disability inequalities. RESULTS We observed a number of COVID-19-related health outcome inequalities. Gender inequality was particularly noticeable in infection rates, with the rate of women 1.16 times higher than that of men. In contrast, socioeconomic inequality was evident in vaccination rates, with a 4.5-fold (SII, -4.519; 95% confidence interval, -7.403 to -1.634) difference between the highest and lowest household income groups. Regarding clinical progression post-infection, consistent findings indicated higher risk for men (RD for hospitalization, 0.90; severe cases, 0.54; and fatality, 0.65), individuals with disabilities (RD for hospitalization, 2.27; severe cases, 2.29; and fatality, 2.37), and those from lower socioeconomic groups (SII for hospitalization, 1.778; severe cases, 0.089; and fatality, 0.451). CONCLUSIONS While the infection risk was nearly ubiquitous, not everyone faced the same level of risk post-infection. To prevent further health inequalities, it is crucial to develop a thoughtful policy acknowledging individual health conditions and resources.
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Affiliation(s)
- Jeangeun Jeon
- Department of Sociology, Yonsei University, Seoul, Korea
| | - Jieun Park
- Department of Sociology, Yonsei University, Seoul, Korea
| | - Min-Hyeok Choi
- Department of Preventive and Occupational & Environmental Medicine, Pusan National University Medical College, Yangsan, Korea
- Office of Public Healthcare Service, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hongjo Choi
- Department of Preventive Medicine, Konyang University College of Medicine, Daejeon, Korea
| | - Myoung-Hee Kim
- Center for Public Health Data Analytics, National Medical Center, Seoul, Korea
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Yamagishi H, Tamura D, Aoyagi J, Suzuki S, Mizobe Y, Wakae K, Yamagata T, Tajima T, Osaka H. Impact of the omicron phase on a highly advanced medical facility in Japan. Front Pediatr 2023; 11:1201825. [PMID: 37497300 PMCID: PMC10366354 DOI: 10.3389/fped.2023.1201825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 07/03/2023] [Indexed: 07/28/2023] Open
Abstract
Background Eight waves of the coronavirus disease 2019 (COVID-19) epidemic have been observed in Japan. This retrospective study was conducted to clarify the clinical characteristics of pediatric COVID-19 patients. Methods We studied 121 patients admitted to the Jichi Children's Medical Center Tochigi between April 2020 and March 2023. Incidence of pediatric COVID-19 in Tochigi Prefecture was used to examine hospitalization and severe illness rates. Results The mean age of the patients was 3 years and 8 months. One hundred and eleven patients (91.7%) were hospitalized after January 2022 (after the 6th wave), when the Omicron strain became endemic in Japan. Convulsions occurred in 30 patients (24.8%), all of whom were admitted after the 6th wave. Twenty-three of the 30 patients had no underlying disease. Eleven patients (9.1%) were diagnosed with acute encephalopathy. One patient died due to hemorrhagic shock and encephalopathy syndrome and two had sequelae after the 6th wave. The patient who died due to encephalopathy had hypercytokinemia. In the Tochigi Prefecture, the number of pediatric COVID-19 patients increased after the 6th wave, but the hospitalization rate declined. The rate of severe illness did not change before the end of 5th and after the 6th wave. Conclusion Although the rate of severe illness in patients with pediatric COVID-19 did not increase after the 6th wave, some patients had complicated critical illnesses. Systemic inflammatory reaction was considered to have been associated with the severe encephalopathy.
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Yi Y, Zhong C, Wei-wei H. The long-term neurodevelopmental outcomes of febrile seizures and underlying mechanisms. Front Cell Dev Biol 2023; 11:1186050. [PMID: 37305674 PMCID: PMC10248510 DOI: 10.3389/fcell.2023.1186050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/16/2023] [Indexed: 06/13/2023] Open
Abstract
Febrile seizures (FSs) are convulsions caused by a sudden increase in body temperature during a fever. FSs are one of the commonest presentations in young children, occurring in up to 4% of children between the ages of about 6 months and 5 years old. FSs not only endanger children's health, cause panic and anxiety to families, but also have many adverse consequences. Both clinical and animal studies show that FSs have detrimental effects on neurodevelopment, that cause attention deficit hyperactivity disorder (ADHD), increased susceptibility to epilepsy, hippocampal sclerosis and cognitive decline during adulthood. However, the mechanisms of FSs in developmental abnormalities and disease occurrence during adulthood have not been determined. This article provides an overview of the association of FSs with neurodevelopmental outcomes, outlining both the underlying mechanisms and the possible appropriate clinical biomarkers, from histological changes to cellular molecular mechanisms. The hippocampus is the brain region most significantly altered after FSs, but the motor cortex and subcortical white matter may also be involved in the development disorders induced by FSs. The occurrence of multiple diseases after FSs may share common mechanisms, and the long-term role of inflammation and γ-aminobutyric acid (GABA) system are currently well studied.
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Affiliation(s)
- You Yi
- Department of Pharmacology and Department of Pharmacy of the Second Affiliated Hospital, Key Laboratory of Medical Neurobiology of the Ministry of Health of China, Zhejiang University School of Medicine, Hangzhou, China
| | - Chen Zhong
- Department of Pharmacology and Department of Pharmacy of the Second Affiliated Hospital, Key Laboratory of Medical Neurobiology of the Ministry of Health of China, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Neuropharmacology and Translational Medicine of Zhejiang Province, Zhejiang Chinese Medical University, Hangzhou, China
| | - Hu Wei-wei
- Department of Pharmacology and Department of Pharmacy of the Second Affiliated Hospital, Key Laboratory of Medical Neurobiology of the Ministry of Health of China, Zhejiang University School of Medicine, Hangzhou, China
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Salleh H, Soon IS, Chong VH. Frequency and risk factors for febrile seizures during COVID-19 pandemic waves: an observational study. Eur J Pediatr 2023:10.1007/s00431-023-05021-0. [PMID: 37178360 PMCID: PMC10182340 DOI: 10.1007/s00431-023-05021-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 05/04/2023] [Accepted: 05/05/2023] [Indexed: 05/15/2023]
Abstract
Febrile seizures (FS) are well-known manifestations of viral illnesses. The purpose of this study is to assess the prevalence and factors associated with FS among pediatric patients with COVID-19 admitted to the National Isolation Centre in Brunei Darussalam. All pediatric patients (< 12 years) during the first (n = 12), second (n = 418), and third (n = 219) waves were included in the study. In Brunei, the first, second, and third waves were caused by the original SARS-CoV-2, Delta, and Omicron variants, respectively. Data was extracted from a prospective database and the national electronic health record system. Patients with and without FS were compared to identify any significant risk factors. FS were only encountered in the third wave (n = 29, 13%) giving an overall prevalence of 4.5%; 24 (83%) occurring in the typical age group for FS (≥ 6 months to < 6 years). Five cases (17%) occurred in children 6 years and older. Comparing patients in the third wave, univariate analyses showed typical age group, previous history of FS, family history of FS, higher temperature (> 38.6 °C), and fewer symptoms on presentation (3 or less) were associated with FS. On multivariate analyses, typical age group, family history of FS, and fewer reported symptoms remained significant (all p < 0.05). Conclusions: The overall prevalence of FS in COVID-19 patients is comparable to rates reported. However, in Brunei Darussalam, FS only occurred in the third wave that has been associated with Omicron variant. Younger age group, family history of FS, and fewer symptoms on presentation are correlated with risk of FS. What is Known: • Viral infections are the most common cause of FS in children. •Young age and a personal and family history of FS are correlated with the risk of FS. What is New: • There were high rates of FS (13%) among pediatric patients admitted with COVID-19 due to the Omicron variant but not with the original and Delta variants. • FS with COVID-19 were correlated with reporting fewer symptoms on presentation.
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Affiliation(s)
- Hafizah Salleh
- Department of Paediatrics, RIPAS Hospital, Bandar Seri Begawan, BA1710, Brunei Darussalam.
| | - Ing Shian Soon
- Department of Paediatrics, RIPAS Hospital, Bandar Seri Begawan, BA1710, Brunei Darussalam
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