Pediatric Obesity-A Potential Risk Factor for Systemic Inflammatory Syndrome Associated to COVID-19, a Case Report

COVID-19 and Laboratory Markers from Romanian Patients-A Narrative Review

COVID-19 has significantly impacted the whole world, and Romania was no exception. Biomarkers play a crucial role in understanding and managing the disease. However, research regarding laboratory analyses for patients with COVID-19 is fairly limited. For detection, PCR testing is still considered the golden standard, while antibodies are still useful for monitoring both patients and their vaccination status. In our country, biomarkers such as CRP, LDH, transaminases, cardiac, and iron markers have been used to assess the status of patients and even predict illness outcome. CRP, IL-6, LDH, FER, fibrinogen, creatinine, and vitamin D levels have been associated with increased severity, risk of ICU admission, and death. Cardiac markers and D-dimers are also good predictors, but their role seems more important in patients with complications. HDL cholesterol and BUN levels were also suggested as potential biomarkers. Hematological issues in SARS-CoV-2 infections include neutrophilia, lymphopenia and their ratio, while PCT, which is a marker of bacterial infections, is better to be used in patients with co- or supra-infections. The current research is a narrative review that focuses on the laboratory results of Romanian COVID-19 patients. The goal of this article is to provide an update on the research on biomarkers and other laboratory tests conducted inside the borders of Romania and identify gaps in this regard. Secondly, options for further research are discussed and encouraged.

COVID-19 and Cardiac Implications-Still a Mystery in Clinical Practice

Although initially the evolution of Coronavirus disease 2019 (COVID-19) seemed less severe in pediatric patients, in the three years since the beginning of the pandemics, several severe cases have been described, pediatric inflammatory multisystem syndrome (PIMS) has been defined, pathogenesis is being continuously studied, and many aspects regarding the long-term evolution and multi-organ damage are still unexplained. Cardiac injuries in COVID-19 represent most-likely the second cause of mortality associated with the infection. A wide-spectrum of cardiac abnormalities were reported to be associated with COVID-19 in children including ventricular dysfunction, acute myocardial dysfunction, arrhythmias, conduction abnormalities, coronary artery dilation or aneurysms, and less common pericarditis and valvulitis. Risk factors for severe COVID-19 in children should be identified, laboratory tests and imaging techniques should be performed to reveal cardiac injury as soon as possible. The aim of this review was to highlight the great value of repeated cardiological monitoring in patients with COVID-19, underlining also the peculiarities in terms of pediatric population. This review is looking for answers on questions like 'Why do some, but not all, patients with COVID-19 develop cardiac injury or severe hyperinflammatory status?', 'Which factors are involved in triggering COVID-19 associated cardiac injury?', 'What are the mechanisms involved in the etiology of cardiac injury?', 'Is there a clear relationship between hyperinflammation and cardiac injury?', 'Is hyperinflammatory status the pre-stage of cardiac injury in COVID-19 patients?' which still lack clear answers. The understanding of mechanisms involved in the development of COVID-19 associated cardiac injury might shed light on all the above-mentioned mysteries and might increase the likelihood of favorable evolution even in severe cases.

Families Chose In-Person Visits over Telehealth for Pediatric Weight Management during the COVID-19 Pandemic

Background: With the onset of the coronavirus disease 2019 (COVID-19) pandemic, telehealth was implemented as a method of care delivery in many pediatric weight management programs (PWMPs). To compare patient/family preference of telehealth vs. in-person visits, we analyzed patient visits during a period when families were given the option of scheduling in-person or telehealth visits for both new and follow-up visits during the pandemic. Methods: A retrospective review was done of our center's electronic medical record of patient visits from July 1, 2020 to December 31, 2020. Results: There were 1356 completed PWMP visits, with 977 (72.1%) done in-person and 379 (27.9%) done by telehealth. Telehealth was selected more often for follow-up visits (31.4%) compared with new visits (18.8%) [odds ratio (OR) = 2.052, p = 0.008]. Black patients (30.5%) selected telehealth more often than White patients (26.1%, OR = 1.371; p = 0.03). Conclusions: Although telehealth increases flexibility and increases options to families, in-person clinic visits seem to be preferred especially for an initial visit.

Cardiological Monitoring – A Cornerstone for Pediatric Inflammatory Multisystem Syndrome Temporally Associated with COVID-19 Outcome: A Case Report and a Review from the Literature

Introduction

Pediatric inflammatory multisystem syndrome temporally associated with COVID-19 (PIMS-TS) is a rare life-threatening condition requiring a complex management and multidisciplinary approach, whose outcome depends on the early diagnosis.

Case report

We report the case of a 2 years and-5-month-old boy admitted in our clinic for fever, abdominal pain and diarrhea. The clinical exam at the time of admission revealed influenced gen-eral status, bilateral palpebral edema and conjunctivitis, mucocutaneous signs of dehydration, and abdominal tenderness at palpation. The laboratory tests performed pointed out lymphopenia, thrombocytopenia, anemia, elevated C-reactive protein – CRP, erythrocyte sedimentation rate and ferritin levels, hyponatremia, hypopotassemia, hypertriglyceridemia, elevated D-dimer, in-creased troponin and NT-proBNP. The real-time polymerase chain reaction (RT-PCR) test for SARS-CoV-2 infection was negative, but the serology was positive. Thus, established the diagnosis of PIMS-TS. We initiated intravenous immunoglobulin, empirical antibiotic, anticoagulation therapy and symptomatic drugs. Nevertheless, the clinical course and laboratory parameters worsened, and the 2nd echocardiography pointed out minimal pericardial effusion, slight dilation of the left cavities, dyskinesia of the inferior and septal basal segments of the left ventricle (LV), and LV systolic dysfunction. Therefore, we associated intravenous methylprednisolone, angiotensin converting enzyme inhibitors, spironolactone and hydrochlorothiazide, with outstanding favorable evolution.

Conclusions

Echocardiographic monitoring might be a lifesaving diagnostic tool in the management of PIMS-TS.

COVID-19, obesity, and immune response 2 years after the pandemic: A timeline of scientific advances

In the 2 years since the COVID-19 pandemic was officially declared, science has made considerable strides in understanding the disease's pathophysiology, pharmacological treatments, immune response, and vaccination, but there is still much room for further advances, especially in comprehending its relationship with obesity. Science has not yet described the mechanisms that explain how obesity is directly associated with a poor prognosis. This paper gathers all published studies over the past 2 years that have described immune response, obesity, and COVID-19, a historical and chronological record for researchers and the general public alike. In summary, these studies describe how the cytokine/adipokine levels and inflammatory markers, such as the C-reactive protein, are associated with a higher body mass index in COVID-19-positive patients, suggesting that the inflammatory background and immune dysregulation in individuals with obesity may be expressed in the results and that adiposity may influence the immune response. The timeline presented here is a compilation of the results of 2 years of scientific inquiry, describing how the science has progressed, the principal findings, and the challenges ahead regarding SARS-CoV-2, COVID-19, and emerging variants, especially in patients with obesity.

COVID-19 and PIMS-Two Different Entities, but the Same Trigger

COVID-19 and PIMS represent two novel pathologies that have challenged the medical world during the last two years on account of their being very similar, but yet very different. Our aim was to comparatively assess children with SARS-CoV-2 infection and PIMS in terms of symptoms, clinical findings, laboratory parameters, echocardiography, and evolution. Our retrospective study included 46 children with COVID-19 (group 1), and 20 children with confirmed PIMS (group 2). We found no significant differences in terms of age, gender, and originating area between the two groups. We noticed that fever was significantly more common in the PIMS group as compared to COVID-19 group (p = 0.0217). In terms of laboratory parameters, increased bilirubin and creatinine were significantly more frequent in children with COVID-19 (p = 0.0064/p = 0.0064), while hypoalbuminemia and elevated ESR were significantly more common in those with PIMS (p < 0.0001/p = 0.0127). Moreover, prognosis parameters such as D-dimers, NT-proBNP, and CK-MB were also found to be significantly higher in the PIMS group as compared to COVID-19 group (p = 0.0003/p = 0.0182/p = 0.0007). In terms of complications, most were identified in PIMS group, among which cardiac and liver impairment along with dehydration were significantly more common in children diagnosed with PIMS as compared to those detected with COVID-19. Similarly, children with PIMS had a significantly higher chance to have pathological echocardiography changes. Although difficult, the distinction between COVID-19 and PIMS is crucial for the patient’s long-term outcome.

Risk factors of a severe course of pediatric multi-system inflammatory syndrome temporally associated with COVID-19

Pediatric multi-system inflammatory syndrome temporally associated with COVID-19 (PIMS-TS) is a serious complication of a previous SARS-CoV-2 infection. The disease causes multiple organ failure, but in some patients, a more severe course of the disease is observed. The treatment is multidirectional and depends on the severity and course of the disease, as some patients do not respond to the recommended treatment. The aim of this study was to identify laboratory risk factors affecting the more severe course of the disease and resistance to standard therapy. It is a single-center retrospective study considering 51 patients with PIMS-TS. Clinical features, laboratory results, and additional imaging tests data were taken into account. Fifty-one patients with PIMS-TS were hospitalized within a 16-month observation period. In the studied group, 26/51 children (51%) were girls. The mean age of patients was 7 years. Sex of the patient was not a risk factor for changes in cardiovascular system or severe course of the disease. Sixteen patients (31.3%) required transfer to the intensive care unit. Children with initially higher concentrations of NT-proBNP, troponin, creatinine, triglycerides, C-reactive protein, procalcitonin, ferritin, D-dimers and lower hematocrit, platelet count, lymphocytes, and ejection fraction should be strictly observed as they have a higher risk of severe course of the disease.

CONCLUSIONS

Laboratory parameters especially markers of myocardial damage, markers of inflammation, blood count, as wells as biochemical parameters are significant risk indicators of severe course of PIMS -TS and their concentration can be defined as predictor of disease severity.

WHAT IS KNOWN

• Pediatric multisystem inflammatory syndrome temporally associated with COVID-19 (PIMS-TS) is a serious complication of a previous SARS-CoV-2 infection in the group of pediatric patients • Course of the disease may be severe, which may cause long-term complications and the need for longitudinal patient care.

WHAT IS NEW

• Children with higher concentrations of NT-proBNP, troponin, creatinine, TG, CRP, PCT, ferritin, D-dimers and lower hematocrit, PLT, lymphocytes, and EF have a higher risk of a severe course of the disease. • Patients with high concentration of NT-proBNP, troponin, CRP, lactates, ferritin, D-dimers, creatinine and a lower concentration of PLT, albumin, leukocytes; lymphopenia, hyponatremia are at risk for intravenous immunoglobulin resistance.