Clinical spectrum and atypical presentations of covid-19 in hospitalized children in a tertiary care hospital: prospective observational study

ORIGINAL ARTICLE

Clinical Spectrum and Atypical Presentations of COVID-19 in Hospitalized Children in a Tertiary Care Hospital: Prospective Observational Study

Shweta Pathak, Monica Lazarus, Pawan Ghanghoriya.

Department of Pediatrics, NSCB Medical College Jabalpur, Madhya Pradesh, India.

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Abstract
Background: Since December 2019, an outbreak of coronavirus disease 2019 (COVID-19) has spread globally. India is now 2^nd worst affected country after USA. In central India, little is known about the clinical spectrum and severity of COVID-19 in children.
Aim: To assess the clinical characteristics of hospitalized COVID-19 infected children below 14 years of age and to describe atypical presentations of COVID-19 in children.
Design: Prospective observational study
Setting: Tertiary care centre and a dedicated COVID hospital in central India.
Participants: All the children with RT-PCR confirmed COVID-19 (Nasopharyngeal or oropharyngeal swabs) or a positive SARS-CoV-2 antibody test between 14^th April to 30^th October 2020 were enrolled in this study. Clinical presentation, progression, course, and outcomes of these children were assessed.
Results: Total 45 children were admitted with COVID-19.The median age of children with COVID-19 was 5.5 years (3 days-14 years). The cohort was predominantly male (66.6%) and only 5 (11%) children had co-morbidities (4 children had malnutrition and 1 had congenital heart disease). The route of transmission was either by close contact with family members with COVID-19 33 (73%) or a history of exposure to epidemic areas 33 (73%). The most common presenting symptoms were fever in 16 (35.5%), cough in 10 (22%), breathing difficulty in 8 (18%), nausea and vomiting in 8 (18%) and seizures in 6 (13.3%) patients. Twenty-three (51%) children were asymptomatic, 8 (17%) children had mild symptoms, 4 (8.8%) had moderate disease and 10 children were admitted with severe/critical disease requiring admission in critical care unit. Of the severe/critical patients, septic shock with respiratory failure was seen in 4 (8.8%), Guillain Barre Syndrome (GBS) in 1 (2%), encephalitis in 2 (4%), Kawasaki disease (KD) in 1 (2%) and acute respiratory distress syndrome (ARDS) in 2 (4%) children. Three (6.6%) children died, and all were in the age group between 2-3 months. Out out of 10 critical patients, 8 had high neutrophil lymphocyte ratio (NLR), 6 had high d-dimers and high ferritin levels.
Conclusion: Our study shows that pediatrics patients with COVID-19 have a simple transmission mode, either by close contact with infected adults or by exposure to epidemic areas. Most children are asymptomatic. Atypical or severe manifestations can be seen in 22% of children and require intensive monitoring. Severe life-threatening illnesses in the form of ARDS, GBS, KD and other multisystem involvement are seen in these patients. Therefore, it is mandatory in current scenario to have a high degree of suspicion for COVID-19 in children admitted in pediatric intensive care units (PICUs) with an unexplained diagnosis, persistent fever and high levels of inflammatory markers.

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