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Indian Pediatr 2021;58:126-128 |
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Clinical Spectrum of
COVID-19 in a Mexican Pediatric Population
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Edgar Bustos-Cordova, Daniela Castillo-Garcia, Magdalena Ceron-Rodriguez
and Nadia Soler-Quinones
From Emergency Department, Hospital Infantil de México Federico Gómez,
Mexico.
Correspondence to: Dr Daniela Castillo-García, 162 Doctor Marquez
Street , Col Doctores, Mexico City, Postal Code 06400, Email:
[email protected]
Received: September 14, 2020;
Initial review: October 08, 2020;
Accepted: December 14, 2020.
Published online: December 19, 2020;
PII: S097475591600261
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Objective: To describe the broader clinical
spectrum of COVID-19 in children. Methods: In this descriptive,
prospective study, we included confirmed pediatric patients with
COVID-19 who presented to the emergency department of a pediatric
tertiary care center from April to July, 2020. All patients were
confirmed by the SARS-CoV-2 RT-PCR test, and we analyzed 24 symptoms and
25 signs. Results: Among the 50 patients with COVID-19, the most
common symptoms were fever, excessive cry and dry cough; digestive
symptoms were frequently found (24%). The most common signs were
pharyngeal erythema and irritability. Conclusion: Clinicians
should recognize that the clinical spectrum of COVID-19 in children is
wider than previously described, often with nonspecific signs and
symptoms, and digestive symptoms should raise suspicion.
Keywords: Diagnosis, Gastrointestinal symptoms, Presentation,
SARS-CoV-2.
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T he incidence of
coronavirus disease (COVID-19) in Mexico began to escalate
rapidly in April, 2020. By August 7, 12,052 cases of COVID-19 in
children were confirmed in Mexico, with 188 deaths [1]. From the
beginning of the COVID-19 pandemic, it has become evident that
the spectrum of manifestations in children is different from
those seen in adults. However, most of the clinical descriptions
have been made from retrospective studies addressing a narrow
number of manifestations. A meta-analysis [2] and a systematic
review [3] evaluated fewer than ten signs and symptoms. The aim
of this study was to describe a broader clinical spectrum of
COVID-19 in children.
METHODS
We conducted a prospective study in the
emergency department of a pediatric tertiary care center from
April to July, 2020. We included patients <18 years of age, with
a history in the week before inclusion of at least one of the
following criteria: a) one respiratory symptom, b) one
gastrointestinal symptom or c) fever and recent exposure to a
confirmed COVID-19 case. Patients with tracheos-tomy, severe
neurologic underlying conditions, use of sedatives in the last
week or children not accompanied by the primary caretaker were
excluded. All cases were tested with severe acute respiratory
syndrome corona-virus 2 (SARS-CoV-2) reverse
transcriptase-polymerase chain reaction (RT-PCR) nasopharyngeal
swabs. For the patients who met the inclusion criteria, we
looked for 24 symptoms present prior to evaluation at the
emergency department and 25 signs at the physical exploration,
and the information was gathered by attending physicians.
Gastrointestinal symptoms were defined as the presence of
diarrhea, vomiting, nausea or abdominal pain. We defined
pneumonia as the presence of one of the following: increased
work of breathing or oximetry <93%.
We analyzed the data from the COVID-19
confirmed patients; the information was analyzed using case
counting and descriptive statistics, and calculating median
(range), quartiles and percentages. To describe the chronology
of the appearance of symptoms, we performed diagrams for each
patient. A horizontal line represents the time (days) before
admission. Time zero represents the day of onset of the first
symptom. The time of appearance of each symptom was placed over
the line.
RESULTS
A total of 92 children were evaluated. Fifty
children (54%) were diagnosed with COVID-19 infection by a
positive SARS-CoV-2 RT-PCR test. Since chronic patients may have
different clinical manifestations, they were described
separately from previously healthy patients.
Twenty-six patients (52%) with confirmed
COVID-19 infection had a previous chronic medical condition. The
most common condition was cancer (16%), followed by chronic lung
disease (12%), obesity (8%), chronic kidney disease (6%) and
neurological disorders (4%). Three patients had more than one
chronic condition.
From the evaluated symptoms, 35 children
presented with fever (70%), 36% excessive crying and dry cough;
and 4% had hyposmia (Table I). Digestive symptoms were
common; 24% of the patients presented only gastro-intestinal
symptoms. All patients without any respiratory or
gastrointestinal symptoms were immunocompromised.
Table I Signs and Symptoms among 50 Pediatric Patients with confirmed COVID-19
| Symptomsa |
No. (%) |
Signs |
No. (%) |
| Time of symptom |
72(33-144) |
Pharyngeal |
30(60) |
|
onsetb |
|
|
erythema |
| Fever |
35(70) |
Irritability |
12(24) |
| Excessive crying |
18(36) |
Rhinorrhea |
10(20) |
| Dry Cough |
18(36) |
Conjunctival |
10(20) |
|
|
|
hyperemia |
| Rhinitis |
13(26) |
Respiratory distress |
6(12) |
| Sore throat |
12(24) |
Dehydration |
6(12) |
| Headache |
11(22) |
Crackles |
4(8) |
| Abdominal pain |
11(22) |
Fever |
4(8) |
|
Conjunctival hyperemia |
11(22) |
Rash |
3(6) |
| Vomiting |
11(22) |
Diminished breath sounds |
3(6) |
| Diarrhea |
11(22) |
Rhonchi |
2(4) |
| Shortness of breath |
10(20) |
Nasal mucosa edema |
2(4) |
| Fatigue |
9(18) |
Dysphonic |
2(4) |
| Hyporexia |
9(18) |
Hyperemia of pillars |
2(4) |
| Myalgia |
7(14) |
Somnolence |
2(4) |
| Dysgeusia |
4(8) |
Type of symptoms |
|
| Arthralgia |
4(8) |
Only respiratory |
25(50) |
| Productive cough |
4(8) |
Only gastrointestinal |
12(24) |
| Rash |
4(8) |
Both |
10(20) |
| Hoarseness |
5(5) |
Without any of them |
3(6) |
| aHyposmia
and cyanosis-2 children each; excessive daytime
sleepiness in 3. bMedian
(IQR) time from admission to onset of first symptom. |
From the evaluated signs, 30 children
presented pharyngeal erythema (60%), 24 with irritability (24%)
and 10 with rhinorrhea and conjunctival hyperemia (20%) (Table
I). The first symptom to appear was fever in 36% and cough
in 12%, followed by fatigue, rhinitis, and excessive crying each
in 8% of the patients. Manifestations intentionally sought but
not found in any patient were expectoration, mucopurulent
rhinorrhea, posterior nasal discharge, mucopurulent conjunctival
discharge, and epistaxis. Manifestations intentionally sought
that were found in only one patient were nasal mucosa edema,
rhonchi, cyanosis, lymphadenopathy, grunting, and wheezing.
Analyzing the diagrams of the symptom
appearance chronology, we defined three different patterns:
Pattern A or almost asymptomatic: with only one or two symptoms;
Pattern S or sudden: onset of 4
³symptoms in
the first 24-36 hours; and Pattern D or disperse: sequential
onset of symptoms over several days. The patterns were
distributed in an irregular form in both groups; nonetheless,
considering only the patients with pneumonia, the S pattern was
found in seven of nine of the chronically ill patients, in two
of eight immunocompromised patients, in four of the five
patients with chronic lung disease and in three of four obese
patients (Table II).
Table II Demographic and Clinical Characteristics, of Pediatric Patients With COVID-19 in Mexico (N=50)
| Characteristics |
Chronic |
Previously |
Total |
|
medical |
healthy |
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illness (n=26)
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(n=24) |
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| Age,a mo |
108(26-153) |
1856.6 |
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(7.25-99.5) |
(13-159) |
| Boys |
20(76.9) |
15(62.5) |
35(70) |
| Immunosuppression |
8(30.8) |
0(0) |
8(16) |
| Pneumonia |
8(30.8) |
10(41.7) |
18(36) |
| Admitted |
16(61.5) |
9(37.5) |
25(50) |
| Past antibiotic treatment |
7(26.9) |
4(16.7) |
15(30) |
| Past symptomatic treatment |
19(73.1) |
16(66.7) |
35(70) |
| Clinical patterns |
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| Pattern A |
4(15.4) |
7(29.1) |
11(22) |
| Pattern S |
12(50) |
9(37.6) |
21(42) |
| Pattern D |
8(30.8) |
10(38.8) |
18(36) |
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Values in no. (%) or amedian (IQR); Clinical
patterns of disease: A: almost asymptomatic; S (sudden);
D (disperse). |
The rate of admission was significantly
higher in chronically ill (61.5%) versus healthy individuals
(31.7%); however, 7 of the 27 chronically ill individuals were
admitted for previous disease decompensation. Of the 8
immunocompromised patients, two developed pneu-monia. Four of
the five patients with obesity also developed pneumonia.
All patients with pneumonia, except one, were
admitted. Only one patient developed Kawasaki-like syndrome. Two
patients required mechanical ventilation: one of them was a
patient with cystic fibrosis, and the other was a kidney
transplant patient who later died.
DISCUSSION
The clinical suspicion of SARS-CoV-2
infection in children has been a challenge for physicians
worldwide. Many case series have been published; however, most
of them are retrospective and collect few clinical features. A
broader description of the disease is of paramount importance
for the clinical suspicion of SARS-CoV-2 infection in children.
Although our study included a limited number of patients, it
explored a wider clinical spectrum in a heterogeneous population
of pediatric patients.
The testing capacity for SARS-CoV-2 in Mexico
is limited and reserved for patients who meet the national
epidemiological definition. Many children with symptoms
consistent with COVID-19 in the community are not tested and
consequently not diagnosed. Our inclusion criteria allowed us to
analyze patients who otherwise would not have been tested. These
results may serve to reconsider epidemiological definitions for
children with suspected COVID-19.
It is important to highlight that this study
captured data from children who were seen or managed within a
tertiary health-care institution; one-half of the patients had a
chronic medical condition. Consequently, the study population is
likely to primarily represent individuals with the more severe
end of the disease spectrum. Statistical differences between the
two groups were not calculated since the research was designed
as a case series description, the sample was small, and there
was a wide difference in age between both groups.
Adult patients with digestive symptoms
without respiratory symptoms are rare [4], while in children it
seems to be more frequent. Our results suggest that SARS-CoV-2
infection often presents with nonspecific signs and symptoms,
and digestive symptoms, even in the absence of respiratory
symptoms, should raise suspicion. Loss of taste and smell in
adults has been reported in up to half of patients [5] and
proposed as an important discriminatory symptom. Chemosensory
dysfunction in children is seldom reported [6], but our results
suggest that both hyposmia and dysgeusia are not so rare.
Pneumonia in patients with COVID-19 has been
reported in up to 64.9% of children with COVID-19 using
radiologic criteria [7], but it is rarely reported using
clinical criteria. We found one-third of patients with pulmonary
infection, exploring only clinical features. The recognition of
different clinical patterns of COVID-19 may help us recognize
patients with a higher risk of poor outcomes. Our results
suggest that the ‘S’ or sudden pattern is associated with
pneumonia in patients with underlying chronic conditions.
Additionally, as shown in young adults [8], obesity appears to
be an important risk factor for poor outcomes (pulmonary
involvement) in children with COVID-19.
Clinicians should recognize that the clinical
spectrum of COVID-19 in children is wider than previously
described and different from the adult presentation; often with
nonspecific signs and symptoms, digestive symptoms should
increase clinical awareness. The order of appearance of symptoms
(clinical pattern) requires more investigations, as our results
suggest that it could predict outcomes.
Ethics Clearance: Institutional ethics
committee of Hospital Infantil de México Federico Gómez; No.
HIM-AE-004-2020, dated September 14, 2020.
Contributors: EB: conceptualized the
study design; EB,DC,NS,MC: recruited patients, collected
demographic and clinical data. EB,DC: analyzed and interpreted
the results; EB: wrote the manuscript in Spanish; NS,DC:
translated the manuscript; DC,NS,MC,EB: commented on and revised
the manuscript. All authors approved the final report.
Funding: None; Competing interest;
None stated.
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WHAT THIS STUDY ADDS?
• The clinical spectrum of COVID-19
in children is wider than previously described.
• Digestive symptoms and other symptoms like loss of
taste or sensation should raise suspicion.
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What we know so far about Coronavirus Disease 2019 in children:
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