Discussion
COVID-19 was declared by World Health Organization as a public health
emergency of international concern (10) and despite the worldwide
spread, clinical patterns of COVID-19 particularly among children remain
largely unclear. (5) The clinical spectrum of COVID-19 could range from
being asymptomatic to developing severe acute respiratory distress. (2)
In the current study, despite of the immunocompromised status of the
hospitalized patients with cancer, 66.7% were asymptomatic at admission
and 33.3% had mild symptoms. This is in comparison to 4.4% and 50.9%
respectively in large Chinese study in which 731 patients were confirmed
positive by laboratory testing. (2)
While other coronaviruses can produce more severe disease in
immunocompromised children with increased risk with coexisting pulmonary
disease or concurrent lower respiratory tract infection (6,11), the
severity of children’s COVID-19 cases was milder than adult. (2) A
systemic review of 110 immunosuppressed patients, mostly presenting with
cancer, along with transplantation and immunodeficiency, they seemed to
have a favorable disease course, as compared to the general population,
72 (65.5%) recovered (discharged or inpatients) or did not require
intensive care and 6 (5.5%) needed intensive care or invasive
ventilation and 23 (20.9%) died. (12) In an Italian pediatric
haemato‐oncology clinic, SARS‐CoV‐2 infection was detected in 4 out 170
patients at the molecular level; three of them were asymptomatic.
(13)The clinical course and outcome of SARS‐CoV‐2 was reported to be
more favorable in children than in adults (1) A possible explanation
that children might have less severe disease was attributed to the lower
expression of ACE2 receptor and present with a different inflammatory
response, with higher numbers of B and T regulator cells, involved in
immune tolerance and leading to a less inflammatory immune response.
(14)
The detrimental impact of COVID-19 pandemic on childhood cancer may be
delay in diagnosis (15), delay in starting treatment, the detrimental
impact of infection on children with cancer, and the uncertainty about
decision for chemotherapy in PCR-positive asymptomatic patients.
Universal testing of asymptomatic cancer patients may help safe
continuation of treatment. (16)
As regards the treatment, all the patients received supportive care in
addition to antivirals or antibiotics guided by radiological findings
and symptom progression (according to Children’s hospital and MOH
guidelines). With the large diversity of therapeutic options, (17)
whether a different treatment approaches in children with cancer on
chemotherapy is not adopted. The important decision is the proper time
to start anticoagulation, the main concern is that childhood cancer is
predisposing for thrombosis (18). Whether early start of anticoagulation
for COVID-19 or delay usage as that it might be an immune thrombosis
related to neutrophil extracellular traps (19); yet it is acceptable
that in both cancer (20) and COVID-19 (21), D-dimer level is the most
important laboratory result in decision for anticoagulation.
As for total and differential leucocytic count, there was wide
variability; lymphocytopenia was present in 50% of patients compared to
3.6% in a previous study that is evaluating children infected with
SARS-CoV-2 and treated at the Wuhan Children’s Hospital. (11) Although
lymphopenia was associated with severe disease (22) which was not
consistent with the clinical manifestations of our patients group, yet
the high frequency of lymphopenia might be attributed to the underlying
cancer, chemotherapy and the wide variation could be due to the
inclusion of three newly diagnosed patients with hematological
malignancy.
The radiological findings in our patients were mainly ground glass
opacities (GGO), not necessarily affecting the periphery, consolidation
(lobar) and interstitial infiltrates. This finding is in agreement with
Chen et al, 2020 who reported that initially, chest
radiography findings can show signs of pneumonia, such as small
irregular lung opacities and interstitial alterations, usually affecting
peripheral areas. The authors also reported that chest computed
tomography also exhibits GGO and segmental consolidation in both lungs
while pleural effusion being uncommon. (23) However, correlation of
radiological findings with COVID-19 severity in the current study may
not be applicable due to small sample size.
Conclusion :
Pediatric oncology patients with SARS-COV-2 infection in this study were
mainly asymptomatic or with mild symptoms. A high index of suspicion
with mild symptoms and regular screening by NP swab in asymptomatic
hospitalized cancer patients admitted for intensive chemotherapy and
initiation of treatment, guided by laboratory data is recommended. More
studies are required to report the incidence, outcomes and therapeutic
decisions of SARS-COV-2 in pediatric patients with cancer.
.