Children with cancer diagnosed with SARS-COV-2
Fifteen patients were diagnosed with SARS-COV-2 by NP swab during the study period; 9 (60%) boys and 6 (40%) girls. Their mean age was 8.3 ± 3.5 years. Their residence mainly in the catchment area of the hospital (8 (53.3%) from Cairo, 2 (13.4%) from Qalyubia, 1 (7%) from El-Fayoum and four were from other governates (1 Suez Canal, 3 Beni-Sweif). Five (33.3%) patients had a positive history of exposure to confirmed SARS-CoV2 positive cases. NP Swab was performed for 3 out of 13 care-givers and it returned positive. The underlying diagnosis of those 15 patients was mainly hematological malignancies; ten (76.9%) were diagnosed with ALL (n=8, 61.5% had Pre B and n=2, 15.3% had T-cell), 1 (6.7%) had acute myeloid leukemia, 1 (6.7%) had lymphoblastic lymphoma, and 1 (6.7%) had post-transplant Hodgkin Lymphoma. Two (13.4%) of these 15 patients had other malignancies; 1 (6.7%) had high risk medulloblastoma and 1 (6.7%) had Ewing’s sarcoma.
Clinical picture
Regarding the clinical picture, 10 (66.7%) were asymptomatic (six patients were newly diagnosed with cancer and three were admitted for chemotherapy and one was screened preoperatively for excisional lymph node biopsy for suspicion of relapse). One of the ten asymptomatic cases who presented at his initial diagnosis found to have a mediastinal mass and malignant pleural effusion on the initial diagnostic work-up. The other five (38.4%) symptomatic patients were admitted for supportive care; 4 presented with fever and 1 presented with cough and dyspnea as illustrated in Figure1. During admission, out of ten asymptomatic children, five remained asymptomatic and the other 5 developed mild symptoms, mainly fever (n=5), cough (n=3), headaches (n=2), myalgia (n=1), fatigue (n=1), and pruritis (n=1).
Laboratory results
Regarding the laboratory results, there was a wide range of lymphocyte count which is attributed to the presence of three newly diagnosed patients with acute leukemia within the study and the detected lymphocytopenia present in 50% of patients. D-dimer was performed in seven patients and was elevated in all of them. LDH was also elevated in all the examined cases. The mean serum creatinine was 0.7 mg/dl, which was elevated only in one newly diagnosed patient with high TLC count and picture of tumor lysis. C-reactive protein (CRP) was mildly elevated in all, except in three patients with a mean of 24.3 mg/dl. Laboratory data of the 15 patients with confirmed SARS-CoV2 infection are summarized in Table 1. Creatine kinase was done for 2 patients; 36 and 41 U/l (reference range 20-200). One patient was isolated at home, whose parents refused doing further laboratory tests, except for a CBC before biopsy.
Radiological data
Among the 15 patients with confirmed SARS-CoV2 infection, 10 (66.7%) performed radiological assessment with significant radiological findings detected in four (40%) patients. One patient had only a plain chest x-ray, which showed bilateral pulmonary infiltrates. Three had an initial plain chest x-ray followed by high resolution CT-scan (HRCT), which was abnormal in one of them revealing bilateral mosaic appearance and left lobar consolidation. Six patients had HRCT from the start and showed abnormal finding in two patients.as illustrated in Figure 2.
Treatment
Treatment was mainly supportive with antibiotic according to the febrile neutropenia protocol and the local Children Hospital, Ain shams University guidance for management of COVID-19. Supportive treatment was mainly in the form of maintaining adequate hydration and nutrition, ensuring adequate sleeping hours, antipyretics (paracetamol), vitamin C (50 mg 1-3 year and 100 mg over 3year), zinc 5-10 mg for young children and 10-15 mg for older children, vitamin D 3 (400-600 IU) below 1 year, and (600-800 IU) for older children in addition to lactoferrin sachet once daily.
Treatment of COVID-19 as per the local children’s hospital guidance includes the following medications: 1) azithromycin 10 mg/kg once on day one max dose 500mg /dose followed by 5 mg/kg (max 250 mg/dose) once daily for 5 days, 2) hydroxychloroquine 6.5 mg/kg orally every 12 hours (max: 600 mg/dose) for two doses, followed by 3 mg/kg orally every 12 hours (max: 200 mg/dose) for a total of 5-10 days, 3) ceftriaxone 100 mg/kg/dose once daily for 5 days max daily dose 2 gm, and 4) anticoagulation prophylaxis (Enoxaparin) <2 months: 0.75 mg/kg SC q12h , ≥2 months: 0.5 mg/kg SC q12hr if D dimer between 500-1000 ng/ml.
Outcome
Out of the 15 patients with confirmed SARS-CoV2 infection, eight (53.3 %) were discharged after their RT-PCR test results became negative, four (26.6 %) are still admitted in isolation, one (6.7 %) patient was isolated at home and managed through the hospital on-call services. The duration of hospital stay ranged from 1-24 days (mean 10.2±8.1) as illustrated in Figure 1.
Mortality
During the study period two death were reported, one of them was 13 years old female who presented on May 16, 2020 with pancytopenia and severe menorrhagia for which she started hormonal therapy with GnRH agonist and platelet transfusion with good initial response, eventually she was diagnosed with ALL pre B. NP swab was performed on the following day and she was confirmed with SARS-CoV-2 and her CT scan was normal. She was transferred to Elobour isolation hospital and treated with supportive treatment, azithromycin, oseltamivir, and hydroxychloroquine. No anticoagulation was started due to persistent thrombocytopenia. After 12 days of her first presentation to hospital she was deceased due to the underlying cancer before commencing anti-leukemic therapy because SARS-CoV-2 RT-PCR was still positive.