الفهرس 
Chapter (I): COVID-19 VirusOnly 14 pages are availabe for public view
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Abstract
Children and young people comprise only 1-2% of cases of coronavirus disease 2019 (covid-19) worldwide. In contrast to other respiratory viruses, children seem to have a lower risk of infection than adults, and the vast majority of reported infections in children are mild or asymptomatic, with few recorded childhood fatalities attributed to covid-19. Initial reports from China showed that only 0.6% of children with covid-19 were critically ill.
A severe disease phenotype has emerged in children that seems to be temporally associated with severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) infection. The condition was first described in May 2020 in a cluster of children admitted to critical care in south London (UK), with evidence of a multisystem hyperinflammatory state with features similar to Kawasaki disease and toxic shock syndrome.
The first data about the disease mainly focused on severe respiratory symptoms observed in adults, and this situation led to a lack of data to explain the different course of COVID-19 in children. The clinical spectrum of COVID-19 ranges from asymptomatic to critical patients. Fever and cough are the most common symptoms in symptomatic adults.
In pediatric patients, clinical findings are not typical and relatively milder than those in adult patients. While these patients are mostly asymptomatic or have upper respiratory symptoms including fever, dry cough, weakness, runny nose, and nasal congestion, some patients may present with gastrointestinal symptoms such as abdominal pain, nausea-vomiting, and diarrhea. Their clinical findings and prognosis are generally good. It was reported that most cases recovered completely within 1 to 2 weeks.
It was reported that acute respiratory distress syndrome, septic shock, metabolic acidosis, and coagulation disorders might occur in rare cases. The laboratory findings data in children with COVID-19 is still limited, with poor
number of studies and reports. Laboratory tests usually show lymphopenia and leukocytosis.
The aim of the present work was to study different presentations, clinical and laboratory findings among children with COVID-19. This cross-sectional study was conducted on 30 children with COVID-19 who were admitted to Shentena Fever Hospital with a diagnosis of COVID-19 during the period study from January 2020 to June 2021.
All included children were subjected to the following:
Detailed history: taking including personal history as (name, age, sex, residence), Family history: history of contact, Detailed vaccination history, Present history of illness including Fever, cough, sputum production, sore throat, running nose, dyspnea, diarrhea, vomiting, fatigue and abdominal pain. Physical examination including: General and Systemic examination including chest, nerves system and GIT examination with special stress on assessment of pneumonia with abnormal findings on chest CT, Evaluation of the clinical courses, treatment and outcome of the disease (including onset, duration of hospital admission, intensive care unit (ICU) admission and mechanical ventilation).
Laboratory investigations including: Complete blood count : Included hemoglobin, white blood cell, absolute neutrophilic count, lymphocytes, monocytes, and platelets, Hepatic and renal function tests: Included ALT, AST, UREA and Creatinine, CRP: C-reactive protein is an acute phase reactant protein made by liver. Erythrocyte sedimentation rate, Serum ferritin assay, D dimer assay, Interloukin-6 assay, Procalcitonin assay, Vitamin D assay, PCR for Covid-19.
Clinical features: Included asymptomatic, mild, moderate and severe. Symptoms: included Common symptoms: Fever, Cough, Dyspnea, Runny nose, Sore throat, Respiratory symptoms: Vomiting, Diarrhea, Fatigue,
Headache Signs: included tachypnea, intercostal retraction, grunting, cyanosis and abdominal rigidity. Radiography included: Plain Chest x-ray and CT whenever indicated. Symptomatic and Treatments: included symptomatic, antibiotic, oxygen supplementation, mechanical ventilation and intravenous immune globulin.
Results of the current study were summarized as follows:
Age was significantly increased among severe group than mild, and moderate clinical features groups. Also, family contact was significantly higher frequent among severe group than mild, and moderate clinical features groups, there were no significant differences between the studied groups regarding sex and residence (p>0.05).
Fever, cough, dyspnea and Duration of fever (days) were significantly decreased among mild group than moderate and severe group. While runny nose and sore throat were significantly decreased among severe group than mild and moderate group (p<0.001).
Regrading extra respiratory symptoms, vomiting, was significantly decreased among severe group, while diarigh, headache and fatigue were significantly decreased among moderate group (p<0.001). However, tachypnea, cyanosis, abdominal rigidity and associated disease (p<0.001) were significantly decreased among mild than moderate and severe.
Hb, WBCs and lymphocytes were significantly decreased among severe than asymptomatic, mild, and moderate groups. While, absolute neutrophilic count, monocytes and platelets were significantly increased among severe than asymptomatic, mild, and moderate groups (p<0.05).
ESR 1h was significantly increased among asymptomatic and severe than mild, and moderate groups. While, CRP, ALT, AST, Urea, creatinine and serum ferritin were significantly increased among severe than mild, moderate and asymptomatic clinical features groups (p<0.05).
D dimer, interleukin 6 and procalcitonin were significantly increased among severe than asymptomatic, mild and moderate clinical feature groups. While, Vitamin D was significantly decreased among severe than asymptomatic, mild, and moderate groups (p<0.05). However, all our patients were surfing from vitamin D insufficiency or deficiency.
Stay in hospital was significantly increased among severe than mild and moderate groups. Regarding outcomes, recovery was found in all mild group, in 90% of moderate, and 45% in sever group. While, there were 2 patients of severe group were died. Also, 4 moderate and 9 severe patients had complicated as AKI, ALI, DIC, ACI, PMIS.
There were significant relations between d dimer, Vitamin D, procalcitonin and interleukin 6 with clinical features of the studied patients (P<0.05). Vitamin D and procalcitonin were significant related with fever, cough and dyspnea, vomiting, diarrhea, fatigue, runny nose, sore throat, tachypnea, intercostal retraction and abdominal rigidity (P<0.05). While, D dimer was significantly related with fatigue, headache and cyanosis. Also, procalcitonin was significantly related with fatigue and cyanosis (P< 0.05).
D dimer, Vitamin D, procalcitonin and interleukin 6 were significantly related with symptomatic and antibiotic. While, vitamin D and procalcitonin were significantly related with oxygen supplementation, (P<0.05).
Vitamin D, procalcitonin and IL-6 were significantly related with ICU admission (P<0.001). Also, procalcitonin and interleukin 6 were significantly related with outcome (P<0.001).
Procalcitonin was significantly increased with diarrhea, headache, intercostal retraction and had abdominal rigidity of severe patients. While, IL-6 was significantly increased with diarrhea of severe patients, (P<0.001).
ROC curve analysis showed that Vitamin D, procalcitonin and IL-6 were the best biomarkers for detection a risk factors for severe dieses, the sensitivity of Vitamin D, procalcitonin and IL-6 were 72.4%, 75.8% and 81.8%
respectively, specificity of them were 64.3%, 36.4% and 79.7% respectively, with AUC of 0.696, 0.844 and 0.635, at cut off 23.4, 0.98 and 7.65, respectively.
The summary of the common complications, lab findings, CT features and risk factors could help medical personnel better manage patients who may develop into severe conditions or death.
Children at any age seem to be susceptible to COVID-19, and even though their symptoms are milder, they still had a diverse range of clinical presentations.
Children with COVID-19 predominantly exhibited respiratory and/or gastrointestinal symptoms, neurological manifestations.
This study has indicated that the main clinical features of COVID-19 in children are fever, dry cough, and mild pneumonia.
ROC curve analysis showed that Vitamin D, procalcitonin and IL-6 were good biomarkers for detection of risk factors for severe disease.
The sensitivity of Vitamin D, procalcitonin and IL-6 were 72.4%, 75.8% and 81.8% respectively, specificity of them were 64.3%, 36.4% and 79.7% respectively, with AUC of 0.696, 0.844 and 0.635, at cut off 23.4, 0.98 and 7.65, respectively.
D dimer, interleukin 6 and procalcitonin were significantly increased among severe than asymptomatic, mild and moderate clinical feature groups.
Vitamin D was significantly decreased among severe than asymptomatic, mild, and moderate groups (p<0.05). However, all our patients were surfing from vitamin D insufficiency or deficiency.
Vitamin D, procalcitonin and IL-6 were significantly related with ICU admission (P<0.001). Also, procalcitonin and interleukin 6 were significantly related with outcome (P<0.001).
Further studies evaluating the laboratory analysis and decision strategies of illness severity and hospitalization are urgently needed in children with COVID-19.
More studies are needed in children for evaluation of the association between best marker: Interleukin 6 and Procalcitonin with clinical and laboratory findings of the disease and its effect on mortality.
We recommend using of biomarker as procalcitonin and interleukin-6 for early detection of covid-19 severity in children.
Early identification, early isolation, early diagnosis and early treatment are important for clinical management.
We recommend vaccination of children according to CDC guidelines to decrease spread of covid-19.