Characteristics of COVID-19 in Pediatric Patients with Malignancy in Sulaymaniyah Governorate, Kurdistan Region of Iraq

BACKGROUND: A recent human’s pandemic of respiratory disease caused by a novel (new) coronavirus that rapidly spreads in the community and may causing life threating complications. All those exposed to it is at risk of becoming infected and getting COVID-19. Cancer Patients may be more likely at risk to getting the infection and developing life threating morbidity and even death as those cancer patients may have weakened immunity either because of the cancer treatment or direct effect of the disease. OBJECTIVE: To obtain local data on the pattern of children and adolescent with cancer on treatment who have been infected with SARS-CoV-2 in our community and compare it with that of noncancerous patients. Journal Home: https://www.scienceworldpublishing.org/journals/journal-of-corona-virus-/COVID19 2/7 Journal of Corona Virus Volume: 1.1 PATIENTS AND METHODS: A prospective study conducted on 54 pediatric patients with cancer during their treatment with chemotherapy that developed RT-PCR approved COVID-19 in Sulaymaniyah Governorate-Kurdistan region of Iraq from April 2020 to October 2020 were carried out to analyze the demographic features and their clinical manifestation. Data analyzed using SPSS software; version 13 and P-value obtained by Chi-square test. RESULTS: The median age at diagnosis was about 7 and peak age incidence occurred in adolescent between 13-17 years old with slightly female predominance. There was no correlation between gender and severity; patients with hematological malignancies seem to have more severe COVID-19 manifestation than solid tumor. CONCLUSION: Overall morbidity and mortality from COVID-19 in cancer patients is seem to be similar to noncancerous patients. INTRODUCTION Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the virus that causes coronavirus disease 2019 (COVID-19), the respiratory illness responsible for the COVID-19 pandemic [1, 2]. SARS-CoV-2 is a member of the family Coronaviridae and orders Nidovirales, is an enveloped and positive-sense single-stranded RNA (+ssRNA) virus[3]. The incidence of SARS-CoV-2 infection is seen most often in adult male patients with the median age of the patients was between 34 and 59 years [4,5], SARS-CoV-2 is also more likely to infect people with chronic comorbidities such as cardiovascular and cerebrovascular diseases and diabetes [6]. The highest proportion of severe cases occurs in adult’s ≥60 years of age, and in those with certain underlying conditions, such as cardiovascular and cerebrovascular diseases and diabetes [4, 5]. Severe manifestations maybe also associated with coinfections of bacteria and fungi [6]. Fewer COVID-19 cases have been reported in children less than 15 years [5, 7, 8]. In a study of 425 COVID-19 patients in Wuhan, published on January 29, there were no cases in children under 15 years of age [9], Nevertheless, 28 pediatric patients have been reported by January 2020. The clinical features of infected pediatric patients vary, but most have had mild symptoms with no fever or pneumonia, and have a good prognosis [10]. Another study found that although a child had radiological ground-glass lung opacities, the patient was asymptomatic [9]. In summary, children might be less likely to be infected or, if infected, present milder manifestations than adults; therefore, it is possible that their parents will not seek out treatment leading to underestimates of COVID-19 incidence in this age group. Patients with hematological or solid malignancy may be more likely at risk to getting the infection and developing life threating morbidity and even death as those cancer patients may have weakened immunity either because of the cancer treatment or direct effect of the disease. Still there is a doubt regarding the potential effects and severity of COVID-19 on patient with active malignancy receiving chemotherapy specially young children and adolescents, and the major question regarding wither to continue or stopping the ongoing chemotherapy for those patients, so we did this study trying to answering this important questions. PATIENTS AND METHODS A prospective study of 54 patients with hematological malignancies and solid tumors in Hiwa cancer center, Sulaymaniyah province, Kurdistan region of Iraq, over a period of six months from April 2020 to October 2020 were carried out to analyze the demographic features, clinical presentations and consequences of SARS-CoV-2 in Pediatric cancer patients on chemotherapy. Diagnosis of SARS-CoV-2 was based on detection of viral antigen on Real Time polymerase chain reaction (RT-PCR) in nasopharyngeal swab. Inclusion criteria included all pediatric patients with any hematological and solid malignancies on chemotherapy, both gender, under the age of 18 years with full recorded data diagnosed with SARS-CoV-2 by RT-PCR from the nasopharyngeal swab. Exclusion criteria included all patients with negative RT-PCR for SARS-CoV-2 in the nasopharyngeal swab and patients who were diagnosed as COVID-19 on the bases of positive serology (SARSCoV-2 IgG and/or IgM) or radiological findings without RT-PCR for SARS-CoV-2, patients who were not on chemotherapy and patients with additional comorbidity as metabolic or cardiac disease. All included patients underwent detailed clinical history including co-morbid conditions; measurement of vital signs, Oxygen saturation (SpO2) evaluated for the severity of the disease specially the respiratory symptoms. Then they have full hematological (Complete blood count and Blood Film), and biochemical investigations (liver adrenals functions, CRP, Lactate dehydrogenase and ferritin level, D-dimer, serum electrolyte and blood culture), radiological examination (chest X-ray and Computerized tomography of chest), SARS-CoV-2 RTPCR from the nasopharyngeal swab. The disease severity was categorized according to “Diagnosis and Treatment Protocol for 2019-nCoV” [11,12] into three classes; mild to moderate (mild symptoms up to mild pneumonia); Severe (dyspnea, hypoxia, or more than 50% lung involvement on imaging); and critical (respiratory failure, shock, or multiorgan system dysfunction), also in our study classified the patients according to the cheat radiological findings into normal and abnormal which included any abnormalities (bilateral, peripheral, ill-defined and ground-glass opacification, consolidation, pleural effusion and Journal Home: https://www.scienceworldpublishing.org/journals/journal-of-corona-virus-/COVID19 3/7 Journal of Corona Virus Volume: 1.1 lung collapsed) any chest X-ray or chest CT scan , then the patients treated according to the local guideline mostly by antibiotic and supportive care. The study was approved by the study was approved by the Review Ethical Committee of Hiwa Hospital. Data were entered into Excel sheet and then transferred to SPSS-Descriptive analysis; Data analyzed using Statistical package for social sciences (SPSS) software; version 13 and P-value obtained by Chi-square test, P value less than 0.05 considered as significant. RESULTS sample of 54 of pediatric patients with different types of hematological malignancies and solid tumors with mean age of 10.2years (standard deviation is 11.6), minimum age was 2.1 years, maximum age was 17 years (range of 14.9 years) with median age of 7 years. Most cases of COVID-19 occurred in adolescents aged 13 to 17 years (37.4%) followed by those in children 9 to 12(27.77%). Table 1 shows the age distribution of our patients (Table 1). Table 1: Age distribution Age Frequency % 1-4 8 14.81 5-8 11 20.37 9-12 15 27.77 13-17 20 37.4 Girls was little bit more common than boy as 55.55% (30)of the patients were female and (24) 44.45% were male with male to female ratio of 0.8:1. Figure 1 shows the gender distribution for our patients (Figure 1). As showed in figure 2, the majority of our pediatric patients with COVID-19 were initially diagnosed as acute lymphoblastic leukemia and the minority with lymphoma, 27 (50%) patients had acute lymphoblastic leukemia (ALL), 12 (22.22%) with Solid tumor, and 9(16.66%) were with acute myeloid leukemia (AML), and only 6(11.11%) patients were with lymphoma (Figure 2). Figure 1: Gender distribution Figure 2: Distribution of primary diagnosis The most Common presenting symptom was fever with core body temperature ranging from 37.8 to 40.2 °C in 39(72.22%) patients, followed by cough in 23(42.6%) , sneezing in 10(18.52%) patients, respiratory distress in 5(9.26%), nausea/vomiting in 4 (7.41%) and diarrhea in 2(3.7%). Table 2 shows the frequency and percentage of COVID-19 clinical manifestations (Table 2). Regarding COVID-19 severity as shown in figure 3, 45(83.33%) with mild to moderate severity, 7(12.96%) patients with severe manifestations, and just 2(3.7%) patients were critical. Our study shows no mortality among our patients (Figure 3). Table 2: Frequency and percentage of COVID-19 clinical manifestations Clinical Manifestation Frequency percentage Fever 39 72.22 Cough 23 42.6 Sneezing 10 18.52 Respiratory Distress 5 9.26 Nausea and vomiting 4 7.41 Diarrhea 2 3.7 Figure 3: The disease severity distribution categorized according to “Diagnosis and Treatment Protocol for 2019-nCoV” [12, 13] Journal Home: https://www.scienceworldpublishing.org/journals/journal-of-corona-virus-/COVID19 4/7 Journal of Corona Virus Volume: 1.1 Chemotherapy related neutropenia (defined as an absolute neutrophil count (ANC) of less than 1500 per microliter (1500/microL) were observed in 38(70.37%) patients and 16(29.63%) without chemotherapy induced neutropenia. Figure 4 shows the distribution of chemotherapy induced neutropenia (Figure 4). Figure 4: Chemotherapy induced neutropenia distribution Chest radiology (as shown in figure 5) was normal in 43(79.62%) patients and abnormal in 11(20.37%) patients, Abnormal Chest radiology defined as bilateral, peripheral, ill-defined and groundglass opacification, consolidation, pleural effusion and lung collapsed) any chest X-ray or ches