O coração de pacientes pediátricos com COVID-19: novos insights a partir de um estudo ecocardiográfico sistemático em um Hospital Terciário no Brasil / The heart of pediatric patients with COVID-19: new insights from a systematic chocardiographic study in a Tertiary Hospital in Brazil

Resumo Fundamento A pandemia da COVID-19 representa uma enorme carga para o sistema de saúde do mundo. Apesar de pacientes pediátricos terem sido relativamente poupados em comparação a adultos, estudos recentes mostraram um número crescente de pacientes críticos com Síndrome Inflamatória Multisistêmica Pediátrica (SIM-P) com disfunção cardiovascular importante. No entanto, pouco se conhece a respeito da relação entre anormalidades cardíacas e biomarcadores inflamatórios e de coagulação. Objetivos Investigar anormalidades ecocardiográficas em pacientes pediátricos com COVID-19 admitidos em um hospital terciário. Métodos Este foi um estudo longitudinal retrospectivo, baseado na revisão de prontuários médicos e ecocardiogramas de pacientes (0-19 anos) admitidos em um hospital terciário entre 30 de março e 30 de junho de 2020. Para a análise estatística, o nível de significância foi estabelecido em 5% (p<0,05). Resultados Foram incluídos 48 pacientes, 73% com doenças pré-existentes, 20 (41,7%) com SIM-P. A idade mediana foi 7,5 (0-18,6) anos; 27 (56,2%) eram do sexo masculino. A duração mediana de internação foi 15,4 (2-92) dias e sete (14,6%) pacientes morreram. Um total de 70 ecocardiografias foram realizadas, 66,7% submeteram-se ao exame somente uma vez, e 33,3% várias vezes. Vinte e três (48%) pacientes apresentaram anormalidades no ecocardiograma: oito (16.6%) disfunção sistólica do ventrículo esquerdo, seis (12.5%) disfunção sistólica do ventrículo direito, e 12 (25%) dilatação da artéria coronária (Z-score>+2,5). Anormalidades ecocardiográficas foram significativamente associadas com SIM-P, admissão na unidade de terapia intensiva pediátrica, suporte ventilatório/vasoativo, e morte ( p <0,05). Níveis significativamente mais altos de d-dímero (ng/mL) foram detectados em pacientes com disfunção ventricular esquerda [16733(4157-115668) vs. 2406.5(190-95040)], disfunção ventricular direita [25769(3422-115668) vs. 2803.5(190-95040)] e dilatação da artéria coronária [9652.5(921-115668) vs. 2724(190- 95040)] (p<0,05). Conclusão Anormalidades ecocardiográficas eram frequentes nos pacientes pediátricos com COVID-19 e associadas com piores desfechos clínicos. Exacerbação das vias de inflamação e coagulação pode exercer um importante papel na lesão cardiovascular nesses pacientes.

Abstract Background COVID-19 pandemic represents a huge burden to the health system in the world. Although pediatric COVID-19 patients have been relatively spared compared with adults, recent reports showed an increasing number of critically ill patients with multisystemic inflammatory syndrome in children (MIS-c), with marked cardiovascular impairment. Nevertheless, little is known about the relationship between cardiac abnormalities and inflammatory and coagulation biomarkers. Objectives to investigate echocardiographic abnormalities in pediatric patients with COVID-19 admitted to tertiary hospital. Methods this was a retrospective longitudinal study, based on the review of medical records and echocardiograms of patients (0-19 years) admitted to a tertiary hospital between March 30 and June 30, 2020. For statistical analysis, the significance level was set at 5% (p < 0.05). Results Forty-eight patients were enrolled, 73% with preexisting diseases, 20 (41.7%) with MIS-c. Median age was 7.5 (0-18.6) years; 27 (56.2%) were male. Median duration of hospitalization was 15.4 (2-92) days and seven (14.6%) patients died. A total of 70 echocardiograms were performed; 66.7% patients were scanned only once and 33.3% multiple times. Twenty-three (48%) patients showed echocardiographic abnormalities: eight (16.6%) left ventricle (LV) systolic dysfunction, six (12.5%) right ventricle (RV) systolic dysfunction and 12 (25%) coronary dilatation (Z-score>+2.5). Echocardiographic abnormalities were significantly associated with MIS-c, admission to the pediatric intensive care unit, multiple organ dysfunction, ventilatory/vasoactive support, and death (p<0.05). Significantly higher d-dimer (ng/mL) levels were detected in patients with LV dysfunction [16733(4157-115668) vs. 2406.5(190-95040)], RV dysfunction [25769(3422-115668) vs. 2803.5(190-95040)] and coronary artery dilation [9652.5(921-115668) vs. 2724(190- 95040)] (p<0.05). Conclusion Echocardiographic abnormalities in COVID-19 pediatric patients were frequent and associated with worse clinical outcomes. Exacerbation of the inflammation and coagulation pathways may play an important role in cardiovascular injury in those patients.

Persistent symptoms and decreased health-related quality of life after symptomatic pediatric COVID-19: A prospective study in a Latin American tertiary hospital

OBJECTIVES: To prospectively evaluate demographic, anthropometric and health-related quality of life (HRQoL) in pediatric patients with laboratory-confirmed coronavirus disease 2019 (COVID-19) METHODS: This was a longitudinal observational study of surviving pediatric post-COVID-19 patients (n=53) and pediatric subjects without laboratory-confirmed COVID-19 included as controls (n=52) was performed. RESULTS: The median duration between COVID-19 diagnosis (n=53) and follow-up was 4.4 months (0.8-10.7). Twenty-three of 53 (43%) patients reported at least one persistent symptom at the longitudinal follow-up visit and 12/53 (23%) had long COVID-19, with at least one symptom lasting for >12 weeks. The most frequently reported symptoms at the longitudinal follow-up visit were headache (19%), severe recurrent headache (9%), tiredness (9%), dyspnea (8%), and concentration difficulty (4%). At the longitudinal follow-up visit, the frequencies of anemia (11% versus 0%, p=0.030), lymphopenia (42% versus 18%, p=0.020), C-reactive protein level of >30 mg/L (35% versus 0%, p=0.0001), and D-dimer level of >1000 ng/mL (43% versus 6%, p=0.0004) significantly reduced compared with baseline values. Chest X-ray abnormalities (11% versus 2%, p=0.178) and cardiac alterations on echocardiogram (33% versus 22%, p=0.462) were similar at both visits. Comparison of characteristic data between patients with COVID-19 at the longitudinal follow-up visit and controls showed similar age (p=0.962), proportion of male sex (p=0.907), ethnicity (p=0.566), family minimum monthly wage (p=0.664), body mass index (p=0.601), and pediatric pre-existing chronic conditions (p=1.000). The Pediatric Quality of Live Inventory 4.0 scores, median physical score (69 [0-100] versus 81 [34-100], p=0.012), and school score (60 [15-100] versus 70 [15-95], p=0.028) were significantly lower in pediatric patients with COVID-19 at the longitudinal follow-up visit than in controls. CONCLUSIONS: Pediatric patients with COVID-19 showed a longitudinal impact on HRQoL parameters, particularly in physical/school domains, reinforcing the need for a prospective multidisciplinary approach for these patients. These data highlight the importance of closer monitoring of children and adolescents by the clinical team after COVID-19.

Differences in children and adolescents with SARS-CoV-2 infection: a cohort study in a Brazilian tertiary referral hospital

OBJECTIVES: To compare demographic/clinical/laboratory/treatments and outcomes among children and adolescents with laboratory-confirmed coronavirus disease 2019 (COVID-19). METHODS: This was a cross-sectional study that included patients diagnosed with pediatric COVID-19 (aged <18 years) between April 11, 2020 and April 22, 2021. During this period, 102/5,951 (1.7%) of all admissions occurred in neonates, children, and adolescents. Furthermore, 3,962 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) detection samples were processed in patients aged <18 years, and laboratory-confirmed COVID-19 occurred in 155 (4%) inpatients and outpatients. Six/155 pediatric patients were excluded from the study. Therefore, the final group included 149 children and adolescents (n=97 inpatients and 52 outpatients) with positive SARS-CoV-2 results. RESULTS: The frequencies of sore throat, anosmia, dysgeusia, headache, myalgia, nausea, lymphopenia, pre-existing chronic conditions, immunosuppressive conditions, and autoimmune diseases were significantly reduced in children and adolescents (p<0.05). Likewise, the frequencies of enoxaparin use (p=0.037), current immunosuppressant use (p=0.008), vasoactive agents (p=0.045), arterial hypotension (p<0.001), and shock (p=0.024) were significantly lower in children than in adolescents. Logistic regression analysis showed that adolescents with laboratory-confirmed COVID-19 had increased odds ratios (ORs) for sore throat (OR 13.054; 95% confidence interval [CI] 2.750-61.977; p=0.001), nausea (OR 8.875; 95% CI 1.660-47.446; p=0.011), and lymphopenia (OR 3.575; 95% CI 1.355-9.430; p=0.010), but also had less hospitalizations (OR 0.355; 95% CI 0.138-0.916; p=0.032). The additional logistic regression analysis on patients with preexisting chronic conditions (n=108) showed that death as an outcome was significantly associated with pediatric severe acute respiratory syndrome (SARS) (OR 22.300; 95% CI 2.341-212.421; p=0.007) and multisystem inflammatory syndrome in children (MIS-C) (OR 11.261; 95% CI 1.189-106. 581; p=0.035). CONCLUSIONS: Half of the laboratory-confirmed COVID-19 cases occurred in adolescents. Individuals belonging to this age group had an acute systemic involvement of SARS-CoV-2 infection. Pediatric SARS and MIS-C were the most important factors associated with the mortality rate in pediatric chronic conditions with COVID-19.

An unusual abdominal wall mass in a child

ABSTRACT Abdominal tumors are one of the most common types of pediatric cancer. Therefore, they should always be included in the differential diagnosis of abdominal masses. Here, we present the case of a child whose initial hypothesis of diagnosis contemplated this possibility. Later, it was demonstrated that the abdominal mass found was secondary to a common parasitosis. A 2-year old, moderately malnourished and pale white boy was referred with a history of a rapidly growing, well-limited, middle abdominal mass. The mass was 10 by 3 cm, hard and poorly movable, apparently involving both abdominal rectus muscles. A complete resection was performed, revealing an abdominal wall abscess, with intense eosinophilic proliferation, secondary to a local and intense reaction to innumerous Ascaris lumbricoides eggs. Extra luminal infestations with Ascaris, that usually form peritoneal granulomas have been previously described. However, neither external trauma nor fistula, that could explain the superficial presence of the eggs, was found. This description reinforces the relevance of infectious diseases within the differential diagnosis of abdominal masses, particularly in areas with high prevalence of parasitic infestations.

Estudo retrospectivo do tratamento do H. pylori com bismuto, tinidazol e tetraciclina / Retrospective study of treatment of H. pylori with bismuth, tinidazole e tetracycline

Objetivo: Aplicação de um modelo alternativo, com três drogas (subcitrato de bismuto 480 mg/d + tetraciclina 2 g/d + tinidazol 1 g/d por sete dias) escolhidas pelo menor custo, menos efeitos colaterais e menos reações alérgicas. Método: Os resultados deste tratamento foram obtidos dos pacientes do Ambulatório de Gastroenterologia e Hepatologia do Hospital Cruzeiro do Sul, entre agosto de 2003 e dezembro de 2007. Resultados: Foram tratados 81 pacientes, 37 homens e 44 mulheres, com idade média de 54 anos (26 a 85 anos). As indicações foram resistência ao tratamento clássico (47), cardiopatia (10), recidiva do H. pylori (7), preço (6), efeitos colaterais aos medicamentos previamente utilizados (5) e alergia (3). Dos pacientes estudados, 33 apresentavam comorbidades, sendo mais prevalentes HAS (11), DM (6), dislipidemia (4) e insuficiência cardíaca obstrutiva (5). Completaram o tratamento 64 pacientes, 15 ainda não retornaram e 2 realizaram tratamento incompleto. Dos que realizaram tratamento completo ou incompleto (66), 56,1% negativaram para H. pylori (teste da urease e/ou biópsia gástrica) e 30,3% permaneceram positivos 13,6% não realizaram o teste. Dos que retornaram após o tratamento, 59 não apresentaram efeitos colaterais. Foram relatados apenas diarreia (1), vômitos (1), enterorragia (1), herpes e prurido vaginal (1), infecção urinária (1), sonolência (1) e mal-estar (1), sendo alguns destes apresentados pelo mesmo paciente. Conclusão: O tratamento com bismuto, tetraciclina e tinidazol se mostrou eficaz em 64,9% dos pacientes, com baixa incidência de efeitos colaterais e menor preço, mostrando-se mais uma alternativa em pacientes com resistência ou alergia aos antibióticos do esquema clássico.

Impacto do diagnóstico e do tratamento de câncer e de Aids no cotidiano e nas redes sociais de crianças e adolescentes / Impact of cancer and Aids diagnostic and treatment on daily life and social networks of children and adolescents

Introdução: Aids e câncer representam, atualmente, um desafio para a saúde pública, com sérias implicações para os aspectos biológicos, sociais e psicológicos dos indivíduos. Essas doenças crônicas interferem no cotidiano familiar, especialmente, quando atingem crianças e adolescentes. Objetivo: Neste artigo, são apresentados os principais resultados de uma pesquisa sobre processos de estigmatização de pacientes pediátricos com câncer ou HIV, com especial atenção à recepção do diagnóstico e de mudanças no cotidiano familiar ocasionadas pela doença. Casuística e Métodos: Foram realizadas 56 entrevistas semiestruturadas com: pacientes de 7 a 15 anos com câncer ou com HIV, atendidos nos ambulatórios da Faculdade de Medicina do ABC (FMABC) (n = 20); acompanhantes desses pacientes (n = 18); população usuária dos ambulatórios da FMABC (n = 18). Resultados: Em geral, os pacientes e acompanhantes não referiram a presença de estigma relacionado à doença; em contrapartida, a população usuária dos ambulatórios aponta a sua existência. Os pacientes com HIV são orientados pelos seus cuidadores (leigos e profissionais) a não revelar o diagnóstico para sua a rede social, evitando assim situações estigmatizantes. Conclusões: Embora poucas situações de estigmatização tenham sido identificadas nos relatos obtidos, estes revelam estratégias de controle da identidade do doente, objetivando evitar preconceitos. O HIV e o câncer geram diferentes expectativas e sofrimentos nos pacientes e familiares, requisitando dos profissionais de saúde conhecimentos e ações sensíveis aos impactos específicos desses problemas de saúde no cotidiano familiar.

Introduction: Aids and cancer represent, nowadays, a challenge for the public health, with important connotation for biological, social e psychological aspects of the patients. These chronic diseases change the familiar daily routine, especially when children and teens are involved. Objective: In this paper, the core results of a research about stigma among children with cancer or HIV are presented, with special attention to the reception of the diagnostic and the presence of changes on the daily routine caused by both diseases. Patients and Methods: Fifty-six pre-structured interviews were done with three distinct groups, with free selection: pediatric patients between 7 and 15 years old (n = 20); companions of the patients (n = 18) and people that use the clinics of Faculdade de Medicina do ABC (n = 18). Results: In the patient’s group the stigma was not present but, on the other hand, in the general population this stigma was more prevalent. HIV patients were oriented by the doctors and the family to not reveal the diagnostic for the social net, avoiding, with it, prejudice situations. Conclusions: Even thus few prejudice situations have been identified; the results show strategies for the control of the patient identity, trying, in this way, to avoid this prejudice. HIV and cancer promote different expectations and kinds of suffering in patients and in their families, demanding to thehealth professionals’ knowledge and sensible actions for the specific impacts for these problems in the familiar quotidian.