Pediatric severe COVID – 19 and MIS-C in the Brazilian Amazon: independent risk factors to mortality (preprint)

Purpose: SARS-CoV-2 infection in children is usually asymptomatic/mild. However, some patients may develop critical forms. Our aim was to evaluate the independent risk factors associated to in-hospital mortality in children with critical disease related to SARS-CoV-2. Methods: This is multicenter prospective cohort included critically ill children (1 month/18 years of age), with confirmed critical disease related to SARS-CoV-2 admitted to three tertiary Pediatric Intensive Care Units (PICU) in Brazilian Amazon, between April 2020/July 2022. Main outcome was in-hospital mortality. The independent risk factors associated with mortality were evaluated with a multivariable Cox proportional regression. Results: 208 patients were assessed. Median age was 33 months and median follow-up was 277 days (range, 2-759). Death occurred in 37 (17.8%) patients with a median follow-up of 7 (4-13) days. Most non-survivors had at least one comorbidity - 34 (91.9%). Substantial clinical features, laboratory and ventilatory parameters were associated with mortality. Independent risk factors for mortality were underweight status (HR= 6.64, p=0.01), vasoactive inotropic score (VIS) > 84 (HR=4.76, p=0.05), acute respiratory distress syndrome (HR=8.63, p=0.02) and erythrocyte sedimentation rate (ESR) >18 mm/hour (HR=3.95, p=0.03). Conclusions: This study of critically ill patients with COVID-19 and MIS-C from the Brazilian Amazon showed a high mortality rate. The risk of death was higher for underweight individuals, those with higher levels of VIS and ESR, presence of ARDS. The majority of deaths occurred within 10 days of hospitalization, highlighting the importance of prompt recognition in regard to these patients.

Hospitalized Children with Critical SARS-CoV-2 Infection Cared for in a Limited Resource Setting: Multicenter Cohort Study (preprint)

Background: Some children can develop severe forms of SARS-CoV-2 infection either acutely or later, as represented by multisystemic inflammatory syndrome in children (MIS- C).  To identify the risk factors for worse outcomes in hospitalized children and adolescents with severe acute SARS-CoV-2 infection and MIS-C. Methods: This multicenter cohort study included all children and adolescents with confirmed or suspected critical SARS-CoV-2 infection admitted to the PICU between April 2020 and September 2021. The exclusion criteria were incomplete vaccinal status, immunocompromised status, and end-of-life decision. The main variables analyzed were epidemiological, clinical, and laboratory data, and ventilator settings at admission and after 72 h. The patients were divided into three groups (G): confirmed coronavirus disease (COVID-19) with MIS-C criteria (G1), confirmed COVID-19 without MIS-C criteria (G2), and MIS-C criteria without confirmed COVID-19. Results: The median age of the patients was 28 months in G1, with comorbidities in 40 patients (72.7%) (p < 0.0001). The duration of exposure (median 23 days; p = 0.004) and fever were longer in G1 (12 days; p = 0.001). Moreover, invasive mechanical ventilation (IMV) was required in 44 patients (80%, p < 0.0001), and cardiogenic shock occurred in 26 patients (54.2%, p < 0.0001) in G1. Subnutrition was most frequent in G1 in 55 cases (57.3%; p = 0.01). Under nutrition (< 2 SD for weight), longer exposure time (odds ratio [OR]: 2.11; 95% confidence interval [CI]: 1.37–3.25; p = 0.001), IMV time (OR: 2.6; 95% CI: 1.15–5.85; p = 0.03), and length of hospital stay (OR: 10.94; 95% CI: 1.93–63.1; p = 0.007) were associated with critical MIS-C in G1. Conclusions: In the Brazilian Amazon area, specifically in the Pará state, we identified a cluster of more severe forms of pediatric acute or late SARS-CoV-2 infection.