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BACKGROUND AND AIM: The COVID-19 pandemic impacted high (HICs) and low to high- middle income countries (LHMICs) disproportionately. We sought to investigate factors contributing to disparate pediatric COVID-19 mortality. METHOD(S): We used the International Severe Acute Respiratory and emerging Infections Consortium (ISARIC) COVID-19 database, and stratified country group defined by World Bank criteria. All hospitalized patients aged less than 19 years with suspected or confirmed COVID-19 diagnosis from January 2020 through April 2021 were included. RESULT(S): A total of 12,860 patients with 3,819 cases from HICs and 9,041 cases from LHMICs were included in this study. Of these, 8,961 (73.8%) patiens were confirmed cases and 2444 (20.1%) were suspected COVID19. Overall in-hospital mortality was 425 (3.3%) patients, with 4.0% mortality in LHMICs (361/9041), which was higher than 1.7% mortality in HICs (64/3819);adjusted HR (aHR) 4.74, 95%CI 3.16-7.10, p<0.001. There were significant differences between country income groups in the use of interventions, with higher use of antibiotics, corticosteroid, prone position, high flow nasal cannula, and invasive mechanical ventilation in HICs, and higher use of anticoagulants and non-invasive ventilation in LHMICs. Infectious comorbidities such as tuberculosis and HIV/AIDS were shown to be more prevalent in LHMICs [2 (0.0%) vs 171 (1.9 %), 1 (0.0%) vs. 149 (1.6%) patients, respectively]. Mortality rates in children who received mechanical ventilation in LHMICs were higher compared with children in HICs [89 (43.6%) vs. 17 (7.2%) patients, aHR 12.0, CI95% 7.2-19.9, p<0.001]. CONCLUSION(S): Various contributing factors to COVID-19 mortality identified in this study may reflect management differences in HICs and LHMICs. (Figure Presented).
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INTRODUCTION: Severe pneumonia is a common indication for admission to the pediatric intensive care unit (PICU) and a leading cause of morbidity and mortality. The lack of epidemiology and outcome data from Asia is a barrier to improving outcomes of severe pneumonia in the region. METHOD(S): This is a prospective multicenter cohort study carried out from April 2019 to April 2022. Fifteen PICUs participated in this study under the Pediatric Acute & Critical Care Medicine Asian Network. Epidemiological, microbiological and outcome data were collected up to hospital discharge. Univariate logistic regression analysis were conducted to explore the association between potential risk factors and severe outcomes [acute respiratory distress syndrome (ARDS) and PICU mortality]. Multivariable analysis was performed withforward stepwise logistic regression adjusted for sites and COVID-19 pandemic including variables with p< 0.05 in univariate model. RESULT(S): There were 786 children with severe pneumonia in PICU with mean (standard deviation) age 2.8 (3.9) years. 384/786 (48.9%) had comorbidities;126/786 (16.0%) had a history of prematurity (gestational age < 37 weeks). Admission Pediatric Index of Mortality 3 (PIM3) and Pediatric Logistic Organ Dysfunction 2 (PELOD2) score were 16.2 (22.9) and 4.1(4.6). A sole viral or bacterial pathogen was identified in 179/786 (22.4%) and 165/786 (21.0%). Co-infections occurred in 114/786 (14.5%) patients. ARDS and mortality occurred in 156/786 (20.1%) and 70/786(8.9%) patients. In the multivariable model, risk factors for ARDS included PIM3 [adjusted odds ratio (aOR) [95% confidence interval (CI)] of 1.02 (1.01, 1.03)], PELOD2 [aOR 1.08 (95%CI 1.02, 1.13)] and involvement of 4 quadrants on chest-x-ray, [aOR 2.69 (95%CI 1.39, 5.18)]. Risk factors for mortality included PIM 3 [aOR 1.03 (95%CI 1.01, 1.04)], involvement of 4 quadrants on chest-x-ray [aOR 2.72 (95%CI 1.10, 6.73)], bacterial [aOR 2.61 (95%CI 1.00, 6.82)], fungus or mycobacterium [aOR 12.30 (95%CI 1.45, 104.57)] and co-infections [aOR 2.72 (95%CI 1.10, 10.35)]. CONCLUSION(S): The rate of ARDS and mortality in severe pneumonia admitted to PICU in Asia was high. Risk factors for poor outcomes were admission severity scores, generalized X-ray involvement and identification of bacteria, fungus/mycobacteria or co-infections.
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We describe a child with acute fever and abdominal pain who developed rash and edema of extremities. Blood test revealed thrombocytopenia, lymphopenia, positive dengue-IgM, and hypoalbuminemia with elevated procalcitonin. Right pleural effusion revealed from chest x-ray. Diagnosed as dengue hemorrhagic fever (DHF) grade 1, however, at 7th day of illness, altered mental status, respiratory and circulatory failure occurred. Laboratory examination showed marked thrombocytopenia, transaminitis, metabolic acidosis, elevated D-dimer, decrease fibrinogen, and elevated cardiac marker (troponin I and CKMB). The patient then developed catecholamine-resistant shock and did not survive after 48 hours. Although rapid test of SARS CoV-2 infection was negative, rapid deterioration with some unusual clinical feature suggest multisystem inflammatory syndrome in children (MIS-C) related to SARS-CoV-2 infection. This case raises an awareness of MIS-C that clinical features resemble dengue infection.