Metabolic and mitochondria alterations induced by SARS-CoV-2 accessory proteins ORF3a, ORF9b, ORF9c and ORF10 (preprint)

Antiviral signaling, immune response and cell metabolism in human body are dysregulated by SARS-CoV-2, the causative agent of the COVID-19. Here, we show that SARS-CoV-2 accessory proteins ORF3a, ORF9b, ORF9c and ORF10 induce a significant mitochondrial and metabolic reprogramming in A549 lung epithelial cells. While all four ORFs caused mitochondrial fragmentation and altered mitochondrial function, only ORF3a and ORF9c induced a marked structural alteration in mitochondrial cristae. ORF9b, ORF9c and ORF10 induced largely overlapping transcriptomes. In contrast, ORF3a induced a distinct transcriptome, including the downregulation of numerous genes for proteins with critical mitochondrial functions and morphology. Genome-Scale Metabolic Models predicted common and private metabolic flux reprogramming, notably a depressed amino acid metabolism, and an enhanced metabolism of specific lipids distinctly induced by ORF3a. These findings reveal metabolic dependencies and vulnerabilities prompted by SARS-CoV-2 accessory proteins that may be exploited to identify new targets for intervention.

Impact of Coronavirus Pandemic on Tuberculosis and Other Imported Diseases Screening among Migrant Minors in Spain.

BACKGROUND: In recent decades, the increase in population movements has turned the focus to imported diseases. The COVID-19 pandemic has negatively impacted the access to health care systems, especially in highly vulnerable populations. We address the effects of the pandemic on the health screening of migrant unaccompanied minors (UM) in Spain. METHOD: Retrospective cross-sectional study including UM screened for imported diseases with a unified protocol at a pediatric reference unit for tropical and infectious diseases in Madrid, Spain. We compared the pre-pandemic (2018-2019) and post-pandemic periods (2020-2021). RESULTS: A total of 192 minors were screened during the study period, with a drop in UM's referral to our center in the post-pandemic years (140 in 2018-2019 vs. 52 in 2020-2021). Out of 192, 161 (83.9%) were diagnosed with at least one medical condition. The mean age was 16.8 years (SD 0.8) and 96.9% were males. Most cases were referred for a health exam; only 38% of children were symptomatic. Eosinophilia was present in 20.8%. The most common diagnosis were latent tuberculosis infection (LTBI) (72.9%), schistosomiasis (15.1%), toxocariasis (4.9%) and strongyloidiasis (4.9%). The prevalence of LTBI did not vary significantly (69.3% vs. 82.7%, p = 0.087). A total of 38% of the patients diagnosed with LTBI never started treatment or were lost to follow-up, as were two out of three patients with active pulmonary tuberculosis. CONCLUSIONS: In this series, the number of UM referred for health screening has dropped dramatically after the COVID pandemic, and two years after the beginning of the pandemic, access to care is still limited. Lost to follow-up rates are extremely high despite institutionalization. Specific resources, including multidisciplinary teams and accessible units are needed to improve diagnoses and linkage to care in this vulnerable population.

Study of Prevalence and Characteristics of Long Covid in Spanish Children (preprint)

Objectives: Prolonged symptoms after acute COVID-19 have been described in the pediatric population. Our objective was to know the prevalence of prolonged symptoms in children with confirmed SARS-CoV-2 infection, and to describe their clinical characteristics and possible risk factors.Patients & methodsMulticentre retrospective study carried by telephone questionnaire of all children under 18 years old diagnosed of symptomatic COVID-19, both hospitalized and outpatient attended in three hospitals in Spain between March and December 2020. Long-COVID was defined as the presence of symptoms longer than 12 weeks. A control group of children attended by other causes was also contacted and compared.Results451 children met criteria and agreed to participate; 370/451 (82%) presented mild outpatient infection, and 23 required admission in PICU (5.1%). The mean age was 5.9 years old (SD 5.3). A control group of 98 children was included.In 66 cases (14.6%) at least one symptom lasted longer than 12 weeks. Insomnia, concentration problems, apathy or sadness and anxiety were the longest (median >90 days). Age above 5 years (48/66; 72.7%, OR: 3, CI 95% (1.8-5)); admission (OR 3.9 CI 95% (2.2-6.8)), the need for PICU (OR 4.3 CI 95% (1.8-10.4)), and to have a relative with prolonged symptoms (OR 2.8 CI 95% (1.5-5.2)) were significantly associated with Long-COVID. When comparing with controls age above 5 years old, myalgia, asthenia, and loss of appetite were significantly associated with Long-COVID.ConclusionsOur study shows that children also suffer prolonged symptoms after COVID-19 infection, and require specific attention.

Comparison of pneumonia features in children caused by SARS-CoV-2 and other viral respiratory pathogens. (preprint)

Pneumonia is a frequent manifestation of COVID-19 in hospitalized children. Methods The study involved 80 hospitals in the SARS-CoV-2 Spanish Pediatric National Cohort. Participants were children <18 years, hospitalized with SARS-CoV-2 community-acquired pneumonia (CAP). We compared the clinical characteristics of SARS-CoV-2-associated CAP with CAP due to other viral etiologies from 2012 to 2019. Results In total, 151 children with SARS-CoV-2-associated CAP and 138 with other viral CAP included. Main clinical features of SARS-CoV-2-associated CAP were cough 117/151(77%), fever 115/151(76%) and dyspnea 63/151(46%); 22/151(15%) patients were admitted to a pediatric intensive care unit (PICU), and 5/151(3%) patients died. Lymphopenia was found in 63/147(43%) patients. Chest X-ray revealed condensation (64/151[42%]) and other infiltrates (87/151[58%]). Compared with CAP from other viral pathogens, COVID-19 patients were older (8 vs.1 year; odds ratio [OR] 1.42 [95% confidence interval, CI 1.23;1.42]), with lower CRP levels (23 vs.48 mg/L; OR 1 [95%CI 0.99;1]), less wheezing (17 vs.53%; OR 0.18 [95%CI 0.11;0.31]) and greater need of mechanical ventilation, MV (7 vs.0.7%, OR 10.8 [95%CI 1.3;85). Patients with non-SARS-CoV-2-associated CAP had a greater need for oxygen therapy (77 vs.44%, OR 0.24 [95%CI 0.14;0.40]). There were no differences in the use of CPAP or HVF or PICU admission between groups. Conclusion SARS-CoV-2-associated CAP in children presents differently to other virus-associated CAP: children are older and rarely have wheezing or high CRP levels; they need less oxygen but more CPAP or MV. However, several features overlap, and differentiating the etiology may be difficult. The overall prognosis is good.

The Spectrum of COVID-19 in Children in Spain (preprint)

Background: We aimed to identify the spectrum of disease in children with COVID-19, and the risk factors for admission in paediatric intensive care units (PICUs). Methods: : We conducted a multicentre, prospective study of children with SARS-CoV-2 infection in 76 Spanish hospitals. We included children with COVID-19 or multi-inflammatory syndrome (MIS-C) younger than 18 years old, attended during the first year of the pandemic. Results: We enrolled 1 200 children. A total of 666 (55.5%) were hospitalized, and 123 (18.4%) required admission to PICU. Most frequent major clinical syndromes in the cohort were: mild syndrome (including upper respiratory tract infection and flu-like syndrome, skin or mucosae problems and asymptomatic), 44.8%; bronchopulmonary syndrome (including pneumonia, bronchitis and asthma flare), 18.5%; fever without a source, 16.2%; MIS-C, 10.6%; and gastrointestinal syndrome, 10%. In hospitalized children, the proportions were: 28.5%, 25.7%, 16.5%, 19.1% and 10.2%, respectively. Risk factors associated with PICU admission were MIS-C (odds ratio [OR]: 37.5,95% CI 22.7 to 57.8), moderate or severe liver disease (OR: 9,95% CI 1.6 to 47.6), chronic cardiac disease (OR: 4.8,95% CI 1.8 to 13) and asthma or recurrent wheezing (OR: 2.8,95% CI 1.3 to 5.8). However, asthmatic children were admitted into the PICU due to MIS-C or pneumonia, not due to asthma flare. Conclusion: Hospitalized children with COVID-19 usually present as one of five major clinical phenotypes of decreasing severity. Risk factors for PICU include MIS-C, elevation of inflammation biomarkers, asthma, moderate or severe liver disease and cardiac disease.

IS ASTHMA A RISK FACTOR FOR COVID-19 IN CHILDREN? (preprint)

The prevalence of asthma in children in Europe is an average of 10.3%. The role of asthma as a risk factor for COVID-19 in children is unknown. Our aim was to study the prevalence of asthma in children with SARS-CoV-2 infection and to compare them in hospitalized children and those with mild ambulatory symptoms. We conducted an observational retrospective study in 99 children (between 3- 17 years of age) with a confirmed SARS-CoV-2 infection between March and December 2020. The existence of a history of asthma was investigated using the validated ISAAC questionnaire and clinical data on COVID-19 were compiled. The median age was 10 years (IQR=13-5), and 60/99 (60.6%) patients had mild infections controlled as outpatient, while 39/99 (39.4%) required admission. The prevalence of asthma ─affirmative response to question 6 of the ISAAC questionnaire─ was 11.1% (11/99). The prevalence of asthma in children who required admission increased to 17.9% and to 21.4% in patients requiring PICU, while in outpatients children was 6.7% (p=0.079). We found a significant association between the use of salbutamol during the last year and the need for admission (23.1% in hospitalized patients vs 3.3% in outpatients; OR= 8.7, 95%CI 1.7-42.8). Likewise, budesonide treatment in the last year (17.9% vs 1.7%, OR= 12.9, 95%CI 1.5-109.5) was also a risk factor for admission. Therefore, a history of asthma was not a risk factor for SARS-CoV-2 infection in our series, but active asthma could be a risk factor for severity and need for hospitalization for COVID-19 in children

Clinical course and seroprevalence of COVID-19 in children with rheumatic diseases. Cross-sectional study from a reference centre in Spain. (preprint)

Background Patients with rheumatic diseases have been considered at risk of COVID-19. A significant percentage of infections in children are asymptomatic or mild and can go unnoticed. This study aims to describe the seroprevalence of SARS-CoV-2 in a cohort of children with rheumatic diseases and assess possible risk factors. Methods: A cross-sectional study was performed in a pediatric rheumatology unit from a reference hospital in Madrid, from September 2020 to February 2021. Serology of SARS-CoV-2 was performed at the same time as their routine laboratory tests, and a specific questionnaire was completed by parents. Demographics, treatment and disease activity from laboratory-confirmed COVID-19 patients were compared to the data of patients without laboratory-confirmed COVID-19.Findings A total of 105 children were included. SARS-CoV-2 infection was demonstrated in 27 patients (25.7%): 6 PCR and 21 positive IgG serology. The mean age was 11.8 years , and the majority of the patients were females (72.4%). Most of the children were diagnosed with juvenile idiopathic arthritis (JIA) (70.3%; 19/27), followed by PFAPA (11.1%; 3/27). Immunosuppresive treatment was given in 88% of cases (24/27). Overall, 44.4% (12/27) of infected patients were asymptomatic. Three patients required hospital admission because of COVID-19, however none of them required oxygen supplementation. A total of 66.7% (18/27) of patients did not require any treatment or medical assistance. The seroprevalence in our cohort was 20% in contrast to the 7.7% population seroprevalence observed during the same study period in Spanish children. SARS-CoV-2 confirmed children with positive IgG or PCR were less frequently in remission (52% vs 72%; p 0.014). Moderate disease activity and treatment with oral corticosteroids were associated with higher risk for COVID-19 (OR 5.05; CI 95%: 1.56 - 16.3 and OR 4.2; CI 95%: 1.26 - 13.9 respectively).                            Conclusions In a cohort of pediatric patients with rheumatic disease and immunosuppressive therapy, moderate disease activity and oral corticosteroids were associated with COVID-19 positive patients. Seroprevalence was significantly higher compared to the same age healthy population. The clinical manifestations were mild and there were no severe infections among the patients.

Fever without source as the first manifestation of SARS-CoV-2 infection in infants less than 90 days old. (preprint)

Fever without source (FWS) in infants is a frequent cause of consultation at the emergency department and the emergence of SARS-CoV-2 could affect the approach to those infants. The aim of this study is to define the clinical characteristics and rates of bacterial coinfections of infants < 90 days with FWS as the first manifestation of SARS-CoV-2 infection. This is a cross-sectional study of infants under 90 days of age with FWS and positive SARS-CoV2 PCR in nasopharyngeal swab/aspirate, attended at the emergency departments of 49 Spanish hospitals (EPICO-AEP cohort) from March 1st to June 26th, 2020. Three hundred and thirty-three  children with COVID-19 were included in EPICO-AEP. A total of 67/336 (20%) were infants less than 90 days old, and 27/67(40%) presented with FWS. Blood cultures were performed in 24/27(89%) and were negative in all but one (4%) who presented a Streptococcus mitis bacteremia. Urine culture was performed in 26/27(97%) children and was negative in all, except in two (7%) patients. Lumbar puncture was performed in 6/27(22%) cases, with no growth of bacteria. Two children had bacterial coinfections: 1 had UTI and bacteremia, and 1 had UTI. C-reactive was protein over 20 mg/L in two children (one with bacterial coinfection), and procalcitonin was normal in all. One child was admitted to the Pediatric Intensive Care Unit because of apnea episodes. No patients died. Conclusion: FWS was frequent in infants under 90 days of age with SARS-CoV-2 infection. Standardized markers to rule out bacterial infections remain useful in this population, and the outcome is generally good.

COVID-19 IN CHILDREN WITH RHEUMATIC DISEASES (RD) IN THE SPANISH NATIONAL COHORT EPICO-AEP. (preprint)

ObjectivesSARS-CoV-2 infection in adults with rheumatic diseases (RD) is a cause for concern. Data in the pediatric population are practically absent. We aimed to describe the prevalence of patients with RD and their complications among children admitted with COVID-19 in the Spanish national cohort EPICO-AEP; a multicenter prospective national study. MethodsChildren <18 years old with RD and COVID-19 enrolled in EPICO-AEP were included in this study. ResultsBy June 30th 2020, 350 children were admitted in secondary and tertiary hospitals of Spain with SARS-CoV-2 infection. A total of 8 patients presented RD (2.2% of those hospitalized). All were female. The median age was 12.1 years (IQR 8.3-14.5). The diagnosis related with COVID-19 were febrile syndrome and/or upper respiratory infection (4 cases) and pneumonia (4 cases). One of the 8 (12.5%) patients with a severe juvenile dermatomyositis (JDM) with interstitial lung disease died. Juvenile idiopathic arthritis (JIA) was the most frequent diagnosis in 3/8 (37.5%) patients. In 5/8 (62.5%) cases, the RD was not fully controlled, and all patients except one received corticosteroid treatment. ConclusionsChildren with RD have accounted for 2.2% of hospitalized patients with COVID-19 in our series. The evolution has been moderately favorable, with one deceased. In case of active disease and use of corticosteroids patients should be managed with caution. What is already known about this subject?O_LIStudies in adults with rheumatic disesases (RD) show that immune-mediated inflammatory disease and use of biologics are not associated with worse COVID-19. C_LIO_LIPoorly controlled active RD or some treatments such as corticosteroids, may have an increased risk of infection and serious disease in adults. No data in children. C_LI What does this study add?O_LIPediatric data from the national EPICO-AEP registry in Spain are presented, where children with RD and COVID-19 were 2.2% of those hospitalized. C_LIO_LIActive disease and the use of corticosteroids could be considered risk factors in the pediatric population as well as in adults. C_LI How might this impact on clinical practice or future developments?O_LIThe rheumatologist pediatrician must be very careful in the management of children with COVID-19 infection, especially if they receive corticosteroid treatment or have active RD. C_LI