Características clínicas y supervivencia en pacientes pediátricos oncohematológicos con COVID-19 en un hospital de referencia del Seguro Social de Salud del Perú, durante el 2020-2021

Introducción: En Latinoamérica, existen pocos estudios y resultados heterogéneos sobre pacientes pediátricos oncohematológicos con COVID-19. Objetivo: Describir las características clínicas y la supervivencia de pacientes pediátricos oncohematológicos con COVID-19 en un hospital de Lima-Perú, 2020-2021. Métodos: Estudio longitudinal retrospectivo de pacientes menores de 14 años hospitalizados. Los datos se recolectaron de las historias clínicas. Resultados: Incluimos 30 pacientes, mayoría hombres y escolares, predominando la fiebre, síntomas respiratorios y gastrointestinales, la neoplasia hematológica, y la enfermedad oncológica avanzada. La mayoría desarrolló enfermedad leve-moderada, pero también presentaron evolución severa con requerimiento de soporte crítico, con mortalidad alta en hospitalización (13,3%) y baja supervivencia durante el seguimiento (a los 526 días, 59,26%, IC95% 36,53 a 76,20%). La supervivencia aumentó con reinicio de la quimioterapia , y disminuyó en pacientes de condición paliativa, con soporte respiratorio y shock. Conclusiones: La mayoría desarrolló enfermedad leve-moderada. Sin embargo, el SARS-CoV-2 también puede causar afectación severa, muerte y baja supervivencia en pacientes oncohematológicos.

Introduction: In Latin America, there are few studies and heterogeneous results on pediatric oncohematology patients with COVID-19. Objective: To describe the clinical characteristics and survival of pediatric oncohematology patients with COVID-19 in a hospital in Lima-Peru, 2020-2021. Methods: Retrospective longitudinal study of hospitalized patients under 14 years of age. The data was collected from the medical records. Results: We included 30 patients, mostly men and schoolchildren, predominantly fever, respiratory and gastrointestinal symptoms, hematological neoplasia, and advanced oncological disease. The majority developed mild-moderate disease, but they also presented severe evolution requiring critical areas, with high mortality in hospitalization (13.3%) and low survival during follow-up (at 526 days, 59.26%, 95% CI 36 .53 to 76.20%). Survival increased with the start of chemotherapy, and decreased in patients in palliative condition, with respiratory support and shock. Conclusion: Most developed mild-moderate disease. However, SARS-CoV-2 can also cause severe involvement, death, and poor survival in oncohematological patients.

Difficult acute lymphoblastic leukaemia diagnosis in a paediatric patient with mixed presentation of COVID-19 acute respiratory failure and multisystemic inflammatory syndrome.

New diagnoses of leukaemia and other malignancies are recently being made in paediatric patients with COVID-19. The rates of mortality and morbidity in some of these children are expected to be higher. In new cases, concurrent diagnosis can be difficult because multisystemic inflammatory syndrome (MIS-C) and malignancies have similar clinical presentations. We present the case of a preteenage child where the diagnosis of leukaemia was complicated and delayed by a multisystem involvement and an inconclusive bone marrow study. Clinical teams managing children with COVID-19 and MIS-C should suspect leukaemia and other malignancies when the clinical course is complicated and bone marrow suppression is persistent. Prompt diagnosis will allow start of treatment on time, minimising complications.

Association of Cancer Diagnosis and Therapeutic Stage With Mortality in Pediatric Patients With COVID-19, Prospective Multicenter Cohort Study From Latin America.

Background: Children with cancer are at risk of critical disease and mortality from COVID-19 infection. In this study, we describe the clinical characteristics of pediatric patients with cancer and COVID-19 from multiple Latin American centers and risk factors associated with mortality in this population. Methods: This study is a multicenter, prospective cohort study conducted at 12 hospitals from 6 Latin American countries (Argentina, Bolivia, Colombia, Ecuador, Honduras and Peru) from April to November 2021. Patients younger than 14 years of age that had an oncological diagnosis and COVID-19 or multisystemic inflammatory syndrome in children (MIS-C) who were treated in the inpatient setting were included. The primary exposure was the diagnosis and treatment status, and the primary outcome was mortality. We defined "new diagnosis" as patients with no previous diagnosis of cancer, "established diagnosis" as patients with cancer and ongoing treatment and "relapse" as patients with cancer and ongoing treatment that had a prior cancer-free period. A frequentist analysis was performed including a multivariate logistic regression for mortality. Results: Two hundred and ten patients were included in the study; 30 (14%) died during the study period and 67% of patients who died were admitted to critical care. Demographics were similar in survivors and non-survivors. Patients with low weight for age (<-2SD) had higher mortality (28 vs. 3%, p = 0.019). There was statistically significant difference of mortality between patients with new diagnosis (36.7%), established diagnosis (1.4%) and relapse (60%), (p <0.001). Most patients had hematological cancers (69%) and they had higher mortality (18%) compared to solid tumors (6%, p= 0.032). Patients with concomitant bacterial infections had higher mortality (40%, p = 0.001). MIS-C, respiratory distress, cardiovascular symptoms, altered mental status and acute kidney injury on admission were associated with higher mortality. Acidosis, hypoxemia, lymphocytosis, severe neutropenia, anemia and thrombocytopenia on admission were also associated with mortality. A multivariate logistic regression showed risk factors associated with mortality: concomitant bacterial infection OR 3 95%CI (1.1-8.5), respiratory symptoms OR 5.7 95%CI (1.7-19.4), cardiovascular OR 5.2 95%CI (1.2-14.2), new cancer diagnosis OR 12 95%CI (1.3-102) and relapse OR 25 95%CI (2.9-214). Conclusion: Our study shows that pediatric patients with new onset diagnosis of cancer and patients with relapse have higher odds of all-cause mortality in the setting of COVID-19. This information would help develop an early identification of patients with cancer and COVID-19 with higher risk of mortality.

Shock séptico, hipercalcemia y síndrome hemofagocítico por paracoccidioidomicosis en una niña de 3 años / Septic shock, hypercalcemia and hemophagocytic syndrome due to paracoccidioidomycosis in a 3-year-old girl

Objetivo: Reportar el caso de una niña que presentó shock séptico, hipercalcemia y síndrome hemofagocítico por paracoccidioidomicosis. Reporte de caso: Paciente mujer de 3 años con 2 meses de enfermedad caracterizada por fiebre, adenopatías, pérdida de peso, distensión abdominal y anemia severa. Llegó en mal estado general, desarrolló shock séptico y un síndrome hemofagocítico. Llamaba la atención la hipercalcemia y lesiones dérmicas. Se le realizó una biopsia de ganglio cervical y aspirado de médula ósea. En esta última se evidenciaron imágenes compatibles con Paracoccidioides, que fueron confirmadas con la tinción de Grocott del ganglio. Se trató con anfotericina B y trimetoprim-sulfametoxazol. La evolución fue favorable y el calcio sérico se mantuvo en rangos normales. Conclusión: Las complicaciones presentadas por paracoccidioidomicosis son raras; sin embargo, el antecedente epidemiológico y el aspirado de médula ósea pueden orientar el diagnóstico y permitir un tratamiento oportuno.

Objetive: Report the case of a girl who presented septic shock, hypercalcemia and hemophagocytic syndrome due to paracoccidioidomycosis. Case report: 3-year-old female patient with 2-month illness characterized by fever, lymphadenopathy, weight loss, abdominal distention, and severe anemia. She arrived in poor general condition, developed septic shock and a hemophagocytic syndrome. The hypercalcemia and dermal lesions were striking. Acervical ganglion biopsy and bone marrow aspirate were performed. In the latter, images compatible with Paracoccidioides were found, which were then confirmed with Grocott's stain. She was treated with amphotericin B and trimethoprim-sulfamethoxazole. The evolution was favorable and serum calcium came back to normal ranges. Conclusion: Complications caused by paracoccidioidomycosis are rare; however, the epidemiological history and bone marrow aspirate should guide the diagnosis and allow prompt treatment.

Guía de Práctica Clínica para el manejo de pacientes con Leucemia Linfoblástica Aguda en el Seguro Social del Perú (EsSalud) / Clinical practice guideline for the management of patients with acute lymphoblastic leukemia in Peruvian Social Security (EsSalud)

RESUMEN El presente artículo resume recomendaciones clínicas basadas en evidencia para la evaluación y el manejo de pacientes con Leucemia Linfoblástica Aguda (LLA) en EsSalud. Se conformó un grupo elaborador de la guía (GEG) que incluyó médicos especialistas y metodólogos. El GEG formuló 8 preguntas clínicas a ser respondidas por la presente GPC. Se realizó búsquedas sistemáticas de revisiones sistemáticas y -cuando fue considerado pertinente- estudios primarios en PubMed y CENTRAL durante el 2019. Se seleccionó la evidencia para responder cada una de las preguntas clínicas planteadas. La certeza de la evidencia fue evaluada usando la metodología Grading of Recommendations Assessment, Development, and Evaluation (GRADE). En reuniones de trabajo periódicas, el GEG usó la metodología GRADE para revisar la evidencia y formular las recomendaciones, los puntos de buenas prácticas clínicas y el flujograma de evaluación y manejo. La presente GPC abordó 8 preguntas clínicas, divididas en cuatro temas: diagnóstico, medidas generales, manejo quimioterápico de LLA, y trasplante. En base a dichas preguntas se formuló 5 recomendaciones (3 recomendaciones fuertes y 2 recomendaciones condicionales), 20 puntos de buena práctica clínica, y 3 flujogramas.

ABSTRACT This paper summarizes the evidence-based clinical recommendations for the assessment and management of patients with acute lymphoblastic leukemia (ALL) in Peruvian Social Security (EsSalud). A guide writing team (GWT) was convened, which included specialized physicians and methodologists. The GWT asked 8 clinical questions to be responded by the Clinical Practice Guidelines (CPG). Detailed searches of systematic reviews and - when it was considered as pertinent - primary studied featured in PubMed and CENTRAL during 2019 were performed. Evidence for responding each of the proposed clinical questions was selected. Certainty of the evidence was determined using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. In scheduled workshops, the GWT used the GRADE methodology for reviewing the evidence and propose recommendations, the points for good clinical practice, and the assessment and management flowcharts. This CPG worked on 8 clinical questions, which were divided in 4 topics: diagnosis, general measures, chemotherapy management for ALL, and transplantation. On the basis of these questions, 5 recommendations were formulated (3 strong recommendations and 2 conditional recommendations), 20 points for good clinical practice, and 3 flow charts.