Clinical Presentation*
- Disease classified as mild, moderate, severe, or critical
- Most children present with mild disease
US Data (CDC)
- Fever, cough, SOB occur less frequently in children
- Per CDC, 23% of infected US children had > 1 underlying condition
- Can present with hyperinflammatory syndrome that mimics
Kawasaki disease or toxic shock syndrome
Differential*
- Infectious (influenza, EBV, viral syndrome, sepsis, meningitis, toxic shock syndrome)
- Rheumatologic (MAS, HLH, Kawasaki disease)
- Pulmonary (bronchiolitis, asthma)
- GI (gastroenteritis, IBD)
Workup*
- Testing criteria vary geographically
- Massachusetts guidelines
- CDC guidelines
- Infectious Diseases Society of America guideline
- Detection of other respiratory pathogens in nasopharyngeal specimens does not exclude COVID-19
- BMC Workup:
- Comprehensive respiratory Panel, COVID-19 PCR, CRP, PCT, CBC, CMP, troponin I, EKG
- BCH Workup:
- PCR via nasopharyngeal swab for symptomatic patients
- Antibody testing can complement PCR in diagnosis
- Obtain at least 10 days after symptom onset
- If critically ill, EKG, Troponin, LDH on admission
- Labs: Bcx (if fever); monitor CBC, Chem, CRP, CK, LFT, Ferritin, Coags (PT/ PTT/ D-Dimer)
- Consider DVT ppx; consider empiric treatment of PNA
- Imaging: CXR: 30% unilateral lesions, 50% b/l lesions, 20% no lesions
Supportive Care*
- Inpatient: Supplemental O2 requirement if increased need from baseline
- If concern for hypoxemic respiratory failure: consider LFNC/HFNC, NIPPV, Intubation & ventilation
- Outpatient: If mild symptoms (fever, cough, pharyngitis), isolation, hydration,
antipyretics (prefer Tylenol)
Investigational Therapies (NIH recommendations here)
- Special considerations:
- Asthma: optimal asthma control outweighs potential risk of steroid use
- Steroids: not indicated routinely for COVID, consult Pedi ID/Pulmonary to discuss use in other conditions or for severe disease
- NSAIDS: To date, inconclusive evidence for or against use of NSAIDs. WHO recommends continuation of typical ibuprofen and tylenol use
- ACEi: Three large observational studies have showed no change in risk with ACEi or ARB therapy and professional societies have recommended that patients continue their ACEi or ARB (review by Jarcho et al. NEJM)
- Hypercoagulability: Possibly increased DVT, PE and stroke risk. Preliminary guidance recommends prophylaxis for teens with D-dimer >2x ULN. Recommend Hematology consult for latest advice
PowerPlans/EPIC/Powerchart/EBG
Epidemiology*
including asthma, immune suppression, cardiovascular disease,
and possibly CKD, diabetes, obesity, liver disease, malignancy
Pathophysiology*
- Virus: SARS-CoV-2 (previously 2019-nCoV)
causes Coronavirus Disease (COVID-19),
single strand RNA-Virus
- Entry: SARS-CoV-2 Spike (S) protein binds
to ACE2 (with high affinity on airway epithelial
cells, type II pneumocytes, GI epithelium, vascular endothelium, kidney) and host proteases (TMPRSS2), entry via endosomes
- Inflammatory Response: Cytokine/chemokine release (IL-6 associated w/ disease severity), increased vascular permeability, infiltration of alveolar macrophages, elevated neutrophils & lymphopenia (associated w/ disease severity). Limited data on pediatric inflammatory response, in most cases, immune dysregulation appears to be less pronounced than adults
- Endothelialitis (pulmonary bed) & coagulopathy (microthrombi)
Transmission*
- Person to person transmission: Enters lungs via respiratory droplets (close contact, ~ 6 ft); potential for aerosol spread (virus remains viable and infectious in aerosols for 3 hours)
- Contaminated surfaces: Self delivery to eyes, nose, mouth
- Asymptomatic Spread: High viral levels detected in people w/o symptoms
- Breastmilk: No evidence of transmission through breastmilk to date
- In Utero: Unknown, virus specific IgM & IgG detected in infants born to mothers w/ COVID-19, definitive evidence of congenital infection needed
- Prevention of transmission: Droplet (facemask), Airborne (N95), Contact (hand hygiene: 20+ seconds w/ soap/water or alcohol containing hand gel, frequent cleaning of surfaces)
- Convalescent Serum: Contains neutralizing antibodies, best if used early, risk for TRALI, Ab-dependent enhancement, may prevent natural immunity
- Lopinavir-ritonavir: HIV antiretroviral, viral protease inhibitor, no benefit beyond standard of care
- Proposed Therapies (not available for use in humans):
- Soluble ACE2 receptor
- Monoclonal antibodies
- Camostat mesylate
General data (black) Pediatric data (purple)
*Select section headers for current literature on pubmed