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Publicly Available Published by De Gruyter July 1, 2021

COVID-19 infection in children with underlying malignancies in Iran

  • Amene Navaeian , Shima Mahmoudi , Babak Pourakbari , Maryam Bakhtiari ORCID logo , Mahmoud Khodabandeh , Mohammad Reza Abdolsalehi , Alieh Safari Sharari and Setareh Mamishi EMAIL logo

Abstract

Objectives

Although coronavirus disease 2019 (COVID-19) prognosis is mostly good in pediatric patients with no underlying diseases, there are a few reports on children with oncological underlying malignancies. This study aimed to describe the clinical and laboratory features of 20 children with COVID-19 who had underlying malignancies in an Iranian referral pediatrics hospital.

Methods

All children under 15-year-old of age with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive real-time polymerase chain reaction (PCR) and presence of an underlying malignancy were included in the study.

Results

In this study, among 20 patients, 11 were male (55%). The mean age of the patients was 6.0 ± 4.1 years. Twelve patients (60%) had acute lymphocytic leukemia, two had acute myeloid leukemia (10%), and six had solid organ tumors (30%). The most common symptoms were fever (65%) and cough (65%). We reported severe pneumonia in seven hospitalized patients (35%) and three patients (20%) required intensive care unit admission and mechanical ventilation. Procalcitonin was normal in 73% of the cases (11 out of 15), but it was highly elevated in four cases (27%). Five patients (25%) had positive blood cultures and a mortality of 20% was reported.

Conclusions

This is the largest study on SARS-CoV-2 infected pediatric patients with underlying malignancies in Iran. Since the risk of exposure to SARS-CoV-2 and even death in children with malignancy, either in the hospital or community setting during the pandemic is high, special precautions to reduce the risk of transmission are highly suggested.

Background

Severe acute respiratory syndrome coronavirus 2 (SARS- CoV-2) which was first discovered and described in Wuhan, China, has spread rapidly around the world and infected more than two million people in 185 countries [1].

Although the numbers of pediatric patients with coronavirus disease 2019 (COVID-19) are increasing, a majority of the cases show mild disease [2], [3]. Children have represented 5% of SARS-CoV-2 positive cases in the USA, 2% of diagnosed cases in China, and 1.2% of cases in Italy [3]. According to the Chinese Center for Disease Control and Prevention’s report on 44,500 confirmed cases, 81% of the patients showed mild symptoms and severe infection with dyspnea, respiratory distress, hypoxia, and lung involvement was found in only 14% of the cases. The total mortality rate was of 2.3% and none of the deceased patients were from the noncritical group [4], [5], [6], [7]. However, the disease severity and mortality might vary according to geographic distribution and some atypical presentations might observe [8], [9], [10], [11], [12], [13], [14].

COVID-19 prognosis is mostly good in pediatric patients with no underlying diseases but it might pose an increased risk in cancer patients, particularly in those who have recently undergone chemotherapy, radiotherapy, or immunotherapy, leading to the deterioration of the patients [15]. According to a previous report, the prevalence of COVID-19 infection among children with cancer in Madrid was of 1.3% [16].

There are a few reports on children with oncological diseases [17], [18]. This study aimed to to describe the clinical and laboratory features of 20 children with COVID-19 who had underlying malignancies in an Iranian referral pediatrics hospital.

Methods

This study was approved by the Ethics Committee of Tehran University of Medical Sciences, Tehran, Iran (IR.TUMS.VCR.REC.1399.060), and signed informed consent was obtained from all patients who participated in the study or their parents/legal guardians.

This study’s inclusion criteria were children under 15-year-old of age who had an underlying malignancy and SARS-CoV-2 positive reverse transcription-polymerase chain reaction (rRT-PCR) and were admitted to Children’s Medical Center, an Iranian referral hospital, between March and June 2020. A confirmed case of COVID-19 was defined as a positive result of SARS-CoV-2 rRT-PCR using a nasopharyngeal swab. The RNA of collected samples on the swab was then extracted using SinaPureTMViral kit (Sinaclon, Iran) and cDNA template synthesis was performed using PrimeScript RT reagent Kit (TaKaRa, Japan). The rRT-PCR was performed according to our previous report using the regions of the virus nucleocapsid gene and RNase P (RP) as an internal control [19].

Epidemiological, clinical, laboratory, and treatment data were obtained from medical records. Demographic characteristics, clinical data, baseline symptoms, and physical signs, treatments ant outcome, and laboratory findings including blood cell counts, hemoglobin level, absolute neutrophilic and lymphocytic count, inflammatory markers (i.e. Ferritin, C-Reactive protein (CRP) and Erythrocyte sedimentation rate (ESR), liver enzymes, coagulation factors (prothrombin time (PT), partial thromboplastin time, and international normalized ratio), electrolytes (calcium, sodium, magnesium, phosphorus, and potassium) and kidney function tests (blood urea nitrogen and creatinine) were collected. Severe pneumonia was defined by the presence of any of the following conditions: hypoxia: SpO2≤93% (<90% in premature infants), increased respiration rate: RR≥70/min (≤1 year), and RR≥50/min (>1 year), blood gas analysis: PaO2<60 mmHg, PaCO2>50 mmHg, or other manifestations [19].

Statistical analysis

All statistical analyses were performed using SPSS (Statistical Package for the Social Sciences) version 13.0 software (SPSS Inc). Categorical variables were described as frequency rates and percentages, and continuous variables were described using median and interquartile range (IQR) values.

Results

Between March and June 2020, a total of 269 patients less than 15 years of age with underlying malignancies were hospitalized in our hospital. Among them, 20 patients (7.4%) with confirmed SARS-CoV-2 infection were included in the study. Nine patients were female (45%) and 11 were male (55%). The median age of the patients was 6.0 years (IQR: 3–10 years). Twelve patients (60%) had acute lymphocytic leukemia (ALL), two had acute myeloid leukemia (AML) (10%) and six had solid organ tumors (30%). None of these patients had received a hematopoietic stem cell transplantation. Six patients (30%) had contact with a family member with confirmed SARS-CoV-2 infection (Table 1).

Table 1:

Characteristics and summary of data in 20 children with malignancy and confirmed SARS-CoV-2 infection.

n %
Sex
Female 9 45
Male 11 55
Age
<1 years 1 5
1–5 years 8 40
6–10 years 6 30
11–15 years 5 25
Underlying malignancy
Acute myeloid leukemia, AML 2 10
Acute lymphoblastic leukemia, ALL 12 60
Solid tumors 6 30
COVID-19 positive family member 6 30
Positive blood culture 5 25
Presenting symptom and signs
Fever 13 65
Cough 13 65
Tachypnea 9 45
Respiratory distress 8 40
Chest pain 1 5
Vomiting 5 25
Abdominal pain 1 5
Diarrhea 3 15
Headache 2 10
Myalgia 3 15
Treatment
Oseltamivir 3 15
Hydroxychloroquine 9 45
Azithromycin 10 50
Third-generation cephalosporin 9 45
Vancomycin 5 25
Meropenem 3 15
Amphotricine liposomal 2 10
Colistin 1 5
Linezolide 1 5
Kaletra 2 10
Corticosteroid 3 15
Outcome
Death 4 20

Overall, 19 patients were on chemotherapy at the time of developing SARS-CoV-2 infection and only one case was SARS-CoV-2 positive before initiation of the chemotherapy.

All the patients were symptomatic. The most common sign and symptoms were fever (65%) and cough (65%). Forty-five percent of the patients had tachypnea and 40% suffered from respiratory distress. Myalgia and diarrhea were reported in 15%. One-fourth of the cases had nausea and vomiting and only one patient presented with symptoms like chest and abdominal pain. We reported severe pneumonia in seven hospitalized patients (35%) and three patients (20%) required intensive care unit (ICU) admission and mechanical ventilation. Unfortunately, four cases (20%) died (three cases with ALL and one case with AML) (Table 1).

The laboratory results of the patients are shown in Table2. The median level of lymphocyte count was 0.83 × 109 cells per L (IQR: 0.33–2.3) which shows lymphopenia in the majority of patients. The median of the neutrophil count was 2.95 × 109 cells per L (IQR: 0.25–6.6). Hemoglobin levels ranged between 6.9 and 14.2 g/dL with a median of 9.7 (IQR: 8–11).

Table 2:

The laboratory results of 20 children with malignancy and confirmed SARS-CoV-2 infection.

Median Interquartile range
White blood cell count (×109 cells per L) 5.9 0.75–9.6
Red blood cell count (×109 cells per L) 3.4 2.9–4.2
Haemoglobin, g/dL 9.7 8–11
Platelet count (×109 cells per L) 140 52–350
Lymphocyte count (×109 cells per L) 0.83 0.33–2.3
Neutrophil count (×109 cells per L) 2.95 0.25–6.6
PH 7.42 7.39–7.48
Partial pressure of carbon dioxide (PaCO2), mmHg 26 23.5–29.8
Partial pressure of oxygen (PaO2), mmHg 87 50–95.25
Bicarbonate (HCO3), mEq/L 17.5 14.9–19.8
O2 saturation, % 97.2 88.8–98
Blood sugar, mg/dL 105 90–124
Blood urea nitrogen, mg/dL 13 10.25–16.75
Creatinine, µmol/L 0.5 0.5–0.7
Potassium, mmol/L 4 3.97–4.3
Sodium, mmol/L 134 131–137
Calcium, mg/dL 8.9 8.5–9.5
Magnesium, mg/dL 1.7 1.47–1.95
Phosphorus, mg/dL 4.7 3.8–5
Creatine phosphokinase, U/L 27 22.25–35
C-reactive protein, mg/dL 62 8.5–63.5
Erythrocyte sedimentation rate, mm/h 67 26–89
Ferritin, ng/mL 8,488 252–12,424
Prothrombine time, s 12.5 12.5–14.1
Partial thromboplastin time, s 31 30–36
International normalized ratio 1 1–1.2
Lactate dehydrogenase, U/L 680 407–995
Procalcitonin, ng/mL 0.025 0.1–1
Alanine aminotransferase, U/L 25 11.5–59
Aspartate aminotransferase, U/L 22 18–41

The median for CRP and ESR was 62 mg/dL (IQR: 8.5–63.5) and 67 mm/h (IQR: 26–89), respectively. Procalcitonin was normal in 73% of the cases (11 out of 15), but it was highly elevated in four cases (27%). Five patients (25%) had positive blood cultures; among them, two patients died.

Lactate dehydrogenase was significantly elevated at admission for deceased patients compared to the discharged patients (1,193 (U/L); IQR, 756–1754 U/L vs. 457 U/L; IQR, 367–883 U/L; p=0.033). The level of procalcitonin (4.5 ng/mL [IQR, 0.02–9.7 ng/mL] vs. 0.02 ng/mL [IQR, 0.01–0.05 ng/mL]), PT (13.9 s [IQR, 12.7–21 s] vs. 12.5 s [IQR, 12.5–14 s]), and CRP (89.5 mg/L [IQR, 15.2–155.5 mg/L] vs. 48 mg/L [IQR, 10–60 mg/L]) was higher in children who are now deceased compared to those who were discharged; however, the differences were not significant (p >0.05).

Discussion

To our knowledge, this is the first report of pediatrics with underlying malignancy and SARS-CoV-2 infection in Iran. According to the previous reports, symptomatic SARS-CoV-2 infection was rarely reported among heavily immunocompromised children [20]. Although it has been reported that the COVID-19 may have a mild course even in children receiving anticancer chemotherapy [20], in our study, 35% of the patients showed severe pneumonia, 20% required ICU admission and mechanical ventilation, and four cases (20%) died. In a recently published systematic review, 9.6% of the patients showed severe COVID‐19 [21]. According to the American Society of Hematology registry, among 146 cases of COVID-19 with hematologic, 26% died and ALL was the commonest malignancy (30%) [22], [23].

In contrast to previous studies [3], [21], children with underlying malignancies were more likely to have severe disease. The possibility of immunosuppressive treatments causing patients to develop a more serious type of COVID-19 should not be underestimated [24]. Moreover, the risk of exposure to the COVID‐19 infection in hospitals is high.

In this study, 45% of the patients were female and 55% of the patients were male. Our findings are in consistent with other published studies, showing that there are no significant differences between sex and age in pediatric patients [19], [25].

All of our patients had underlying malignancies before the diagnosis of COVID19. Sixty percent of our cases had ALL, 30% solid tumor malignancies, and AML was present in 10% of the cases. So, the most common underlying malignancy in children with COVID-19 was ALL. This result could be affected by the fact that leukemias are the most common malignancy in pediatric patients. However, there are rare reports on the impact of the COVID‐19 pandemic on pediatric cancer patients is available [26].

In the study of Carlotti et al., severe COVID-19 was found higher in patients with hematologic cancer, lung cancer, or metastatic cancer (stage IV) compare to the patients without these conditions [27], [28].

In a previous report conducted in Madrid, the median age of pediatrics with malignancy and COVID-19 was 10.6 years; 73% of the patients had hematologic malignancies and 21% of the patients had solid tumors which are in consistent with our report [16]; however, the age of our patients was lower.

In our study, 36% of the patients had a COVID-19 confirmed family member. In the study of Qiu et al., the most common route of transmission for pediatric patients was close contact with family members with COVID-19 (89%) [6].

In this repot, 25% of the patients had positive blood cultures. Previous studies suggested that bloodstream infections are very rare in patients with COVID-19 [29], but there are no studies available in pediatric patients. However, this finding might be due to the fact that cancer patients are more susceptible to bacteremia because of their reduced immunity. On the other hand, cytotoxic therapies for hematological malignancies may lead to the reduction of lymphocyte subsets, making the patients more vulnerable to infection [30], [31].

Unfortunately, 20% of our patients died during the course of treatment which is significantly higher than the reported mortality in healthy children with COVID-19 [3].

The most common symptom in our patients was fever (65%) and cough (65%) that was similar to previous reports [16], [19], while chest pain and abdominal pain was only reported in 5% of the cases.

The most common treatment used in our patients were hydroxychloroquine (45%), azithromycin (50%) and third-generation cephalosporins (45%) which were chosen based on the underlying disease, accompanying neutropenia, and the presence of bacteremia and the antibiotic susceptibility test. Hydroxychloroquine and azithromycin were the most widely used treatments in other studies as well [16, 19, 27]. In some pediatric cases in China, lopinavir, ritonavir, and inhaled recombinant human interferon-alpha have been applied [32]. However, the World Health Organization discontinues hydroxychloroquine and lopinavir/ritonavir because they have little or no reduction in the mortality of hospitalized COVID-19 patients. Moreover, the guidelines for the medical management of COVID-19 have changed over time which could explain the differences in various studies [32].

According to the laboratory results, lymphopenia was found in the majority of patients that was higher than previous reports [19], [33]; however, the effects of the underlying malignancy and immune dysregulation should not be forgotten [34].

Since a risk of exposure to SARS-CoV-2 both in the hospital or community setting resulting in extensive anxiety among families of children with cancer [35], standard precautions for basic and respiratory hygiene to reduce the risk of transmission are highly recommended.

Conclusion

This is the largest study on SARS-CoV-2 infected pediatric patients with underlying malignancies in Iran. Since the risk of exposure to SARS-CoV-2 and even death in children with malignancy, either in the hospital or community setting during the pandemic is high, special precautions to reduce the risk of transmission are highly suggested.

There are some important issues that were not discussed in our study. First, the outbreak of COVID-19 started in December 2019, so detailed case descriptions and clinical courses are limited and the long-term outcome and sequelae may need further follow-up; second, the treatment strategy in children may need additional debate and caution and more studies on this topic to learn more about this virus as well as better treatment options and care for pediatric patients with malignancy is highly needed. And third, the emotional burden and the high-stress levels these patients are experiencing in this pandemic should not be ignored.


Corresponding author: Setareh Mamishi, Department of Infectious Diseases, Pediatrics Center of Excellence, Children’s Medical Center, Tehran University of Medical Sciences, Dr. Gharib Street, Keshavarz Boulevard, Tehran, Iran; and Department of Pediatrics, Pediatrics Center of Excellence, Children’s Medical Center, Tehran University of Medical Sciences, Dr. Gharib Street, Keshavarz Boulevard, Tehran, Iran, Phone: +98-021-6642-8996, Fax: +98-021-6642-8996, E-mail:

Award Identifier / Grant number: 99-1-149-47172

Acknowledgment

This study was taken from Dr. Amene Navaeian’s postgraduate thesis.

  1. Research funding: This study was supported by a grant (grant number: 99-1-149-47172) from Tehran University of Medical Sciences to Dr. Setareh Mamishi.

  2. Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  3. Competing interests: The authors did not have any conflicts of interest relevant to this article.

  4. Informed consent: Informed consent was obtained from all individuals included in this study.

  5. Ethical approval: This study was approved by the Ethics Committee of Tehran University of Medical Sciences, Tehran, Iran (IR.TUMS.VCR.REC.1399.060) and signed informed consent was obtained from all patients who participated in the study or their parents/legal guardians.

References

1. Xia, W, Shao, J, Guo, Y, Peng, X, Li, Z, Hu, D. Clinical and CT features in pediatric patients with COVID‐19 infection: different points from adults. Pediatr Pulmonol 2020;55:1169–74. https://doi.org/10.1002/ppul.24718.Search in Google Scholar

2. Liu, H, Liu, F, Li, J, Zhang, T, Wang, D, Lan, W. Clinical and CT imaging features of the COVID-19 pneumonia: focus on pregnant women and children. J Infect 2020;80:e7–13. https://doi.org/10.1016/j.jinf.2020.03.007.Search in Google Scholar

3. Ludvigsson, JF. Systematic review of COVID‐19 in children shows milder cases and a better prognosis than adults. Acta Paediatr 2020;109:1088–95. https://doi.org/10.1111/apa.15270.Search in Google Scholar

4. Liu, JJ, Bao, Y, Huang, X, Shi, J, Lu, L. Mental health considerations for children quarantined because of COVID-19. Lancet Child Adolesc Health 2020;4:347–9. https://doi.org/10.1016/s2352-4642(20)30096-1.Search in Google Scholar

5. Viner, RM, Russell, SJ, Croker, H, Packer, J, Ward, J, Stansfield, C, et al.. School closure and management practices during coronavirus outbreaks including COVID-19: a rapid systematic review. Lancet Child Adolesc Health 2020;4:397–404. https://doi.org/10.1016/s2352-4642(20)30095-x.Search in Google Scholar

6. Qiu, H, Wu, J, Hong, L, Luo, Y, Song, Q, Chen, D. Clinical and epidemiological features of 36 children with coronavirus disease 2019 (COVID-19) in Zhejiang, China: an observational cohort study. Lancet Infect Dis 2020;20:689–96. https://doi.org/10.1016/s1473-3099(20)30198-5.Search in Google Scholar

7. Hong, H, Wang, Y, Chung, H-T, Chen, C-J. Clinical characteristics of novel coronavirus disease 2019 (COVID-19) in newborns, infants and children. Pediatr Neonatol 2020;61:131–2. https://doi.org/10.1016/j.pedneo.2020.03.001.Search in Google Scholar PubMed PubMed Central

8. Ekbatani, M, Hassani, S, Tahernia, L, Yaghmaei, B, Mahmoudi, S, Navaeian, A, et al.. Atypical and novel presentations of coronavirus disease 2019: a case series of three children. Br J Biomed Sci 2020;78:47–52.10.1080/09674845.2020.1785102Search in Google Scholar PubMed

9. Mahmoudi, S, Mehdizadeh, M, Badv, RS, Navaeian, A, Pourakbari, B, Rostamyan, M, et al.. The coronavirus disease 2019 (COVID-19) in children: a study in an Iranian Children’s Referral Hospital. Infect Drug Resist 2020;13:2649. https://doi.org/10.2147/idr.s259064.Search in Google Scholar

10. Mamishi, S, Heydari, H, Aziz-Ahari, A, Shokrollahi, MR, Pourakbari, B, Mahmoudi, S, et al.. Novel coronavirus disease 2019 (COVID-19) outbreak in children in Iran: atypical CT manifestations and mortality risk of severe COVID-19 infection. J Microbiol Immunol Infect 2020;S1684–1182:30177–8. https://doi.org/10.1016/j.jmii.2020.07.019.Search in Google Scholar PubMed PubMed Central

11. Mamishi, S, Movahedi, Z, Mohammadi, M, Ziaee, V, Khodabandeh, M, Abdolsalehi, MR, et al.. Multisystem inflammatory syndrome associated with SARS-CoV-2 infection in 45 children: a first report from Iran. Epidemiol Infect 2020;148:e196. https://doi.org/10.1017/S095026882000196X.Search in Google Scholar PubMed PubMed Central

12. Memar, EHE, Mamishi, S, Ekbatani, MS, Alimadadi, H, Yaghmaei, B, Chegini, V, et al.. Fulminant hepatic failure: a rare and devastating manifestation of coronavirus disease 2019 in an 11-year-old boy. Arch Pediatr 2020;27:502–5. https://doi.org/10.1016/j.arcped.2020.09.009.Search in Google Scholar PubMed PubMed Central

13. Mahmoudi, S, Rostamyan, M, Aziz-Ahari, A, Pourakbari, B, Ghaffari, M, Mamishi, S. The first confirmed case of coronavirus disease 2019 (COVID-19) in an adolescent with abdominal pain in Iran. Tanaffos 2020;19:156.Search in Google Scholar

14. Memar, EHE, Pourakbari, B, Gorgi, M, Ekbatani, MS, Navaeian, A, Khodabandeh, M, et al.. COVID-19 and congenital heart disease: a case series of nine children. World J Pediatr 2021;17:1–8. https://doi.org/10.1007/s12519-020-00397-7.Search in Google Scholar PubMed PubMed Central

15. Wei, J, Zhao, J, Han, M, Meng, F, Zhou, J. SARS-CoV-2 infection in immunocompromised patients: humoral vs. cell-mediated immunity. J Immunother Canc 2020;8:e000862. https://doi.org/10.1136/jitc-2020-000862.Search in Google Scholar PubMed PubMed Central

16. de Rojas, T, Perez-Martinez, A, Cela, E, Baragano, M, Galan, V, Mata, C, et al.. COVID-19 infection in children and adolescents with cancer in Madrid. Pediatr Blood Canc 2020;67:e28397. https://doi.org/10.1002/pbc.28397.Search in Google Scholar PubMed PubMed Central

17. Bisogno, G, Provenzi, M, Zama, D, Tondo, A, Meazza, C, Colombini, A, et al.. Clinical characteristics and outcome of SARS-CoV-2 infection in Italian pediatric oncology patients: a study from the Infectious Diseases Working Group of the AIEOP. J Pediatr Infect Dis Soc 2020;9:530–4.10.1093/jpids/piaa088Search in Google Scholar PubMed PubMed Central

18. Marcia, M, Vania, B, Pruccoli, G, Vallero, SG, Barisone, E, Scolfaro, C, et al.. Acute lymphoblastic leukemia onset in a three-year-old child with COVID-19. Pediatr Blood Canc 2020;67:e28423. https://doi.org/10.1002/pbc.28423.Search in Google Scholar PubMed PubMed Central

19. Ogimi, C, Englund, JA, Bradford, MC, Qin, X, Boeckh, M, Waghmare, A. Characteristics and outcomes of coronavirus infection in children: the role of viral factors and an immunocompromised state. J Pediatr Infect Dis Soc 2019;8:21–8. https://doi.org/10.1093/jpids/pix093.Search in Google Scholar PubMed PubMed Central

20. Hrusak, O, Kalina, T, Wolf, J, Balduzzi, A, Provenzi, M, Rizzar, C, et al.. Flash survey on SARS-CoV-2 infections in pediatric patients on anti-cancer treatment. Eur J Canc 2020;132:11–6. https://doi.org/10.1016/j.ejca.2020.03.021.Search in Google Scholar PubMed PubMed Central

21. Prasad Meena, J, Kumar Gupta, A, Tanwar, P, Ram Jat, K, Mohan Pandey, R, Seth, R. Clinical presentations and outcomes of children with cancer and COVID-19: a systematic review. Pediatr Blood Canc 2021;68:e29005. https://doi.org/10.1002/pbc.29005.Search in Google Scholar PubMed PubMed Central

22. Yadav, SP. COVID-19 in children with blood and cancer disorders: what do we know so far? J Pediatr Hematol Oncol 2020;42:413–4. https://doi.org/10.1097/mph.0000000000001872.Search in Google Scholar

23. ASH RC COVID-19 registry for hematologic malignancy. Available from: www.ashresearchcollaborative.org/s/covid19-registry-data-summaries [Accessed 25 May 2020].Search in Google Scholar

24. Mamishi, S, Ghazizadeh Esslami, G, Mahmoudi, S, Navaeian, A, Behfar, M, Hamidieh, AA, et al.. COVID-19 in transplant recipient children: an Iranian referral hospital-based study. Acta Bio-Med: Atenei Parmensis 2021;92:e2021095. https://doi.org/10.23750/abm.v92i2.11189.Search in Google Scholar

25. Dong, Y, Mo, X, Hu, Y, Qi, X, Jiang, F, Jiang, Z, et al.. Epidemiology of COVID-19 among children in China. Pediatrics 2020;145:e20200702. https://doi.org/10.1542/peds.2020-0702.Search in Google Scholar

26. Ferrari, A, Zecca, M, Rizzari, C, Porta, F, Provenzi, M, Marinoni, M, et al.. Children with cancer in the time of COVID-19: an eight-week report from the six pediatric onco-hematology centers in Lombardia, Italy. Pediatr Blood Canc 2020;67:e28410. https://doi.org/10.1002/pbc.28410.Search in Google Scholar

27. Carlotti, A, Carvalho, WB, Johnston, C, Rodriguez, IS, Delgado, AF. COVID-19 diagnostic and management protocol for pediatric patients. Clinics 2020;75:e1894. https://doi.org/10.6061/clinics/2020/e1894.Search in Google Scholar

28. He, W, Chen, L, Chen, L, Yuan, G, Fang, Y, Chen, W, et al.. COVID-19 in persons with haematological cancers. Leukemia 2020;34:1637–45. https://doi.org/10.1038/s41375-020-0836-7.Search in Google Scholar

29. Sepulveda, J, Westblade, LF, Whittier, S, Satlin, MJ, Greendyke, WG, Aaron, JG, et al.. Bacteremia and blood culture utilization during COVID-19 surge in New York City. J Clin Microbiol 2020;58:00875–20. https://doi.org/10.1128/JCM.00875-20.Search in Google Scholar

30. Allegra, A, Pioggia, G, Tonacci, A, Musolino, C, Gangemi, S. Cancer and SARS-CoV-2 infection: diagnostic and therapeutic challenges. Cancers 2020;12:1581. https://doi.org/10.3390/cancers12061581.Search in Google Scholar

31. Project TUCCM. The UK Coronavirus Cancer Monitoring Project: protecting patients with cancer in the era of COVID-19. Lancet Oncol 2020;21:622. https://doi.org/10.1016/S1470-2045(20)30230-8.Search in Google Scholar

32. von Lilienfeld-Toal, M, Vehreschild, JJ, Cornely, O, Pagano, L, Compagno, F, EHA Infectious Disease Scientific Working Group, et al.. Frequently asked questions regarding SARS-CoV-2 in cancer patients-recommendations for clinicians caring for patients with malignant diseases. Leukemia 2020;34:1487–94. https://doi.org/10.1038/s41375-020-0832-y.Search in Google Scholar PubMed PubMed Central

33. Henry, BM, Lippi, G, Plebani, M. Laboratory abnormalities in children with novel coronavirus disease 2019. Clin Chem Lab Med 2020;58:1135–8. https://doi.org/10.1515/cclm-2020-0272.Search in Google Scholar

34. Mahmoudi, S, Rezaei, M, Mansouri, N, Marjani, M, Mansouri, D. Immunologic features in coronavirus disease 2019: functional exhaustion of T cells and cytokine storm. J Clin Immunol 2020;40:1–3. https://doi.org/10.1007/s10875-020-00824-4.Search in Google Scholar

35. Kotecha, RS. Challenges posed by COVID-19 to children with cancer. Lancet Oncol 2020;21:e235. https://doi.org/10.1016/s1470-2045(20)30205-9.Search in Google Scholar

Received: 2021-02-18
Accepted: 2021-05-04
Published Online: 2021-07-01

© 2021 Walter de Gruyter GmbH, Berlin/Boston

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