Clinical Profile and Outcome of COVID-19 Among Immunocompromised Children

Data of 409 children were extracted during the study period; 162 (396%) of these were immunocompromised. Of the 409 children, 26 (6.3%) were diagnosed with SARS-CoV-2. Data of one child was incomplete and he was excluded from the analysis. The proportion of SARS-CoV-2 positivity in immuno-compromised and immunocompetent children was 16 (9.9%) and 9 (3.6%), respectively [OR (95% CI) 2.89 (1.24-6.73); P=0.01]. Comorbidities were present in 184 (44.9%) children, mainly malignancy in 78 (18.9%) and nephrotic syndrome (NS) in 67 (16.3%). The clinical profile and outcome of children with COVID-19 is shown in Table I. All children with severe COVID-19 disease had features of sepsis and shock; however, 3 children had acute respiratory distress syndrome (ARDS). Only 12 children with COVID-19 underwent blood biochemistry, and reports revealed anemia (n=6), leucopenia (n=5), neutrophil-lymphocyte ratio>3 (n=5) and thrombocytopenia in 3 children. High resolution computed tomography of chest showed ground glass opacities in two and air-bronchogram in three children. One child presented with severe abdominal pain and computed tomography of abdomen was suggestive of pancreatitis, he also had elevated amylase (217µ/L) and lipase (365µ/L).

Immunocompromised children had a significantly higher risk of SARS CoV-2 infection which may be due to the need of frequent hospital visits for their medications (chemotherapy), which exposed them to get infection. However, they had a lower hospitalization rate [8 (50%) vs 9 (100%), P=0.01] as compared to immunocompetent children possibly because of day care treatment protocol. The occurrence of disease was lesser in immunocompromised children, with most being either asymptomatic or with mild disease, and with complete recovery. It is possibly due to weaker immune response under the influence of immunosuppressants. Similar observations were reported in a survey conducted in 25 countries (>200 children tested and 10000 at risk) among children on anticancer treatment [8] and in a systematic review of 16 articles (100 adults, 10 children) by Minotti, et al. [5], which concluded that these children had asymptomatic or mild disease, and had a favorable outcome. Severe disease manifestations and require-ment of intensive care, respiratory support, and inotropes were comparable between the two groups. Overall mortality was 16% and this might be a reflection of high incidence of non-COVID sepsis and associated complications in these patients. In a study on 113 children with kidney diseases receiving immunosuppressive medications from 30 countries; authors found that only 9.7% had severe grade of disease [3]. Features of relapse, or new organ involvement (pancreas) or new onset glomerulonephritis have been seen in children with nephrotic syndrome in present study and this might be like other viruses, SARS Co-V-2 infection may also precipitate relapses or infect new organ [9,10].

The present study has few limitations, one being retrospective analysis and small sample size, and short term follow-up. Additionally, admitting policy kept on changing during the study period depending on government guidelines. We conclude that children with immunosuppressant medication are at an increased risk of SARS Co-V-2 infection, and disease manifestations may be asymptomatic or mild with predominantly gastrointestinal symptoms.

Contributors: SKR, RP, VG, OPM: concept, design, drafting of the manuscript, critical analysis; AK: acquisition of data, analysis and interpretation. All authors approved the final version of manuscript, and are accountable for all aspects related to the study.

Funding: None; Competing interests: None stated.