Tuesday, April 10, 2018

Frontiers Med.: MERS-CoV In 7 Pediatric Patients



For reasons that aren't completely understood, MERS-CoV infection is seldom  reported in pediatric patients (age ≤ 18 years).  Deaths are even rarer still, although a few have been reported. 
Given their scarcity, and the limited flow of MERS information out of Saudi Arabia, we don't have a lot of data regarding pediatric infection with MERS-CoV.   
In September of 2017, the CDC's MERS Clinical Features page had this to say:

MERS Clinical Features

Clinical Presentation

A wide clinical spectrum of MERS-CoV infection has been reported ranging from asymptomatic infection to acute upper respiratory illness, and rapidly progressive pneumonitis, respiratory failure, septic shock and multi-organ failure resulting in death.
Most MERS-CoV cases have been reported in adults (median age approximately 50 years, male predominance), although children and adults of all ages have been infected (range 0 to 109 years). Most hospitalized MERS-CoV patients have had chronic co-morbidities. Among confirmed MERS-CoV cases reported to date, the case fatality proportion is approximately 35%.

Limited clinical data for MERS-CoV patients are available; most published clinical information to date is from critically ill patients. At hospital admission, common signs and symptoms include fever, chills/rigors, headache, non-productive cough, dyspnea, and myalgia.
Other symptoms can include sore throat, coryza, nausea and vomiting, dizziness, sputum production, diarrhea, vomiting, and abdominal pain. Atypical presentations including mild respiratory illness without fever and diarrheal illness preceding development of pneumonia have been reported. Patients who progress to requiring admission to an intensive care unit (ICU) often have a history of a febrile upper respiratory tract illness with rapid progression to pneumonia within a week of illness onset.
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A few pediatric slanted journal articles have appeared over the past couple of years, but again, with very few specifics.

Middle East Respiratory Syndrome Coronavirus and Children: What Pediatric Health Care Professionals Need to Know
Middle East respiratory syndrome in children Dental considerations
Providing a bit more insight, a new study has been published in Frontiers of Medicine (alas, behind a pay wall), which details 7 pediatric MERS-CoV cases.  We do have the abstract, however.  
The lead author is  Dr. Ziad Memish, who in 2014 found himself abruptly removed from his position of Deputy Minister of Health for Saudi Arabia (see An Unexpected Announcement From The Saudi MOH).
Since then Dr. Memish has published an impressive number of papers, many focusing on MERS-CoV and mass gathering medicine.

Middle East respiratory syndrome coronavirus in pediatrics: a report of seven cases from Saudi Arabia

Sarah H. Alfaraj, Jaffar A. Al-Tawfiq, Talal A. Altuwaijri, Ziad A. Memish Email author

Case Report

Infection with Middle East respiratory syndrome coronavirus (MERS-CoV) emerged in 2012 as an important respiratory disease with high fatality rates of 40%–60%. Despite the increased number of cases over subsequent years, the number of pediatric cases remained low. 

A review of studies conducted from June 2012 to April 19, 2016 reported 31 pediatric MERS-CoV cases. In this paper, we present the clinical and laboratory features of seven patients with pediatric MERS.

Five patients had no underlying medical illnesses, and three patients were asymptomatic. Of the seven cases, four (57%) patients sought medical advice within 1–7 days from the onset of symptoms. The three other patients (43%) were asymptomatic and were in contact with patients with confirmed diagnosis of MERS-CoV. The most common presenting symptoms were fever (57%), cough (14%), shortness of breath (14%), vomiting (28%), and diarrhea (28%). 

Two (28.6%) patients had platelet counts of < 150 × 109/L, and one patient had an underlying end-stage renal disease. The remaining patients presented with normal blood count, liver function, and urea and creatinine levels. The documented MERS-CoV Ct values were 32–38 for four of the seven cases. 

Two patients (28.6%) had abnormal chest radiographic findings of bilateral infiltration. One patient (14.3%) required ventilator support, and two patients (28.6%) required oxygen supplementation. All the seven patients were discharged without complications.
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Because testing of asymptomatic contacts of cases was only rarely done prior to 2016 (see Sept 2015 WHO Statement On The 10th Meeting Of the IHR Emergency Committee On MERS), it is likely some number of mild or asymptomatic pediatric cases flew under the radar during the stated study period (June 2012 to April 19, 2016).   
Of course, that reporting gap isn't limited to pediatric cases. 
We've previously looked at estimates that have suggested the number of MERS cases far exceeds the numbers reported by countries on the Arabian Peninsula.
Despite these higher estimates, the good news is we've seen no signs of any sustained or efficient transmission of the MERS virus outside of health care facilities.

Hopefully we'll be seeing more case reports like today's, which will give us a better understanding of how to deal with this virus, should the status quo start to change.

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