key: cord-0703978-xvdc5mgo
authors: Pourakbari, Babak; Mahmoudi, Shima; Mahmoudieh, Yasmine; Eshaghi, Hamid; Navaeian, Amene; Rostamyan, Maryam; Mamishi, Setareh
title: SARS‐CoV‐2 RNAaemia in children: An Iranian referral hospital‐based study
date: 2021-05-15
journal: J Med Virol
DOI: 10.1002/jmv.27065
sha: 3d9f813e6187288fefe7b0f98d420305d1ff20ae
doc_id: 703978
cord_uid: xvdc5mgo

Although severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) RNA is generally detected in nasopharyngeal swabs, viral RNA can be found in other samples including blood. Recently, associations between SARS‐CoV‐2 RNAaemia and disease severity and mortality have been reported in adults, while no reports are available in pediatric patients with coronavirus disease 2019 (COVID‐19). The aim of this study was to evaluate the mortality, severity, clinical, and laboratory findings of SARS‐CoV‐2 RNA detection in blood in 96 pediatric patients with confirmed COVID‐19. Among all patients, 6 (6%) had SARS‐CoV‐2 RNAaemia. Out of the six patients with SARS‐CoV‐2 RNAaemia, four (67%) had a severe form of the disease, and two out of the 6 patients with SARS‐CoV‐2 RNAaemia passed away (33%). Our results show that the symptoms more commonly found in the cases of COVID‐19 in the study (fever, cough, tachypnea, and vomiting), were found at a higher percentage in the patients with SARS‐CoV‐2 RNAaemia. Creatine phosphokinase and magnesium tests showed significant differences between the positive and negative SARS‐CoV‐2 RNAaemia groups. Among all laboratory tests, magnesium and creatine phosphokinase could better predict SARS‐CoV‐2 RNAemia with area under the curve levels of 0.808 and 0.748, respectively. In conclusion, 67% of individuals with SARS‐CoV‐2 RNAaemia showed a severe COVID‐19 and one‐third of the patients with SARS‐CoV‐2 RNAaemia passed away. Our findings suggest that magnesium and creatine phosphokinase might be considered as markers to estimate the SARS‐CoV‐2 RNAaemia.

Although SARS-CoV-2 RNA is generally detected in nasopharyngeal swabs, viral RNA can be found in other samples including sputum, saliva, lung samples, peripheral blood, serum, stool, and even urine samples. [5] [6] [7] Recently, there have been associations between SARS-CoV-2 RNAaemia and disease severity and mortality reported in adults, 3, [7] [8] [9] [10] while there are no reports available in pediatric patients with COVID-19.

The aim of this study was to evaluate the mortality, severity, clinical and laboratory findings of SARS-CoV-2 RNA detection in blood in pediatric patients with confirmed COVID-19. This study was performed at the Children's Medical Center, the primary center for pediatric medicine and research in Iran. More than 35,000 outpatients and 2,500 inpatients are admitted to our hospital monthly.

Hospitalized patients with confirmed COVID-19 were included.

All participants gave written informed consent, and the study was carried out following the guidelines of the Declaration of Helsinki. Signed informed consent was obtained from all patients who participated in the study. In cases where patients did not have the legal capacity to provide informed consent or had not reached the age of consent, their parents/legal guardians provided it for them.

A confirmed case of COVID-19 was defined as a positive result of SARS-CoV-2 real-time reverse-transcription polymerase chain reaction (rRT-PCR) using a nasopharyngeal swab. 2 The rRT-PCR assay was performed using the Premix Ex Taq™ (Probe qPCR; Takara) according to the manufacturer's instructions. The PCR cycle using N1 and N2 probes of the virus nucleocapsid gene and RNase P (RP) as an internal control was run as follows: 95°C for 3 min, followed by 45 cycles of 95°C for 3 s, and 58°C for 30 s. A cycle threshold value (C t value) of less than 37 was considered as a positive result.

The severity of COVID-19 was categorized into two groups (severe/critical vs. mild/moderate) based on the clinical findings, severity of pneumonia, respiratory failure, shock, and other organ failures. 11 Severe pneumonia was defined based on the following criteria: hypoxia (SpO 2 ≤ 93%), increased respiration rate of RR ≥ 70/ min (≤1 year), RR ≥ 50/min (>1 year), and blood gas analysis (PaO 2 < 60 mmHg, PaCO 2 > 50 mmHg). 4 Demographic characteristics, baseline symptoms, and physical signs, laboratory findings, severity, and outcome of the disease were collected.

Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS version 18.0, SPSS Inc.). Categorical data were described as percentages and a comparison of the differences between the two groups was conducted using the χ 2 test. Comparison of the laboratory tests between the two groups, with and without SARS-CoV-2 RNAaemia, was performed using Mann-Whitney U tests. The results were presented in terms of the median (interquartile range [IQR] ). The receiver operating characteristic (ROC) curve and area under the curve (AUC) were used to analyze the optimal cut-off for prediction of positive SARS-CoV-2 RNAaemia cases.

In this study, 96 COVID-19 positive patients were included into this study, 48% of the patients were male and 52% were female. Among all patients, 6 (6%) had SARS-CoV-2 RNAaemia, detected with rRT-PCR in the serum sample, and all of them were male. Presentation of symptoms such as fever, sore throat, cough, tachypnea, chest pain, rhinorrhea, diarrhea, abdominal pain, headache, and vomiting was recorded between the patients with and without SARS-CoV-2 RNAaemia ( Table 1) . Out of 88 recorded patients without SARS-CoV-2 RNAaemia, 67 patients with a fever (76%). All six patients with SARS-CoV-2 RNAaemia had a fever. Out of 93 recorded patients, three patients experienced sore throat (3.2%). All of these three patients tested negative in their SARS-CoV-2 rRT-PCR blood test. Out of 87 recorded patients, 30 patients were recorded to have a cough (34.5%). Three out of the six in the SARS-CoV-2 rRT-PCR positive blood test group were also recorded to have a cough (50%).

Within the SARS-CoV-2 rRT-PCR blood test negative group, 34 of the 87 total recorded patients suffered from tachypnea (39%).

Although, four out of the six patients with positive blood test results had tachypnea (47%) (p value = .22). Out of 87 recorded SARS-CoV-2 rRT-PCR blood negative patients, 5 reported chest pain (5.7%). None of the patients in the positive group are reported chest pain ( Table 1) 

Thirty-day all-cause mortality was calculated using all deaths within 

The median duration of time spent in the hospital for the 90 recorded SARS-CoV-2 rRT-PCR blood negative patients was 8 days 

The laboratory findings of the patients with negative SARS-CoV-2 rRT-PCR blood test are shown in Table 2 The AUC of all laboratory tests was used to predict SARS-CoV-2

RNAemia (Table 2) . Among all tests, magnesium and creatine phosphokinase could better predict SARS-CoV-2 RNAemia with AUC levels of 0.808 and 0.748, respectively.

As the COVID-19 outbreak progresses, it becomes increasingly important to quantify different aspects of pediatric cases of the disease.

Increasing evidence suggesting that pediatric cases are less severe should be grounds to expand research, rather than focus efforts elsewhere, as the younger generation plays a large role in disease transmission. 12 As viral load in respiratory specimens of both asymptomatic and symptomatic patients might show, detection of SARS-CoV-2 may not accurately reveal the disease severity. 10, 16 In this study, 6% of patients had SARS-CoV-2 RNAaemia. Serum/ plasma SARS-CoV-2 viral RNA was detected in 9.4% to 74.1%, with a pooled estimate of 34% (95% CI, 26%-43%) in patients with a positive nasopharyngeal swab RT-PCR test. [7] [8] [9] [10] 17, 18 Our results show that the symptoms that are more commonly found in cases with COVID-19 (fever, cough, tachypnea, and vomiting), were found at a higher percentage in the patients with SARS-CoV-2 RNAaemia. Less commonly observed symptoms (sore throat, chest pain, rhinorrhea, diarrhea, abdominal pain, and headache), were rare or not found in both the negative and positive PCR blood test groups. Similar to the previous report, 8 

The authors declare that there are no conflict of interests. 

All analysis is available from the corresponding author on reasonable request. All the remaining data are included in this article. 

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SARS-CoV-2 RNAaemia in children: An Iranian referral hospital-based study