key: cord-0910165-4r2lcqpr authors: Erat, Tuğba; Güler, Şükran title: Use of radiological tests in COVID‐19 positive child cases: Is chest computed tomography necessary? date: 2021-06-06 journal: Int J Clin Pract DOI: 10.1111/ijcp.14259 sha: 77b9f7c7939cdf60246314b6085cfba369c1689f doc_id: 910165 cord_uid: 4r2lcqpr OBJECTIVE: This study aimed to correlate the radiographic findings of the coronavirus disease 2019 (COVID‐19) positive children with their clinical and laboratory findings and discuss the frequency and necessity of chest computed tomography (CT) used for the radiological imaging in paediatric patients with COVID‐19 infection. MATERIALS AND METHODS: Sixty‐nine paediatric inpatient cases were retrospectively analysed using their clinical, laboratory and imaging features. The National Public Health Guide was used in the diagnosis and treatment of paediatric patients. COVID‐19 infections for all patients were confirmed by the COVID‐19 nucleic acid test using a pharyngeal swab. RESULTS: The median age of the patients was 11 years [3‐15]. The most common clinical symptoms were fever (40.6%) and cough (33.3%). When the laboratory findings of patients were examined, the median white blood cell (WBC) count was 5.8/mm(3) (4.8‐8.05/mm(3)), median lymphocyte count was 2.3/mm(3) (1.7‐3.55/mm(3)) and median C‐reactive protein (CRP) level was 2.3/mm(3) (1‐2.1/mm(3)). All patients had chest radiographs (CRXs), while only 44.9% of the patients underwent a chest CT. The 8.7% of CXRs and 12.8% of chest CT findings were found as pathological. Ground‐glass opacity was the most frequent finding. In the tomography group, the count of lymphocytes was lower, and creatine kinase (CK) and lactate dehydrogenase (LDH) levels were significantly higher. The patients with pathological tomography findings demonstrated no statistically significant difference in lymphocyte count and CK and LDH levels; however, their CRP value was significantly higher. CONCLUSION: In this study, it is emphasised that chest CT should be requested by considering the underlying diseases and severity of clinical findings in paediatric patients. In this way, unnecessary chest CT could be prevented in the paediatric population. nonpathological during the early stage of the disease and, therefore, are not recommended as the first-line imaging tool. [3] [4] [5] Generally, COVID-19 seems to have a less severe clinical presentation for children than adults. The most common CT findings are unilateral or bilateral subpleural ground-glass opacities and consolidations with surrounding halo sign in paediatric patients. Additional findings may include peribronchial opacities and bronchial wall thickening. As the disease progresses, the consolidations can extend diffusely, presenting a "white lung" appearance, accompanied by airbronchogram signs. [6] [7] [8] [9] Especially in Turkey, where the pandemic is well controlled, COVID-19 occurs as asymptomatic or with mild clinical symptoms in children. At the same time, children with other comorbid diseases (such as immunosuppressive patients, congenital heart, lung and airway diseases and tumours) are more vulnerable to infection with COVID-19 than healthy children. 10, 11 We aim to correlate the radiographic findings of the COVID-19 positive children with clinical and laboratory findings. We presented a series of 69 paediatric cases with clinical and imaging features and evaluated the unnecessary chest CT. Sixty-nine paediatric inpatients with COVID-19 infection, confirmed by COVID-19 nucleic acid test using a pharyngeal swab, admitted into our hospital within the duration of 2 months were included in this study. Patients were diagnosed either from the contact screening or the admission to the hospital with symptomatic presence. The National Public Health Guide was used in the diagnosis and treatment of paediatric patients. 12 The criteria for the diagnosis of COVID-19 in children were combined with the epidemiology and clinical manifestations. Epidemiological history is the cornerstone of diagnosis in children. Data of patients hospitalised within 2 months were recorded using the medical database. We analysed demographic characteristics, contact history, previous medical history, clinical symptoms, laboratory findings and radiological tests. The patients' radiological images were obtained by CXRs and chest CT methods. Noncontrast multislice chest CT images were taken by using GE Healthcare Revolution The protocol for this retrospective study was approved by the University Medical School. The written informed consent was waived for emerging infectious diseases. Statistical analyses of the data were performed using SPSS 20.0 for Windows (IBM Corp., Armonk, NY, USA). Distribution of data was evaluated using the Kolmogorov-Smirnov test. Differences in the means of variables were tested using both parametric and nonparametric tests, depending on the distribution of the variables. Categorical variables across groups were compared using the chisquare test or Fisher's exact test (if a cell number was 5 or less). For numerical comparisons, Student's t test or Mann-Whitney U tests were used to assess differences between two groups according to the normal distribution of the measured parameters. Mean values and standard errors were used as descriptive statistics. Data were presented as mean ± standard deviation (SD) or median and interquartile range (IQR, 25th-75th percentile). In all statistical tests, P < .05 was considered as statistically significant. Sixty-nine children with COVID-19 positive were admitted to the hospital in April and May 2020. The patients' median age was • The risk of developing complications, severe pneumonia in previously healthy children is significantly lower than in adults. • Tomography shows more specific and early diagnosis. • Routine use of tomography in children due to mild clinical course is controversial. • In this study, it is emphasised that chest CT should be requested by considering the underlying diseases and severity of clinical findings in paediatric patients. • In this way, unnecessary chest CT should be prevented in the paediatric population. were <1 year of age, 15.9% were between 1 and 5 years, 20.3% were 6 and 10 years, 50.7% were ≥10 years; 36 (52.2%) of the patients were female. The most common clinical symptoms were fever (40.6%) and cough (33.3%). Less frequent symptoms were sore throat, abdominal pain, myalgia and shortness of breath. The characteristics of paediatric patients with COVID-19 infection were presented in Table 1 . The laboratory findings of the patients revealed that white blood cell counts of 48 (69.6%) patients were between 4 and 10.000/mm 3 , and lymphocyte count of 44 (68.1%) patients was <3.000/mm 3 . CRP value was <3 mg/L in 85.5% of patients. There was an increase in alanine aminotransferase (ALT) level in one case (1.4%), lactate dehydrogenase (LDH) levels in 18 cases (26.1%) and creatine kinase (CK) levels in 12 cases (17.4%). Laboratory findings were shown in Table 2 . One of our patients, who was 16 years old, had an underlying disease and underwent allogeneic haematopoietic stem cell transplantation for thalassemia major. Only this immunosuppressive patient was admitted to the paediatric intensive care unit. Other patients were hospitalised in the paediatric pandemic department. Hydroxychloroquine was used in the treatment of 12.8% of COVID-19 positive patients. The CXRs were obtained from all patients. There was a pathological presence in 6 (8.7%) of the CXRs. Pathological findings included consolidations, peribronchial opacities and bronchial wall thickening. According to their clinical and laboratory findings, 31 patients (44.9%) had chest CT scans. Among them, nine patients' (12.8%) CT images were accepted as pathological, which included millimetric nodules, parenchymal nodular consolidations, ground-glass opacities and consolidations, consolidations with surrounding halo sign, dilated bronchus, bronchial wall thickening and subpleural nodular consolidations (Figures 1-4) . The ground-glass opacities were the most frequent, and the least was the air-bronchogram sign, which was observed in immunosuppressive patients. The median age of patients who underwent chest CT was 15 years. 12- 16 The majority of these patients were men. When the frequency of fever and cough of the patients who underwent chest CT was examined, there was no statistically significant difference compared to patients without chest CT. However, when the laboratory findings were examined, the count of lymphocytes was lower in patients with tomography, which was statistically significant. CK and LDH values were also significantly higher in the tomography group ( Chest radiographs (CRXs) and chest computed tomography (CT) images from 13-y-old boy. A, Normal CRXs on admission; B, nodular consolidation in the right lung median lobe; C, mm-sized ground-glass nodule ın the left lung ınferıor lobe F I G U R E 2 Chest radiographs (CRXs) and chest computed tomography (CT) images from 14-y-old girl. A, Perihillar dilated bronchus in the right lung parenchyma and suspected opacities related to infiltration on admission; B, dilated bronchus, peribronchial septal thickenıng and ground-glass opacities in the right lung inferior lobe; C, ground-glass opacity in the right lung inferior lobe's posterior-basal segment F I G U R E 3 Chest radiographs (CRXs) and chest computed tomography (CT) images from 10-y-old girl. A, Suspected images related to infiltration in the right lung medial and inferior lobes, on admission; B, subplevral localised central consolidation surrounded by ground-glass opacity (halo sıgn); C, multiple ground-glass nodules in the right lung inferior lobe patients with pathological tomography findings were examined, only the CRP value was significantly higher than the group with normal tomography. There was no statistically significant difference in age, gender, lymphocyte count, CK and LDH values ( severe. Severe cases were reported to be at a rate of 6.7%. Similar clinical manifestations were reported in other series. Studies and clinical experiences have shown that the symptomatic clinical presence is less common in children. 13, [16] [17] [18] According to Turkey's surveillance data, 50.4% of paediatric cases had mild disease, and 0.8% had severe disease. 19 The majority of children in our study also had mild clinical feature. In our 69 cases of children whose information of exposure was and 12.8% of these chest CTs were pathological. As in other studies, ground-glass images were the most common findings in our patients. Radiological findings reported in paediatric cases were bilateral ground-glass opacity, patchy local shadowing, patchy bilateral shadowing and interstitial abnormalities. 15 Lymphopenia is one of the cautionary findings in the literature. In our study, although tomography was preferred in lymphopenic patients, lymphopenia was not detected as a significant indicator of the pathological findings of patients with a tomography. During the hospitalisation, there was no worsening in clinical presentation of pneumonia; therefore, chest CT was not performed in patients for a second time. The early diagnosis and more common radiological findings of chest CT do not provide additional advantages in monitoring the previously healthy children's clinic. Besides, we did not need to perform chest CT in any of our patients who were followed up with CXRs. Patients were hospitalised approximately for 3-5 days. The COVID-19 positive patients were followed up by the provincial public health directorate after discharge and isolated for 14 days, and the isolation was terminated with being asymptomatic and RT-PCR negativity. Except for the immunosuppressive patient, there was no clinical deterioration in these patients. Due to the high dose of radiation administered during chest CT scanning, even though we used thin slice and low dose highresolution computed tomography (HRCT), each scanning is equal to 25-30 CXRs on average, and it should be applied according to clinical necessity, especially in the paediatric population. We have no potential conflicts of interest to disclose. The protocol for this retrospective study was approved by the Abbreviations: chest CT, chest computed tomography; CK, creatine kinase; COVID-19, coronavirus disease 2019; CRP, C-reactive protein; CRXs, chest radiographs; LDH, lactate dehydrogenase; RT-PCR, real-time reverse transcription polymerase chain reaction. 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