key: cord-0971270-d4x11usx authors: Kebudi, Rejin; Kurucu, Nilgün; Tuğcu, Deniz; Hacısalihoğlu, Şadan; Fışgın, Tunç; Ocak, Süheyla; Tokuç, Gülnur; Nihal Özdemir, Gül; Bozkurt, Ceyhun; İnce, Dilek; Aras, Seda; Ayçiçek, Ali; Aksoy, Başak Adaklı; Karadaş, Nihal; Öztürk, Gülyüz; Orhan, Mehmet Fatih; Ataseven, Eda; Akbayram, Sinan; Yılmaz, Ebru; Tüfekçi, Özlem; Vural, Sema; Akyay, Arzu; Ayhan, Aylin Canbolat; Kılıç, Suar; Uzel, Veysiye Hülya; Düzenli, Yeter; Kazancı, Elif Güler; Acıpayam, Can; Elli, Murat; Tanyeli, Atilla; Karakas, Zeynep; Somer, Ayper; Kara, Ateş title: COVID‐19 infection in children with cancer and stem cell transplant recipients in Turkey: A nationwide study date: 2021-02-03 journal: Pediatr Blood Cancer DOI: 10.1002/pbc.28915 sha: cb577b84904301342848830d7e1ab1b885267876 doc_id: 971270 cord_uid: d4x11usx nan To the Editor: Adults with cancer are reported to have a higher risk for coronavirus disease (COVID- 19) infection and more severe disease and mortality than the general population. 1, 2 Although children seem to be at a lower risk for COVID-19 than adults, [3] [4] [5] data specifically addressing children with cancer are limited. [6] [7] [8] [9] [10] [11] [12] We conducted a retrospective, multicenter, cross-sectional study on behalf of the Turkish Pediatric Hematology Society (TPHD) and Turk- Following the national recommendations and guidelines of the MoH, 13, 14 centers tested all symptomatic patients or patients with contact history or patients who were planned to undergo transplantation or surgery. All patients and caregivers were questioned at the entrance of the hospital/oncology center and if there were any symptoms or contact history they were sent to the special clinics within the hospital that were allocated for suspected/proven COVID-19 patients. If a patient was suspected of having COVID-19 and found positive while in the oncology clinic, she/he was transferred to the COVID clinic and all staff, patients, and accompanying persons with whom she/he was in contact were tested for COVID-19. Samples from the naso-oropharyngeal swabs were tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by polymerase chain reaction (PCR There were 51 children with cancer, six of whom (four leukemia/lymphomas, two solid tumors) had undergone SCT ( Table 1 ). The median age was 6 (0. (Table 1) . Convalescent plasma was used in three patients, one of whom additionally received mesenchymal stem cell, tocizulumab, and granulocyte transfusions and was intubated. At the time of COVID-19 diagnosis, 26 patients had neutropenia and among them 15 had fever. In all patients with febrile neutropenia, broad-spectrum empirical antibiotics were initiated. In addition, 12 patients received antimicrobial therapy due to clinically and/or microbiologically documented infections. All patients, but one, fully recovered and the PCR tests became negative at a median of 7 (2-17) days. The patient who had received allogeneic SCT for relapsed leukemia/lymphoma and had progressive disease and fungal infection died due to COVID-19 infection. The incidence of critical care disease and need for ICU care were found to be higher in patients with hematologic malignancies (P = .012), patients post SCT (P = .001), patients with other infections (P = .005), and patients with abnormal findings on chest CT scan (P = .004). Age, gender, elevated CRP, elevated D-dimer, being neutropenic, and having relapsed/refractory disease were not significant for critical disease. It has been reported that children constitute about 2% of all patients with COVID-19. 15 Abbreviations: ALL, acute lymphoblastic leukemia; AML, acute myeloid leukemia; ARDS, acute respiratory distress syndrome; BMT, bone marrow transplantation; GIS, gastrointestinal system; HL, Hodgkin lymphoma; HLH, hemophagocytic lymphohistiocytosis; ICU, intensive care unit; LCH, Langerhans cell hystiocytosis; MDS, myelodysplastic syndrome; NHL, non-Hodgkin lymphoma. a ALL, n = 18; AML, n = 7; MDS, n = 1. b HL, n = 2; NHL, n = 1; HLH, n = 1; LCH, n = 1. c Medulloblastoma, n = 4; atypical teratoid rhabdoid tumor, n = 1. d Ewing Sarcoma, n = 2; osteosarcoma, n = 1. e Rhabdomyosarcoma, n = 2; desmoid fibromatosis, n = 1. f Germ cell tumors, n = 2; hepatoblastoma, n = 1; Wilms tumor, n = 1; metastatic carcinoma, n = 1. g Presented with diarrhea, colitis, and gastrointestinal bleeding. h Six were already hospitalized for other reasons (such as diagnostic workup and surgery) and they received COVID-19 diagnosis during this time. i Antivirals (favipiravir, lopinavir). The COVID-19 infection prevalence among adult cancer patients has been reported to be higher than in the general population (1% vs 0.29%). 1 For pediatric cancer patients, prevalence was estimated as 1.3%, which is higher than that of the general pediatric population (0.8%). 7 The median age of our patients was younger than most reports in the literature (6 vs 11 years). [7] [8] [9] 12 There was a male preponderance (64.7%) similar to the gender distribution in the general adult and pediatric population. 4, 17, 18 Most of our cases (60.8%) had hematological malignancies, similar to some other series. 9, 12 COVID-19 causes multiple organ involvement due to widespread distribution of angiotensin-converting enzyme-2, the functional receptor for SARS-CoV-2 in multiple organs. 11, 19 Shekerdemian et al 20 reported that 73% of the pediatric cases were admitted with respiratory findings, while 25% of cases presented with other system findings such as gastrointestinal and neurological systems. Involvement of other systems was documented in 35% of our cases. In many pediatric cancer series, as in our study, 30-50% of the cases had febrile neutropenia. 6, 7, 9 Since differential diagnosis between COVID-19 and other infections is difficult during neutropenia, we suggest that children with cancer and febrile neutropenia should be tested for COVID-19. Twenty-one percent of our patients had severe/critical disease and 17.6% of cases needed ICU care. Mortality rate was found to be 1.9%. Having a hematological malignancy, SCT, a mixed infection and abnormal CT findings were found to significantly increase the severity of the disease and the need of ICU in our study. In addition, delay in specificcancer treatment may pose a problem. It is hard to speculate which drugs are best for the disease as the search for the "standard of care" drugs are still under debate globally, national and international guides for management are frequently being revised. 6, 7, [10] [11] [12] 20, 21 The evaluation and sharing of national data, as in our study that includes all children with cancer/SCT and COVID-19 within a time frame, without any selection bias, and accumulation of international data shall lead to a better understanding of the disease, treatment and risk factors to guide health care professionals. We thank the president of the The data that support the findings of this study are available from the corresponding author upon reasonable request. 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