Pediatric radiologic manifestations of COVID-19

Abstract

Purpose While full description of pediatric COVID-19 manifestations is evolving, children appear to present less frequently, and often display a less severe disease phenotype. There is correspondingly less data regarding pediatric radiologic findings. To describe the imaging findings of pediatric COVID-19, we evaluated the radiologic imaging of the initial patient cohort identified at our institution. Methods In this IRB approved study, all patients at our institution aged 0–21 with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) based on PCR or immunoglobulin testing were identified. Imaging was reviewed by the co-authors and presence of abnormalities determined by consensus. Pre-existing comorbidities and alternative diagnoses were recorded. Rates of each finding were calculated. Findings were compared to published data following review of the available literature. Results Out of 130 Covid-19 positive patients, 24 patients underwent imaging, including 21 chest radiographs and 4 chest CT scans. Chest x-rays were normal in 33%. Patchy or streaky opacities were the most common radiographic abnormality, each seen in 38% of patients. CT findings included ill-defined or geographic ground glass opacities, dense opacities, septal thickening and crazy paving, and small pleural effusions. Results are similar to those reported in adults. Multiple COVID-19 positive children presented for symptoms due to an additional acute illness, including appendicitis and urinary infection. Conclusions Radiologic findings of COVID-19 in pediatric patients range from normal to severe ARDS type appearance. During this ongoing pandemic, these radiographic signs can be useful for the evaluation of disease status and guiding care, particularly in those with comorbidities. Precis Radiologic findings of COVID-19 in pediatric patients are similar to those seen in adults, and may range from normal to severe ARDS type appearance.

Abdominal pain and appendicitis in children during the COVID-19 pandemic – do we need to be especially careful?

“…Another COVID-positive patient had abdominal pain, fever, vomiting, and hypotension. Abdominal CT showed minimal lymphadenopathy and traces of free fluid in the abdomen as well as minimal clouding of the basilar pulmonary lung glass (44) . Meyer et al draw attention to the possible association between COVID-19 and appendicitis.…”

“…Polites and Azarow (2020) (37) With comparable outcomes for operative and non-operative management of uncomplicated appendicitis, hospitals must consider capacity and resources in determining the best course of action Tankel et al (2020) (38) The significant decrease in the number of patients admitted with acute appendicitis during the onset of COVID-19 possibly represents successful resolution of mild appendicitis treated symptomatically by patients at home Saleem et al (2020) (39) More than half of the patients had perforated appendix, which was the highest percentage observed in the group of patients during the period of two months Mehl et al (2021) (40) COVID-19 children requiring surgery have a favourable postoperative course and short-term outcomes compared to the reported adult experience Rohani et al (2021) (41) COVID-19 has many different and mysterious presentations. Gastrointestinal manifestations are among the most important, common presentations Hwang et al (2021) (42) Laboratory criteria, specifically low-normal white blood cell count and thrombocytopenia, appear to be of high relevance in differentiating MIS-C from acute appendicitis, even when the appendix is radiologically dilated Gerall et al (2021) (43) A rash as well as tachycardia and/or hypotension and elevated inflammatory markers out of proportion to the amount of inflammation seen on imaging should be used to differentiate a typical surgical abdomen from MIS-C and prompt testing for active SARS-CoV-2 infection as well as antibodies Romberg et al (2021) (44) CT of COVID-positive patients with severe abdominal pain showed lymphadenopathy, mild thickening of the intestinal wall, and mesenteric oedema Meyer et al (2021) (45) We encourage consideration of testing for SARS-CoV-2 in paediatric patients with severe gastrointestinal symptoms to inform about strategies to alleviate transmission and possible complications due to unnecessary surgical treatment Rico Espiñeira et al (2021) (46) Gastrointestinal symptoms can be the primary manifestation of the new coronavirus infection, which simulates an acute abdomen with a potentially unfavourable evolution. For an accurate diagnosis to be achieved, a good clinical record and a comprehensive physical exploration, as well as complementary tests in search of characteristic findings of COVID-19, should be carried out Jackson et al (2020) (47) MIS-C should be considered in patients with prominent gastrointestinal symptoms and a history of recent SARS-CoV-2 exposure or infection.…”

Imaging findings in acute pediatric coronavirus disease 2019 (COVID-19) pneumonia and multisystem inflammatory syndrome in children (MIS-C)

“…The most common CT abnormalities described in pediatric COVID-19 pneumonia are multiple ground-glass opacities, with or without consolidation, which can be subpleural/peripheral or central in location [ 45 – 48 , 51 , 54 , 56 , 63 – 72 ] (Figs. 4 and 5 ).…”

“…Interstitial-type opacities and small airway-type findings, such as bronchial wall thickening, septal thickening and tree-in-bud nodules, have been described as highly frequent in some studies, but uncommon in other studies [ 45 , 51 , 54 , 64 , 66 – 68 ]. As with chest radiography, pleural effusions are not usually seen, and when present are typically small in size [ 45 , 51 , 56 , 67 ]. An increased risk for pulmonary embolism in COVID-19-infected adults has been well described, but thus far it appears to be uncommon in children [ 45 , 68 , 73 , 74 ].…”

“…These issues limit the meaningfulness of radiographic interpretations in pediatric COVID-19 disease. In a few studies, some data support a link between the severity of pulmonary opacities on imaging and indicators of clinical severity, such as degree of respiratory distress, need for hospital admission and intensive care stay, presence of underlying conditions, and patient fatalities [ 45 , 47 , 50 , 51 , 53 , 71 , 72 ]. Thus, while imaging might not play a primary diagnostic role in acute pediatric COVID-19, it remains an integral part of patient care, mainly to assess disease progression or anticipate a change in management, especially in children with critical illness and chronic comorbidities [ 20 , 41 , 43 , 45 , 48 ].…”