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Chapter 10: Pediatric SARS

Bernd Sebastian Kamps, Christian Hoffmann

Clinical Manifestation

Two studies have so far reported on SARS among children. In one study, persistent fever, cough, progressive chest radiograph changes and lymphopenia were noted in all 10 patients (Hon). Teenage patients presented with symptoms of malaise, myalgia, chill, and rigor similar to those seen in adults, whereas the younger children presented mainly with a cough and runny nose, and none had chills, rigor, or myalgia.

In the second study, fever was the presenting symptom in 19 of 21 children. Other prodromal symptoms reported included malaise, loss of appetite, chills, dizziness, and rhinorrhea. Headache, myalgia, diarrhea, sore throat, and skin rash were relatively uncommon (Chiu; Table 1). During the lower respiratory phase of the illness, approximately one half of the children had coughing, one third of which was productive. Dyspnea or tachypnea was uncommon (Chiu).

At presentation, all 21 children had normal hemoglobin values. The total white cell count was low in five children (23.8%). All neutrophil counts were normal. Twelve children (57.1%) had lymphopenia, and five (23.8%) had thrombocytopenia (Chiu). Subsequently, during the course of the disease, 19 children (90.5%) developed lymphopenia and ten of them (47.6%) had mild thrombocytopenia. All elevated activated partial thromboplastin time levels during the acute phase in six children (28.6%) subsequently returned to normal levels. D-dimer was abnormal in three children (14.3%). All children had normal renal function. Abnormal ALT levels were found in two children (9.5%) at admission. Mild biochemical hepatitis, defined as an elevation three times that of a normal ALT level with a normal bilirubin level, was observed in five children (23.8%). Fifteen children (71.4%) had a raised LDH level, and nine children (42.9%) had a raised CPK level (Chiu).

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Table 1. Clinical features of children with severe acute respiratory syndrome*

Features	No. of Children (%)
Fever	19 (90.5)
Malaise	13 (61.9)
Loss of appetite	12 (57.1)
Chills	10 (47.6)
Cough	9	(42.9)
Dizziness	8	(38.1)
Rhinorrhea	7	(33.3)
Sputum	3	(14.3)
Dyspnea/tachypnea	3	(14.3)
Headache	3	(14.3)
Myalgia	2	(9.5)
Diarrhea	2	(9.5)
Sore throat	1	(4.8)
Rash	1	(4.8)

* from Chiu: Severe acute respiratory syndrome in children: experience in a regional hospital in Hong Kong

When comparing the 11 children below 12 years with the ten children 12 years and older, the older group had less cough. However, these children had higher temperatures, a longer duration of fever, and more constitutional upset in terms of malaise and dizziness. They had more derangement in laboratory variables, including platelet counts, ALT, LDH, and CPK. All of them received steroid treatment. The changes in their chest radiographs took a longer time to resolve (Chiu).

Radiologic Features

In the same series (Chiu), pneumonic changes on chest radiographs were present in ten children (47.6%) at admission, but all 21 children developed abnormal chest radiographs during the course of the disease. The primary radiological abnormality was airspace opacity. Unilateral focal opacity was the most common presentation and was found in 18 children (85.7%). Two children (9.5%) had unilateral multi-focal opacities, and one child (4.8%) had bilateral involvement. There was no particular distribution pattern. Peripheral zone involvement was found in six children (28.6%). The opacities found in the

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chest radiographs of the children showed evidence of progression, with an increase in the size or involvement of multiple areas in 18 children (85.7%). Bilateral involvement was observed in ten children (47.6%). Chest radiographic abnormalities were worst on day 6.5 +/- 2.7 days after admission. Two children (9.5%) had high-resolution computerized tomography of the thorax done because of a high clinical suspicion of SARS, although chest radiographs were initially negative. Both tomographs were abnormal and showed the characteristic ground-glass opacities, as described previously in adults (Chiu).

Treatment

The treatment protocol proposed by Hon et al. is shown in Table 2. In this series, four teenagers required oxygen therapy and two needed assisted ventilation, whereas none of the younger children required oxygen supplementation (Hon). Among the 21 children reported by Chiu, only two children (9.5%) required supplemental oxygen. None of them required mechanical ventilation.

Table 2. Treatment of children with SARS*

Diagnosis of SARS sus-	Intravenous cefotaxime, oral clarithromycin, and
pected on admission	oral ribavirin** (40 mg/kg daily, given in two or
	three doses)
Fever persists >48 h	Oral prednisolone** (0·5 mg/kg daily to 2·0 mg/kg
	daily)
Patients with moderate	Intravenous ribavirin** (20 mg/kg daily, given in
symptoms of high fluctu-	three doses) and hydrocortisone** (2 mg/kg every
ating fever and notable	6 h) immediately after admission
malaise
Persistent fever and	Pulse intravenous methylprednisolone (10–20
progressive worsening	mg/kg)
clinically or radiologically

*from Hon: Clinical presentations and outcome of severe acute respiratory syndrome in children.

**Ribavirin was administered for 1–2 weeks and corticosteroid dose was tapered over 2–4 weeks.

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Clinical Course

The clinical course seems to be much milder and shorter among patients less than 12 years of age (Hon, Chiu). In addition, the radiological changes are milder and generally resolve more quickly than in teenagers. Compared with adults and teenagers, SARS seems to have a less aggressive clinical course in younger children (Hon, Chiu). The reason why children with SARS fare better than adults and adolescents infected with the disease is unclear.

References

1.Chiu WK, Cheung PC, Ng CK, et al. Severe acute respiratory syndrome in children: experience in a regional hospital in Hong Kong. Pediatr Crit Care Med 2003; 4: 279-83. http://SARSReference.com/lit.php?id=12831407

2.Health, Welfare & Food Bureau. SARS Bulletin 25 April 2003. (accessed on April 27) http://www.info.gov.hk/dh/diseases/ap/eng/bulletin0425.htm

3.Hon KL, Leung CW, Cheng WT, et al. Clinical presentations and outcome of severe acute respiratory syndrome in children. Lancet 2003, 361:1701-3. Published online April 29, 2003. http://image.thelancet.com/extras/03let4127web.pdf

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