A brief presentation about some typical symptoms in children diagnosed with COVID-19 in Oman along with atypical or unusual presentations of the disease in the same age group in the USA and Bahrain.

1. Typical & atypical clinical presentations of
COVID-19 in children
LITERATURE REVIEW
Moosa Allawati
Medical student at
SQU, Sultanate of
Oman

2. Research no. 1
COVID-19 in the pediatric age group in Oman
Al Yazidi LS et al. Epidemiology, characteristics and outcome of children hospitalized with COVID-19 in Oman: A multicenter cohort study. Int J Infect
Dis. 2021 Jan 18;104:655-660. doi: 10.1016/j.ijid.2021.01.036.

3. Findings
56 children <14 years old required hospitalization in 7 Omani centers over 5 months
(February – July 2020).
Common clinical presentations Uncommon clinical presentations
Uncomplicated disease (68%) MIS-C (5 cases (9%))
Respiratory symptoms (59%) Lymphadenopathy (7%)
Documented fever (57%) Cyanosis (4%)
Gastrointestinal symptoms (55%) Oral mucosal changes (4%)
Fatigue or decreased activity (50%) Conjunctival injection (4%)

4. Research no. 2
BMJ Case Rep: first published as 10.1136/bcr-2020-237306 on 8 September 2020.

5. Case report
• A previously healthy 8-year-old African-American twin boy, presented to the
emergency department with a mild periumbilical abdominal pain and 2 days of
fever unresponsive to antipyretics.
• The patient’s mother had screened positive for COVID-19 by nasopharyngeal
PCR 28 days prior to presentation. The mother was never symptomatic, and she
subsequently screened negative on repeat testing per work policy as a geriatric
nurse. No other family members were tested, and all remained asymptomatic.
• Physical examination was significant for mild abdominal tenderness in the
periumbilical area without guarding or peritoneal signs. And the patient was
discharged with a diagnosis of mild gastritis, early gastroenteritis and constipation.

6. Case report
• The patient returned to the ED the following day due to persistently high
fever, continued abdominal pain and decreased appetite. He was febrile and
tachycardic, and his examination revealed mild periumbilical pain.
• Laboratory tests revealed mild thrombocytopenia and elevated CRP. The
patient was then transferred to the paediatric emergency department (PED)
for further evaluation with a working diagnosis of appendicitis.
• He tested negative for COVID-19 by nasopharyngeal swab PCR,
ordered per hospital policy. A repeat abdominal ultrasound remained
inconclusive for appendicitis.

7. Case report
Investigations:
Urinalysis revealed pyuria and
hematuria, other findings are shown
in the table.

8. Case report
• The patient continued to spike high-grade
fevers with persistent tachycardia.
• Abdominal MRI showed diffuse bowel wall
thickening.
• A 12-lead ECG demonstrated sinus
tachycardia, and repeated inflammatory,
coagulation and cardiac markers from that
morning had worsened.
• The RVP, blood culture and urine culture were
negative. Serologies for SARS-CoV-2 were
sent given the maternal exposure. An
echocardiogram showed significant ectasia of
the left anterior descending (LAD) coronary
artery.

9. Case report
• DDx: At 18 hours after admission, our differential diagnoses included
atypical KD (mucocutaneous signs were absent), viral myocarditis, and
COVID-19-related Kawasaki-like inflammatory syndrome that was later
known as MIS-C.
• He was started on high-dose aspirin and IVIG for the treatment of presumed
atypical KD based on echocardiogram findings.
• 24 hours after admission, the patient developed hypotension, cool extremities
with diminished pulses and tachypnea.
• Post-transfer, viral antibodies for SARS-CoV-2 returned positive for mixed
IgM and IgG, and he was formally diagnosed with post-viral MIS-C.

10. https://www.cdc.gov/mis-c/hcp/index.html

11. Children 2020, 7, 69; doi:10.3390/children7070069

12. Case report
• He was started on low molecular weight heparin, received a second dose
of IVIG, and continued on aspirin.
• In the PICU, he developed cardiogenic shock (ejection fraction 30%).
He was intubated and started on inotropic support.
• He was started on methylprednisolone as the clinical protocol for
moderately severe MIS-C.
• A repeat nasal swab for SARS-CoV-2 PCR was ordered per protocol and
subsequently resulted as positive.

13. Case report
• There was suspicion for cytokine storming with declining cardiac function,
anakinra was initiated.
• Remdesivir was also started given the positive SARS-CoV-2 PCR finding.
• A repeat echocardiogram performed approximately 20 hours after
administration of anakinra and remdesivir showed improvement in the
patient’s ejection fraction from 30% to 60% and improvement in
myocardial strain.
• A repeat echocardiogram performed approximately 20 hours after
administration of anakinra and remdesivir showed improvement in the
patient’s ejection fraction from 30% to 60% and improvement in
myocardial strain.

14. Conclusion: medications used as part of the
management
Medications given during
admission
Indication
High-dose aspirin Treatment of presumed atypical
Kawasaki disease
Intravenous immunoglobulins
(IVIG)
Methylprednisolone Treatment of moderately severe
MIS-C
Low molecular weight heparin
(LMWH)
Anticoagulation
Anakinra Suspicion for cytokine storm
Remdesivir Positive SARS-CoV-2 PCR
finding
Discharge medications
Aspirin
Famotidine
Enalapril
Enoxaparin
Prednisolone

15. Research no. 3
BMJ Case Rep: first published as 10.1136/bcr-2020-239910 on 6 January 2021.

16. Case report
• A 4-year-old boy presented with
a 1-day history of rash in his
lower limbs. He had an acute
onset of pruritic, non-
blanching, maculopapular
rash of varying sizes distributed
all over his lower limbs
bilaterally, extending from the
soles up to the knees. The rash
was also present in minimal
amounts in his buttocks.

17. Ann Rheum Dis: first published as 10.1136/ard.2009.116657 on 22 April 2010

18. Case report
• Associated with mild edema in the ankles
• The father reported that the child was not complaining of fever,
abdominal pain, diarrhea or hematuria and that this was the first
occurrence of such episode.
• Investigations (including CRP, ESR, autoimmune antibodies and
ASO titers) were normal.
• Treated with PRN paracetamol only.
• Outcome: At 1-week follow-up in the clinic, the rash was still
present bilaterally. His urine dipstick revealed trace blood, but
urinalysis was unremarkable.

19. Research no. 4
Pediatrics February 2021, 147 (2) e2020016774; DOI: https://doi.org/10.1542/peds.2020-016774

20. Case report
• A case of a 16-month-old boy with a history of:
1. Prematurity
2. Intrauterine growth restriction (IUGR)
3. Severe failure to thrive
4. Microcephaly
5. Pachygyria
6. Agenesis of the corpus callosum
7. Postnatal embolic stroke

21. Case report
• He was in his usual state of health until a day before
presentation, when he developed fever, emesis, and respiratory
distress.
• On presentation he was toxic, appearing with fever, tachycardia,
and tachypnea.
• Investigations revealed low pH, AG of 40, high glucose, high
HbA1c and elevated ketone bodies (Dx: DKA)
Tested positive for glutamic acid decarboxylase, zinc transporter
8, and islet antigen-2 antibodies.

22. Case report
• He developed progressive thrombocytopenia and anemia on days 4 to 5
of admission.
• Workup revealed reticulocytosis (13%), undetectable haptoglobin,
elevated LDH and hyperbilirubinemia. Peripheral blood smear revealed
abundant schistocytes.
• Additional abnormalities included elevated fibrinogen and ferritin, and
rising BUN and creatinine (peak at 39 and 0.39 mg/ dL, respectively, up
from baseline of 5 and 0.1 mg/dL). C3 and C4 were normal (142 and 19
mg/dL, respectively).
Treated with insulin for his T1D and with eculizumab for HUS