Clinical presentation, treatment, and outcomes
In Toddlers and preschoolers, the frequency of peribronchial thickening
and interstitial opacities was higher than in the other age groups.
Regarding to clinical findings, patients that presented with fever for
more than 3 days did not have a predominant radiological pattern. When
comparing the group with SARS-CoV-2 alone to the group with codetection,
there was a significant difference in the frequency of peribronchial
thickening and interstitial opacities (56% versus 79%, respectively p=
0.002). On the other hand, virus-virus isolation showed a higher
frequency of peribronchial thickening and interstitial opacities
compared to virus-bacteria isolation. Furthermore, there was not
difference in consolidation pattern between different isolation groups
(p >0.9). (Table 3)
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When treatment was assessed, it was observed that among the 126 patients
who received antibiotic therapy, only 8.1% exhibited a consolidation
pattern, which was significantly higher than the frequency observed in
the group that did not receive antibiotics (1.9%) (P=0.02). Antibiotic
treatment was given to eleven of the sixteen patients (69%) that had a
consolidation pattern. Conversely, there was no significant difference
in the radiograph findings between patients who received corticosteroids
and those who did not.
Out of 267 patients on oxygen therapy, 25% had normal chest x-rays,
compared to 45% of the 125 patients who did not receive oxygen therapy.
The requirement of oxygen was not associated with a different pattern in
the chest x-ray. However, patients presenting with respiratory failure
had higher (32%) of alveolar opacities in comparison to patients that
did not present respiratory failure.
Location of radiological findings did not have a variation in frequency
among different outcomes assessed. Nevertheless, difusse distribution
had a higher frequency in patients with ventilatory failure (37%).
Patients admitted to PICU had lower percentage of normal radiological
results compared to those in standard care. From the ones that had
abnormal radiological findings, peribronchial thickening was the most
common pattern. There was not a significant difference of radiological
pattern in relation to the duration of stay in the PICU as well as in
standard care.
Mortality was observed in 11 patients, with alveolar opacities being the
most common finding at 45%, followed by peribronchial thickening at
36%. Meanwhile, among the group of patients who survived, predominant
pattern was peribronchial thickening followed by normal pattern was
found in 32%.
DISCUSSIONTo our knowledge, compared to other studies conducted in Colombia
regarding this topic, this study involves a greater number of patients.
Our findings shed light on key aspects related to patient demographics
and clinical features, as well as the interobserver agreement among
radiologists in interpreting the radiographs. In contrast to previous
studies, different populations reported average ages ranging from 5 to 7
years (27)(28). We found that the median age of our patients was 2 years
old. However, our clinical characteristics, including main symptoms,
microorganism codetection, hospitalization days, and admission to
pediatric intensive care units (PICU), were in line with other studies
conducted in Colombia and internationally
Regarding the interobserver agreement, we found a moderate kappa
coefficient for alveolar opacities. Previous studies have indicated that
interobserver variability may be influenced by the level of expertise,
lack of precise definitions for findings other than consolidation, and
occasionally the quality of the image . Interestingly, we observed that
the quality of the image did not significantly impact kappa’s value in
our study, which is an essential consideration for future
interpretations.
Alveolar opacities emerged as the category with the best interobserver
concordance in our study. This finding contrasts with the study
developed by Ugas-Charcape et al., where peribronchial thickening showed
the highest interobserver agreement
In our cohort, we also identified peribronchial thickening as the most
common radiological finding, in line with previous studies .
Interestingly, we did not observe a significant association between
oxygen requirement and specific radiological findings, which contrasts
with the study by Mania et al., where interstitial and/or ground-glass
opacities were more frequent in patients receiving oxygen therapy . This
can be explained by considering that, in the aforementioned study, the
average age is higher than that of this group, this difference in age
could account for the observed radiological findings lacking
specificity. Presumably, older children may exhibit patterns akin to
those established as typical in adults, such as ground glass opacities.
Regarding the location of radiological findings, we did not find
significant variation among assessed outcomes. However, central
distribution was more frequent in patients with ventilatory failure. A
descriptive study by Oterino Serrano et al. in 2020, evaluating chest
tomography and X-ray findings, reported that unfavorable outcomes were
more common with extensive involvement, characterized by peribronchial
thickening, ground-glass opacities, and bilateral or diffuse
consolidation . While our study did not provide a specific definition
for unfavorable outcomes, it is important to consider these radiological
patterns in the context of clinical assessment.
In our cohort, peribronchial thickening was the most common radiological
pattern and was associated with admission to PICU, antibiotic
prescription, isolated viral or bacterial detection, and a fever lasting
more than three days. Although this finding is nonspecific, fever has
consistently been reported as the most frequently observed symptom in
different studies .
A noteworthy finding in our cohort of patients who died was the higher
occurrence of alveolar opacities as the main pattern on their chest
x-rays. While there is limited literature that directly relates these
variables, a retrospective cohort study with 110 patients MIS-C
described diffuse bilateral coalescent opacities observed in three
patients admitted to the intensive care unit with severe respiratory
distress, with one of these patients deteriorating on the fourth day of
admission to the PICU. A similar pattern has been studied in adults,
where it has been associated with mortality.Although the presence of
this pattern does not necessarily imply a different treatment approach
from the clinical indications, it may work as an alert to closely and
strictly monitor the patient.