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Frontiers of Medicine

ISSN 2095-0217

ISSN 2095-0225(Online)

CN 11-5983/R

Postal Subscription Code 80-967

2018 Impact Factor: 1.847

Front. Med.    2019, Vol. 13 Issue (1) : 126-130
Middle East respiratory syndrome coronavirus in pediatrics: a report of seven cases from Saudi Arabia
Sarah H. Alfaraj1,2, Jaffar A. Al-Tawfiq3,4, Talal A. Altuwaijri5, Ziad A. Memish6,7,8()
1. University of British Columbia, Vancouver, V6T 1Z4, Canada
2. Corona Center, Infectious Diseases Division, Department of Pediatric, Prince Mohamed Bin Abdulaziz Hospital, Ministry of Health, Riyadh 11676, Saudi Arabia
3. Indiana University School of Medicine, Indianapolis, IN 46202, USA
4. Johns Hopkins Aramco Healthcare, Dhahran 31311, Saudi Arabia
5. Department of Surgery, King Saud University, Riyadh 11692, Saudi Arabia
6. College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
7. Infectious Diseases Division, Department of Medicine, Prince Mohamed Bin Abdulaziz Hospital, Ministry of Health, Riyadh 11676, Saudi Arabia
8. Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA
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Infection with Middle East respiratory syndrome coronavirus (MERS-CoV) emerged in 2012 as an important respiratory disease with high fatality rates of 40%–60%. Despite the increased number of cases over subsequent years, the number of pediatric cases remained low. A review of studies conducted from June 2012 to April 19, 2016 reported 31 pediatric MERS-CoV cases. In this paper, we present the clinical and laboratory features of seven patients with pediatric MERS. Five patients had no underlying medical illnesses, and three patients were asymptomatic. Of the seven cases, four (57%) patients sought medical advice within 1–7 days from the onset of symptoms. The three other patients (43%) were asymptomatic and were in contact with patients with confirmed diagnosis of MERS-CoV. The most common presenting symptoms were fever (57%), cough (14%), shortness of breath (14%), vomiting (28%), and diarrhea (28%). Two (28.6%) patients had platelet counts of<150 × 109/L, and one patient had an underlying end-stage renal disease. The remaining patients presented with normal blood count, liver function, and urea and creatinine levels. The documented MERS-CoV Ct values were 32–38 for four of the seven cases. Two patients (28.6%) had abnormal chest radiographic findings of bilateral infiltration. One patient (14.3%) required ventilator support, and two patients (28.6%) required oxygen supplementation. All the seven patients were discharged without complications.

Keywords Middle East respiratory syndrome coronavirus      MERS-CoV      pregnancy      pediatrics     
Corresponding Authors: Ziad A. Memish   
Just Accepted Date: 12 February 2018   Online First Date: 09 April 2018    Issue Date: 12 March 2019
 Cite this article:   
Sarah H. Alfaraj,Jaffar A. Al-Tawfiq,Talal A. Altuwaijri, et al. Middle East respiratory syndrome coronavirus in pediatrics: a report of seven cases from Saudi Arabia[J]. Front. Med., 2019, 13(1): 126-130.
Number Age Gender Symptom Comorbidity CXR finding Intensive care unit Day of illness before hospitalization Linked to O2 requirement
1 16 Male Fever, SOB, diarrhea, vomiting ESRD, asthma Pneumonic infiltration YES 2 Contact with confirmed case 6 days
2 10 Female Fever, cough, vomiting, diarrhea NO Normal NO 7 NA Nil
3 13 Female Fever Miliary TB Bilateral diffuse NO 2 NA 12 days
4 6 Female Fever NO Normal NO 1 No Nil
5 0.75 Male Asymptomatic NO Normal NO Asymptomatic Mother and grandmother confirmed cases Nil
6 9 Female Asymptomatic Sickle cell anemia Normal NO Asymptomatic NA Nil
7 1.5 Male Asymptomatic NO Normal NO Asymptomatic Mother confirmed case Nil
Tab.1  Summary of clinical presentation and outcome of pediatric MERS-CoV cases
Fig.1  Graph showing the most common clinical findings (percentage) among the presented pediatric MERS-CoV cases.
Number Viral Ct value WBC Hgb Plat Neut count Neut % CK ALT AST Creat Albumin
1 NA 6.1 91 58 4.95 81.0 169 37 91 1256.1 NA
2 37 3.8 149 145 0.18 4.6 NA NA NA NA 34
3 32 3 90 467 2.25 70.6 NA 6 71 44 26
4 36 8.6 138 500 5.14 60.0 NA NA NA NA 41
5 NA 17.9 105 406 1.93 10.8 62 NA NA 36.3 NA
6 38 13.3 77 352 9.19 69.2 NA NA NA NA 44
7 NA 11 113 383 2.16 19.6 NA 23 42 NA 45
Tab.2  Laboratory data on presentation of pediatric MERS-CoV cases
Fig.2  Portable chest X-ray showing bilateral mid and lower zone patchy air space consolidation with mild right-sided pleural effusion.
1 AMZaki, S van Boheemen, TMBestebroer, ADMEOsterhaus, RAMFouchier. Isolation of a novel coronavirus from a man with pneumonia in Saudi Arabia. N Engl J Med 2012; 367(19): 1814–1820 pmid: 23075143
2 JAAl-Tawfiq, ZA Memish. Middle East respiratory syndrome coronavirus: epidemiology and disease control measures. Infect Drug Resist 2014; 7: 281–287 pmid: 25395865
3 AAssiri, A McGeer, TMPerl, CSPrice, AAAl Rabeeah, DATCummings, ZNAlabdullatif, MAssad, AAlmulhim, HMakhdoom, HMadani, RAlhakeem, JAAl-Tawfiq, MCotten, SJWatson, PKellam, AIZumla, ZA; KSA MERS-CoV Investigation Team.Memish Hospital outbreak of Middle East respiratory syndrome coronavirus. N Engl J Med 2013; 369(5): 407–416 pmid: 23782161
4 AAssiri, JA Al-Tawfiq, AAAl-Rabeeah, FAAl-Rabiah, SAl-Hajjar, AAl-Barrak, HFlemban, WNAl-Nassir, HHBalkhy, RFAl-Hakeem, HQMakhdoom, AIZumla, ZAMemish. Epidemiological, demographic, and clinical characteristics of 47 cases of Middle East respiratory syndrome coronavirus disease from Saudi Arabia: a descriptive study. Lancet Infect Dis 2013; 13(9): 752–761 pmid: 23891402
5 PMPenttinen, K Kaasik-Aaslav, AFriaux, ADonachie, BSudre, AJAmato-Gauci, ZAMemish, DCoulombier. Taking stock of the first 133 MERS coronavirus cases globally€—€is the epidemic changing? Euro Surveill 2013; 18(39): 20596 pmid: 24094061
6 World Health Organization (WHO). Middle East respiratory syndrome coronavirus (MERS-CoV). WHO, 2017
7 IKOboho, SM Tomczyk, AMAl-Asmari, AABanjar, HAl-Mugti, MSAloraini, KZAlkhaldi, ELAlmohammadi, BMAlraddadi, SIGerber, DLSwerdlow, JTWatson, TAMadani. 2014 MERS-CoV outbreak in Jeddah€—€a link to health care facilities. N Engl J Med 2015; 372(9): 846–854 pmid: 25714162
8 CDrosten, D Muth, VMCorman, RHussain, MAl Masri, WHajOmar, OLandt, AAssiri, IEckerle, AAl Shangiti, JAAl-Tawfiq, AAlbarrak, AZumla, ARambaut, ZAMemish. An observational, laboratory-based study of outbreaks of Middle East respiratory syndrome coronavirus in Jeddah and Riyadh, kingdom of Saudi Arabia, 2014. Clin Infect Dis 2015; 60(3): 369–377 pmid: 25323704
9 JAAl-Tawfiq, ZA Memish. An update on Middle East respiratory syndrome: 2 years later. Expert Rev Respir Med 2015; 9(3): 327–335 pmid: 25790840
10 JAAl-Tawfiq, ZA Memish. Middle East respiratory syndrome coronavirus: transmission and phylogenetic evolution. Trends Microbiol 2014; 22(10): 573–579 pmid: 25178651
11 BHijawi, M Abdallat, ASayaydeh, SAlqasrawi, AHaddadin, NJaarour, SAlsheikh, TAlsanouri. Novel coronavirus infections in Jordan, April 2012: epidemiological findings from a retrospective investigation. East Mediterr Health J 2013; 19(Suppl 1): S12–S18
pmid: 23888790
12 YKim, S Lee, CChu, SChoe, S Hong, YShin. The characteristics of Middle Eastern respiratory syndrome coronavirus transmission dynamics in South Korea. Osong Public Health Res Perspect 2016; 7(1): 49–55 pmid: 26981343
13 MWSeong, SY Kim, VMCorman, TSKim, SI Cho, MJKim, SJLee, JS Lee, SHSeo, JSAhn, BS Yu, NPark, MDOh, WB Park, JYLee, GKim, JS Joh, IJeong, ECKim, C Drosten, SSPark. Microevolution of outbreak-associated Middle East respiratory syndrome coronavirus, South Korea, 2015. Emerg Infect Dis 2016; 22(2): 327–330 pmid: 26814649
14 ZAMemish, M Cotten, SJWatson, PKellam, AZumla, RFAlhakeem, AAssiri, AARabeeah, JAAl-Tawfiq. Community case clusters of Middle East respiratory syndrome coronavirus in Hafr Al-Batin, Kingdom of Saudi Arabia: a descriptive genomic study. Int J Infect Dis 2014; 23: 63–68 pmid: 24699184
15 ZAMemish, JA Al-Tawfiq, AAssiri, FAAlRabiah, SAl Hajjar, AAlbarrak, HFlemban, RFAlhakeem, HQMakhdoom, SAlsubaie, AAAl-Rabeeah. Middle East respiratory syndrome coronavirus disease in children. Pediatr Infect Dis J 2014; 33(9): 904–906 pmid: 24763193
16 WHO. MERS-CoV summary and literature update€—€as of 20 June 2013. 2013.
17 JAAl-Tawfiq, RF Kattan, ZAMemish. Middle East respiratory syndrome coronavirus disease is rare in children: an update from Saudi Arabia. World J Clin Pediatr 2016; 5(4): 391–396 pmid: 27872828
18 SFFagbo, MA Garbati, RHasan, DAlShahrani, MAl-Shehri, TAlFawaz, AHakawi, TAWani, LSkakni. Acute viral respiratory infections among children in MERS-endemic Riyadh, Saudi Arabia, 2012−2013. J Med Virol 2017; 89(2): 195–201 pmid: 27430485
19 FSAlhamlan, MS Majumder, JSBrownstein, JHawkins, HMAl-Abdely, AAlzahrani, DAObaid, MNAl-Ahdal, ABinSaeed. Case characteristics among Middle East respiratory syndrome coronavirus outbreak and non-outbreak cases in Saudi Arabia from 2012 to 2015. BMJ Open 2017; 7(1): e011865 pmid: 28082362
20 FSAleanizy, N Mohmed, FYAlqahtani, RAEl Hadi Mohamed. Outbreak of Middle East respiratory syndrome coronavirus in Saudi Arabia: a retrospective study. BMC Infect Dis 2017; 17(1): 23 pmid: 28056850
21 AASaeed, GR Abedi, AGAlzahrani, ISalameh, FAbdirizak, RAlhakeem, HAlgarni, OAEl Nil, MMohammed, AMAssiri, HMAlabdely, JTWatson, SIGerber. Surveillance and testing for Middle East respiratory syndrome coronavirus, Saudi Arabia, April 2015–February 2016. Emerg Infect Dis 2017; 23(4): 682–685 pmid: 28322710
22 Command and Control Center Ministry of Health Kingdom of Saudi Arabia Scientific Advisory Board. Infection Prevention and Control Guidelines for Middle East Respiratory Syndrome Coronavirus (MERS-CoV) Infection 2015. (accessed March 9, 2017)
23 JAAl-Tawfiq, K Hinedi, JGhandour, HKhairalla, SMusleh, AUjayli, ZAMemish. Middle East respiratory syndrome coronavirus: a case-control study of hospitalized patients. Clin Infect Dis 2014; 59(2): 160–165 pmid: 24723278
24 VMCorman, MA Müller, UCostabel, JTimm, T Binger, BMeyer, PKreher, ELattwein, MEschbach-Bludau, ANitsche, TBleicker, OLandt, BSchweiger, JFDrexler, ADOsterhaus, BLHaagmans, UDittmer, FBonin, TWolff, CDrosten. Assays for laboratory confirmation of novel human coronavirus (hCoV-EMC) infections. Euro Surveill 2012; 17(49): 49 pmid: 23231891
25 ZAMemish, JA Al-Tawfiq, HQMakhdoom, AAAl-Rabeeah, AAssiri, RFAlhakeem, FAAlRabiah, SAl Hajjar, AAlbarrak, HFlemban, HBalkhy, MBarry, SAlhassan, SAlsubaie, AZumla. Screening for Middle East respiratory syndrome coronavirus infection in hospital patients and their healthcare worker and family contacts: a prospective descriptive study. Clin Microbiol Infect 2014; 20(5): 469–474 pmid: 24460984
26 JAAl-Tawfiq, ZA Memish. Managing MERS-CoV in the healthcare setting. Hosp Pract (1995) 2015; 43(3): 158–163 pmid: 26224424
27 JAAl-Tawfiq, ZA Memish. Update on therapeutic options for Middle East respiratory syndrome coronavirus (MERS-CoV). Expert Rev Anti Infect Ther 2017; 15(3):269–275 pmid: 27937060
28 JAAl-Tawfiq, AS Omrani, ZAMemish. Middle East respiratory syndrome coronavirus: current situation and travel-associated concerns. Front Med 2016; 10(2): 111–119 pmid: 27146399
29 HAMohd, ZA Memish, SHAlfaraj, DMcClish, TAltuwaijri, MSAlanazi, SAAloqiel, AMAlenzi, FBafaqeeh, AMMohamed, KAldosari, SGhazal. Predictors of MERS-CoV infection: a large case control study of patients presenting with ILI at a MERS-CoV referral hospital in Saudi Arabia. Travel Med Infect Dis 2016; 14(5): 464–470 pmid: 27671972
30 JAAl-Tawfiq, K Hinedi, SAbbasi, MBabiker, ASunji, MEltigani. Hematologic, hepatic, and renal function changes in hospitalized patients with Middle East respiratory syndrome coronavirus. Int J Lab Hematol 2017; 39(3): 272–278 pmid: 28444873
31 JHKo, MA Müller, HSeok, GEPark, JYLee, SY Cho, YEHa, JYBaek, SHKim, JM Kang, YJKim, IJJo, CR Chung, MJHahn, CDrosten, CIKang, DRChung, JHSong, ESKang, KRPeck. Serologic responses of 42 MERS-coronavirus-infected patients according to the disease severity. Diagn Microbiol Infect Dis 2017; 89(2): 106–111 pmid: 28821364
32 JZhao, AN Alshukairi, SABaharoon, WAAhmed, AABokhari, AMNehdi, LALayqah, MGAlghamdi, MMAl Gethamy, AMDada, IKhalid, MBoujelal, SMAl Johani, LVogel, KSubbarao, AMangalam, CWu, P Ten Eyck, SPerlman, JZhao. Recovery from the Middle East respiratory syndrome is associated with antibody and T-cell responses. Sci Immunol 2017; 2(14): eaan5393 pmid: 28778905
33 AVolz, A Kupke, FSong, SJany, R Fux, HShams-Eldin, JSchmidt, CBecker, MEickmann, SBecker, GSutter. Protective efficacy of recombinant modified vaccinia virus Ankara delivering Middle East respiratory syndrome coronavirus spike glycoprotein. J Virol 2015; 89(16): 8651–8656 pmid: 26018172
34 JLan, Y Deng, HChen, GLu, W Wang, XGuo, ZLu, GF Gao, WTan. Tailoring subunit vaccine immunity with adjuvant combinations and delivery routes using the Middle East respiratory coronavirus (MERS-CoV) receptor-binding domain as an antigen. PLoS One 2014; 9(11): e112602 pmid: 25405618
35 WJLiu, M Zhao, KLiu, KXu, G Wong, WTan, GFGao. T-cell immunity of SARS-CoV: implications for vaccine development against MERS-CoV. Antiviral Res 2017; 137: 82–92 pmid: 27840203
36 WJLiu, J Lan, KLiu, YDeng, Y Yao, SWu, HChen, L Bao, HZhang, MZhao, Q Wang, LHan, YChai, J Qi, JZhao, SMeng, C Qin, GFGao, WTan. Protective T cell responses featured by concordant recognition of Middle East respiratory syndrome coronavirus-derived CD8+ T cell epitopes and host MHC. J Immunol 2017; 198(2): 873–882 pmid: 27903740
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