Evolving Epidemiology of Pediatric Respiratory Syncytial Virus (RSV) Cases Around COVID-19 Pandemic: Impact and Clinical Insights, Retrospective Cohort Study.

BACKGROUND: The burden of respiratory syncytial virus (RSV) in high-risk pediatric patients remains unclear. Therefore, this study aims to characterize pediatric RSV cases from January 2019 to December 2022 and assess the impact of the COVID-19 pandemic on RSV burden and RSV-related outcomes. In addition, examining factors influencing RSV-related hospitalization. METHODS: This is a retrospective study that included pediatric patients (aged 14 and below) who presented at King Faisal Specialist Hospital and Research Centre (KFSHRC) in Riyadh, Saudi Arabia with RSV infection identified using real-time reverse-transcriptase polymerase chain reaction assays. Statistical analyses were performed using STATA. RESULTS: A total of 885 RSV cases were reported; (56.05%) were males and (43.95%) were females with a median age of 24 months [interquartile range (IQR): 11-60]. 534 (60.34%) required hospitalization. As for RSV seasonality, there was a significant increase in RSV prevalence following the COVID-19 pandemic, escalating from 205 cases in 2019 to 425 cases in 2022. The increase in 2022 was evident in January and persisted from September to December, reaching its peak during the months of October (20.70% - 88 cases) and November (32.00% - 136 cases). About (27.12%) of RSV infected children were medically free patients. Symptomatic patients exhibited various clinical manifestations, with ventilation necessary in (13.11%) of cases. Further analysis revealed significant changes in RSV-related outcomes post-COVID-19, including a decrease in hospitalization rates, an increase in medically free patients, and a lower need for ventilation (p < 0.05). Notably, a significant proportion of RSV admissions occurred within the first 6 months of life, with (77.69%) in the age group of 0 to 5 months. In addition, previous RSV infection, prematurity, low birth weight, renal disease, congenital heart disease, endocrine/metabolic disease, neuro/neuromuscular diseases, and genetic disorders were positively associated with hospitalization (P < 0.05). Interestingly, asthma and bone marrow transplantation were negatively associated with hospitalization (P < 0.05). The mortality rate in this study is (2.37%) (21/885). CONCLUSION: This study provides a comprehensive understanding of the demographic and clinical factors influencing RSV outcomes, highlighting the impact of the COVID-19 pandemic and shedding light on potential risk factors for RSV-related hospitalization. The highest prevalence of RSV during (September to January), aligning with global patterns and emphasizing the importance of timing in preventive strategies.

Omicron variants of SARS-CoV-2: Epidemiological and clinical insights from a tertiary care center in Saudi Arabia.

BACKGROUND: The actual burden of the Omicron variants remains unclear. Therefore, this study aims to analyze the epidemiological and clinical features of Omicron-infected patients and investigate factors influencing hospital admission. METHODS: This retrospective single-center study included individuals with positive SARS-CoV-2 infection, specifically the Omicron variants (XBB, EG or JN), identified through real-time reverse-transcriptase polymerase chain reaction assays from January 2022 to December 2023. RESULTS: A total of 305 Omicron-infected patients were included; (53.11 %) were females and (46.89 %) were males, with a median age of 39 years [interquartile range (IQR): 30, 53]. Underlying diseases, including endocrine/metabolic disorders (22.30 %), hypertension (12.79 %), chronic respiratory disease (10.49 %), and malignancy (9.18 %) were prevalent, while (40.98 %) were medically free. The XBB variant was predominant (73.11 %), followed by JN (20.33 %), and EG variant (6.56 %). The seasonality analysis demonstrates XBB variants' domination in 2022, with a surge to 40 cases in December. The trend continued in 2023, peaking at 76 XBB cases in March. May 2023 reported 38 XBB cases and the emergence of 17 EG instances. Notably, in December, only one XBB case was reported, and 62 instances emerged with the JN variant. Overall, 233 out of 305 cases were reported during flu season (September to March) (76.39 %). Moreover, hospitalization occurred in (16.39 %), with a (1.31 %) mortality rate (all deaths in the JN variant). Multivariable analysis confirmed renal disease, chronic respiratory disease, endocrine/metabolism issues, and polymicrobial infection as positive predictors of hospitalization (p < 0.05). While COVID-19 vaccination significantly reduced hospitalization odds (Odds Ratio: 0.20, p = 0.001). CONCLUSIONS: These findings contribute valuable insights into Omicron epidemiology and factors influencing hospitalization. The dynamic fluctuations in Omicron variants, particularly XBB, EG, and JN, over 2022 and 2023, with JN emerging as the dominant circulating variant globally, underscore the need for continuous vigilance and urgency for updated vaccine formulations.

Graves' disease thyroid dermopathy: a case report.

BACKGROUND: Graves' disease is the autoimmune activation of the thyroid gland causing diffuse enlargement and hyperfunction of the gland. Manifestations of Graves' disease are multisystemic and include thyroid orbitopathy; pretibial myxedema, also referred to as thyroid dermopathy; and thyroid acropachy, described as a severe form of thyroid dermopathy. Our paper focuses on an atypical case of thyroid dermopathy. CASE PRESENTATION: An 11-year-old Saudi male presented with a prominent diffuse goiter and exophthalmos. Investigations were consistent with a diagnosis of Graves' disease. The physical exam showed diffuse, non-pitting swelling of the ankle and penis, mimicking a lymphatic malformation. Further, multiple nodules were found on the hands and feet. Treatment of the nodules with cautery resulted in more severe nodules. CONCLUSION: This report describes rare presentations of thyroid dermopathy mimicking lymphatic malformation. The Koebner phenomenon can explain this patient's atypical presentations. Intralesional injections of triamcinolone and total thyroidectomy showed clear improvement.

Coxiella burnetii-Associated Endocarditis in a Saudi Adolescent: A Rare Encounter.

Here, we present the case of a 15-year-old Saudi male with a history of cardiac interventions who initially presented with persistent fever. The patient's complex medical history, including cardiac procedures and recent antibiotic use, added layers to the diagnostic challenge. Despite initial empirical antibiotic therapy, persistent fever prompted further investigations, leading to the identification of vegetation causing right ventricular outflow tract obstruction. Coxiella burnetii serology confirmed Q fever infective endocarditis. Tailored antimicrobial therapy, including doxycycline, ciprofloxacin, and hydroxychloroquine, resulted in clinical improvement. During the last visit, he remained well, with a painless rash resolved. His parents were satisfied with the progress. Ongoing antimicrobial therapy, periodic ophthalmology assessments, and potential surgical interventions were planned.

Munchausen Syndrome by Proxy Presenting as Pharyngeal Dysphagia and Recurrent Mouth Ulcers: A Case Report.

We report a Munchausen syndrome by proxy (MSBP) case, which presented as pharyngeal dysphagia and an acquired tracheoesophageal fistula (TEF). A six-month-old Saudi male presented with fever, persistent oral ulcers, intermittent bleeding from the ulcers, failure to thrive (FTT), poor appetite, and possible genetic disease. He had a history of recurring admissions due to infections, including those affecting the chest, ear, and bowel. Additionally, he tested positive for vancomycin-resistant enterococcus. There was no history of surgical procedures or blood transfusions. Due to the patient's nutritional status, a gastrostomy tube was inserted. The patient had recurrent bleeding from the tracheostomy tube during the hospital stay despite normal coagulation and platelet profile. Consequently, after diagnostic laryngoscopy, the otolaryngologist specialist pointed out that such retropharyngeal injuries are seen in patients with inflicted injuries, which is, in this case, caused by the mother, as she was the only one with the child during the recurrent bleeding episodes. Thus, we describe a clinical instance of MSBP, especially imitating pharyngeal dysphagia, leading to a delayed diagnosis. We advise adding MSBP to the possible diagnoses upon encountering pharyngeal dysphagia and oral ulcers.

The outcome of high-frequency oscillatory ventilation in pediatric patients with acute respiratory distress syndrome in an intensive care unit.

BACKGROUND: In adults with acute respiratory distress syndrome (ARDS), high-frequency oscillatory ventilation (HFOV) has been associated with higher mortality rates. Therefore, its use in children with ARDS is still controversial. OBJECTIVES: Evaluate the overall mortality of HFOV in children with ARDS and explore mortality-related risk factors; compare the outcome of using HFOV post-endotracheal intubation early (≤24 hours) versus late (≤24 hours). DESIGN: Retrospective (medical record review) SETTING: Pediatric intensive care unit in a tertiary care center in Saudi Arabia. PATIENTS AND METHODS: Data were collected from medical records of all pediatric patients with ARDS aged one week to 14 years, who were admitted to the pediatric intensive care unit (PICU) from January 2016-June 2019 and who required HFOV. MAIN OUTCOME MEASURES: PICU mortality. SAMPLE SIZE AND CHARACTERISTICS: 135 ARDS patients including 74 females (54.8%), and 61 males (45.2%), with a median age (interquar-tile range) of 35 (72) months. RESULTS: The overall mortality rate was 60.0% (81/135), and most died in the first 28 days in the PICU (91.3%, 74/8). Of non-survivors, 75.3% (61/81) were immunocompromised, and 24.7% (20/81) were immuno-competent patients, 52 (64.2%) received inotropic support, 40 (49.4%) had a bone-marrow transplant (BMT) before HFOV initiation. Although the prone position was used in 20.7% (28/135) to improve the survival rate post-HFOV ventilation, only 28.6% (8/28) survived. In addition, altered code status or chemotherapy reported a significant association with mortality (P<.05). Interestingly, early HFOV initiation (≤24 hours) did not seem to have a high impact on survival compared to late initiation (>24 hours); (57.4% vs. 42.6%, P=.721). CONCLUSION: Immunocompromised and oncology patients, including post-BMT, reported poorer outcomes, and neither the prone position nor early use of HFOV improved outcomes. However, it is recommended to replicate the study in a larger cohort to generalize the results. LIMITATIONS: Retrospective single-center study.

Hajdu-Cheney syndrome with a novel variant in NOTCH2 gene: A case report.

Introduction: Hajdu-Cheney syndrome is a rare disorder caused by truncation mutations in exon 34 of the NOTCH2 gene. The main presentation includes acro-osteolysis, osteoporosis, and dysmorphism. This syndrome affects the other body systems as well. Case presentation: We report a case of a 6-year-old female that initially developed polyhydramnios and short upper limbs as a fetus. In addition, the patient had multiple anomalies as a neonate, including dysmorphism, congenital heart disease, hearing loss, recurrent respiratory tract infections, skeletal abnormalities, renal cysts, and hypertension. She continues to receive multidisciplinary care, and the finding of a C.7021C > T: P.Q2341x mutation in exon 34 of the NOTCH2 gene confirms the diagnosis. To our knowledge, this is the first case to report this variant in the literature. Discussion: Because of the rarity of this syndrome and its diverse presentation, a high index of suspicion accompanied by genetic testing is paramount for diagnosing Hajdu-Cheney syndrome. We recommend a multidisciplinary approach for these patients to provide the highest possible quality of care.

Cardiopulmonary outcomes following high flow nasal cannula in pediatric population: A systematic review.

BACKGROUND: The high-flow nasal cannula (HFNC) has received much attention in various clinical settings and has been approved recently for application in pediatric care. OBJECTIVES: To determine whether HFNC use improves cardiopulmonary outcomes in pediatric patients with the cardiac disease more effectively than alternative oxygen therapies. METHODS: Systematic review was performed using PubMed, Scopus, and Web of Science databases. Randomized controlled trials comparing HFNC with alternative oxygen therapies and observational studies that solely reported on the use of HFNC in the pediatric population were included between 2012 and 2022. RESULTS: Nine studies with approximately 656 patients were reported in this review. HFNC significantly increased systemic oxygen saturation across all literature investigating this parameter. Other notable outcomes in HFNC patients included normalizing heart rate, partial blood pressure, and PaO2/FiO2 ratio. However, some studies reported a complication rate concurrent with traditional oxygen therapies, and a suggested HFNC failure rate of 50% was observed. CONCLUSIONS: Compared with traditional oxygen therapies, HFNC can reduce anatomical dead space and normalize systemic oxygen saturation, PaO2/FiO2 ratio, heart rate, and partial blood pressure. We advocate using HFNC therapy in children with cardiac diseases as the currently available evidence supports HFNC use over other oxygenation treatments in the pediatric population.

Munchausen syndrome by proxy: a case report.

BACKGROUND: Inappropriately high levels of insulin secretion can cause the potentially fatal condition of persistent hyperinsulinemic hypoglycemia of infancy. Our paper focuses on another cause of severe hypoglycemia, which can be easily missed. CASE PRESENTATION: An 18-month-old Saudi female was referred to our hospital for further investigation and management of her recurrent hypoglycemic attacks as a case of persistent hyperinsulinemic hypoglycemia of infancy. During admission, we noticed multiple red flags from the history; the mother was insisting on a pancreatectomy, rather than going for a positron emission tomography scan, and most importantly, all hypoglycemic attacks occurred while the mother was around. Consequently, after further investigation, the case was diagnosed as a caregiver-fabricated illness, and the case was referred to the Child Protection Center. CONCLUSIONS: One must have a high index of suspicion to diagnose caregiver-fabricated illness. Physicians should be more attentive to prevent such a disease, which could eventually become lethal if left unnoticed.

CYP3A4 Mutation Causes Vitamin D-Dependent Rickets Type 3: A Case Report in Saudi Arabia.

Rickets is a childhood disorder of vitamin D deficiency that is characterized by growth retardation and impairment in skeletal mineralization. Vitamin D deficiency is usually due to decreased dietary vitamin D intake, decreased sunlight exposure, or genetic defects. A recurrent gain-of-function missense mutation (p.I301T) in the gene encoding CYP3A4 has been identified as a cause of excessive inactivation of vitamin D metabolites that causes vitamin D-dependent rickets type 3 (VDDR3). We hereby report a case of a six-year-old girl with poor growth and bone deformities, such as genu valgum. In addition, the patient has a strong family history of short stature and bone deformities. She continues to receive multidisciplinary care, and the finding of a heterozygous missense variant in CYP3A4: c.902 T > C; p.Ile301Thr in the CYP3A4 gene confirms the diagnosis of VDDR3. To our knowledge, this is the first case to be reported in Saudi Arabia and the fourth case in the literature. Our findings highlight the importance of vitamin D in those with high activity in CYP3A4 to maintain vitamin D hemostasis, and we need to reach optimal doses to help them maintain their biochemical and radiological finding within the normal range.

Understanding the epidemiology and impact of the COVID-19 pandemic on domestic violence and child abuse in Saudi Arabia: A cross-sectional study.

Objectives: The purpose of this paper is to highlight the impact of a pandemic on the lives of vulnerable members of the community who have experienced or are 'at risk' of experiencing intimate family violence and child abuse in Saudi Arabia. By reviewing the experience in Saudi Arabia in the context of the international literature, the study explores similarities and differences in the impact of the pandemic on family violence. Methods: The study investigated the impact of the COVID-19 pandemic on family violence and child abuse in Saudi Arabia by conducting a comparative analysis of the prevalence of cases, types of abuse, and geographical location of those experiencing violence between the years 2019 and 2020. Data were obtained from the Family Violence Reporting Center 1919 in Saudi Arabia. Results: The study found that the risk of family violence and child abuse increased during the COVID-19 pandemic in Saudi Arabia, similar to findings in other countries. Conversely, there was a decrease in the number of reports due to factors associated with COVID-19. Conclusions: The study highlighted the importance of ensuring that existing policies and services are sufficient to ensure the risks arising from the impact of COVID-19 responses and minimize the negative consequences.