To the Editor,
Severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) has been
spreading worldwide.1-4 Since sustained and timely courses of
chemotherapy are exceedingly critical for children with leukemia, any
interruption may lead to an unfavorable prognosis.5 It is an urgent
demand to establish a strategy of the coronavirus disease 2019
(COVID-19) detection in children with leukemia.6,7 Based on the
experience, we have developed a flowchart involving an innovative
scoring system to help pediatric hematologists to evaluate each
outpatient before admission for the further chemotherapy (Figure 1).
All patients should be surveyed for epidemiological history at first.
Patients without symptoms such as cough, fever, shortness of breath or
other concerning symptoms, or without exposure to COVID-19 could receive
planned chemotherapy.8,9 Otherwise further tests should be carried out
before any chemotherapy. These include complete blood counts, C-reactive
protein, chest CT scans and tests for common respiratory pathogens,
including influenza virus, respiratory syncytial virus, adenovirus,
parainfluenza virus, mycoplasma pneumoniae , and chlamydia
pneumoniae . As the weight of each test differs, an innovative scoring
system is applied to help doctors to identify the suspected COVID-19
cases. The complete blood count is not included in this scoring system
as it is not applicable for differentiating diagnosis of COVID-19 in
leukemia patients.
Patients scoring less than 5 are at low risk for COVID-19 and should
receive chemotherapy on schedule. Patients scoring equal to or larger
than 5 are considered as suspected cases and at high risk for COVID-19.
For these patients, chemotherapy should be postponed and nuclear acid
tests for SARS-CoV-2 be ordered. Confirmed COVID-19 cases would be
transferred to a designated hospital for further treatment under the
cooperation of pediatric hematologist, infectious disease specialist and
intensive care specialist. Consecutive negative results (at least twice)
of SARS-CoV-2 without viral pneumonia could be excluded from COVID-19
and should receive timely chemotherapy, while a finding of viral
pneumonia deserves relevant treatment and continuous monitoring until
excluding or confirming COVID-19 eventually.
During the early phase of COVID-19 pandemic in Wuhan, we had 88 patients
throughout this flowchart. All the patients had epidemiological history
as they were all from Wuhan. And they were evaluated by the scoring
system. 68 patients had a score less than 5 and underwent timely
chemotherapy or anti- infection therapy if present. The other 20
patients scoring not less than 5 were considered suspected cases.
Chemotherapy were postponed and they got SARS-CoV-2 tests. Two patients
were tested positive and transferred to the designated hospital for
further treatment of COVID-19. The other 18 ones were tested negative
twice and continued the chemotherapy, or were treated for present
infections.
This flowchart strategy successfully screened out two cases of COVID-19
for us in pediatric leukemia patients without any missed diagnosis or
nosocomial infections. Our strategy is especially useful for
non-designated hospitals for COVID-19 in areas who are in shortage of
personal protective materials and SARS-CoV-2 test reagents. 10
Author’s contributions: Hongbo Chen, Hui Li and Yining Qiu wrote the
manuscript. They contributed equally as the co-first authors. Zhujun
Wang, Hui Yu, Jiawei Xu, Yun Peng, Xia Wan, Bingyu Zhang, Tiantian Song
and Fen Zhou collected the data. Runming Jin and Xiaoyan Wu designed the
study and finalized the manuscript.
Conflict of interests: All authors declared no competing interests.
Funding: None.
This work was approved by the ethics committee of Union Hospital, Tongji
Medical College, Huazhong University of Science and Technology.
References
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Figure 1. The flowchart for the management of pediatric outpatients with
leukemia