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COVID-19 Pediatric Multisystem Inflammatory Syndrome

Written by: Dr Raghavendra Bhat MD FRCP(Glasg),Professor Internal Medicine RAKCOMS RAKMHSU

COVID-19 is an interesting illness. It has important effects on the immune system. It is best known for its effects on the respiratory system. It also known to affect gastrointestinal system, skin, cardiovascular system and the central nervous system. Recently, an interesting syndrome involving children was observed and reported in New York – which they called “Pediatric multisystem inflammatory syndrome” (1).

“Pediatric multisystem inflammatory syndrome” is a rare syndrome linked to the coronavirus that causes life-threatening inflammation in critical organs and blood vessels of children reported from The Mount Sinai Kravis Children’s Hospital, reported in the New York Times. Seventy threereported cases of children in New York area who had been afflicted with the illness. Most of the children had also tested positive for the coronavirus or for antibodies to it.

The syndrome appears to target the heart and coronary arteries of children infected with Covid-19, the disease caused by the coronavirus, SARS-CoV-2. This illness can send children into a kind of toxic shock, as blood pressure plummets and the heart fails to send enough blood to vital organs.

According to Lancet online on 6 May South Thames Retrieval Service in London, UK, during a period of 10 days in mid-April, 2020, reported an unprecedented cluster of eight children with hyper inflammatory shock, showing features similar to atypical Kawasaki disease, Kawasaki disease shock syndrome, or toxic shock syndrome (2). Most children were critically unwell, with laboratory evidence of infection or inflammation including elevated concentrations of C-reactive protein, procalcitonin, ferritin, triglycerides, and D-dimers, no pathological organism was identified in seven of the children. Adenovirus and enterovirus were isolated in one child.

Baseline electrocardiograms were non-specific; however, a common echocardiographic finding was echo-bright coronary vessels (appendix), which progressed to giant coronary aneurysm in one patient within a week of discharge from paediatric intensive care (appendix). One child developed arrhythmia with refractory shock, requiring extracorporeal life support, and died from a large cerebrovascular infarct.The myocardial involvement in this syndrome is evidenced by very elevated cardiac enzymes during the course of illness.

All children were given intravenous immunoglobulin (2 g/kg) in the first 24 h, and antibiotic cover including ceftriaxone and clindamycin. Subsequently, six children have been given 50 mg/kg aspirin. All of the children were discharged from PICU after 4–6 days. Since discharge, two of the children have tested positive for SARS-CoV-2 (including the child who died, in whom SARS-CoV-2 was detected post mortem). All children are receiving ongoing surveillance for coronary abnormalities.

This clinical picture represents a new phenomenon affecting previously asymptomatic children with SARS-CoV-2 infection manifesting as a hyperinflammatory syndrome with multiorgan involvement similar to Kawasaki disease shock syndrome

MEDPAGE TODAY (3) reported the differences between “Pediatric Multisystem Inflammatory Syndrome “and Kawasaki disease. Kawasaki disease typically affects children age 5 years and younger, but many of these cases reported have been in teens. Other atypical features are the high prevalence of abdominal and GI symptoms.

In the NYC health department report, the 15 cases in children ages 2 to 15 years were hospitalized with typical or incomplete Kawasaki disease, some with shock. All had fever and more than half had rash, abdominal pain, vomiting, or diarrhea (4). However, less than half have had respiratory symptoms.

Some clinical symptoms of both these disorders -- Kawasaki disease and COVID-19 -- such as fever, rash and eye redness (conjunctival injection) are present in many childhood illnesses. However, the laboratory testing of these two groups of children seems quite different, and in particular, the children with COVID-19 infection have inflammation of the heart muscle rather than the characteristic swelling of the coronary arteries that is observed with Kawasaki disease."

The last word about this rare syndrome remains to be said!

References

1. NYT
https://www.nytimes.com/2020/05/08/nyregion/child-dead-new-virus-kawasaki.html

2. Lancet
https://www.thelancet.com/lancet/article/s0140-6736(20)31094-1

3. Medpage today
https://www.medpagetoday.com/infectiousdisease/covid19/86393

4. Hospital pediatrics (American Academy of Pediatrics)
https://hosppeds.aappublications.org/content/hosppeds/early/2020/04/06/hpeds.2020-0123.full.pdf