Multisystem inflammatory syndrome in children during the COVID-19 pandemic in turkey: First report from the eastern mediterranean

Background: The severity of COVID-19 symptoms can range from mild to severe. Severe COVID-19 cases with excessive hyperinflammation have many overlap features with multisystem inflammatory syndrome in children (MIS-C). Objectives: We aimed to describe the typical clinical and laboratory features and treatment of children diagnosed with MIS-C and to understand the differences as compared to severe/critical pediatric cases with COVID-19 in an eastern Mediterranean country. Methods: Children (aged <18 years) who diagnosed with MIS-C and severe/ critical pediatric cases with COVID-19, were admitted to hospital between 26 March and 3 November 2020 were enrolled in the study. Results: A total of 52 patients, 22 patients diagnosed with COVID-19 with severe/critical disease course and 30 patients diagnosed with MIS-C. Although severe COVID-19 cases and cases with MIS-C share many clinical and laboratory features, MIS-C cases had longer fever duration and higher rate of the existence of rash, conjunctival injection, peripheral edema, abdominal pain, altered mental status, and myalgia than in severe cases (p<0.001 for each). Of all, 53.3% of MIS-C cases had the evidence of myocardial involvement as compared to severe cases (27.2%). Additionally, C-reactive protein (CRP) and white blood cell (WBC) are the independent predictors for the diagnosis of MIS-C, particularly in the existence of conjunctival injection and rash. Corticosteroids, intravenous immunoglobulin (IVIG), and biologic immunomodulatory treatments were mainly used in MIS-C cases rather than cases with severe disease course. There were only 3 deaths among 52 patients, one of whom had Burkitt lymphoma and the two cases with severe COVID-19 of late referral. Conclusion: Differences between clinical presentations, acute phase responses, organ involvements, and management strategies indicate that MIS-C might be a distinct immunopathogenic disease as compared to pediatric COVID-19. Conjunctival injection and higher CRP and low WBC count seem good diagnostic parameters for MIS-C cases.

Holding on to life with ECMO in severe multisystem inflammatory syndrome in children (MIS-C)

Objective: MIS-C is a rare hyperinflammatory syndrome requiring intensive care due to severe cardiovascular effects associated with COVID 19. It has been reported that 68% of the patients need intensive care, while about 4% need extracorporeal membrane oxygenation (ECMO). The mortality rate of cases developing ECMO need has been reported as 22.5%. Methods: We reported a patient who developed a need for ECMO with a diagnosis of severe MIS-C and who was successfully weaned from ECMO. Results: Herein we present a 14.5-year-old female patient who was diagnosed with MIS-C because of fever, diarrhea, and COVID 19 antibody positivity. Inotrope treatments were started immediately after the development of fluid-resistant hypotension. Plasma exchange, IVIG, pulse steroid and anakinra treatments for immunomodulation were started. Vasoactive inotrope score of the patients was 42 and ejection fraction was 20% in echocardiography. Despite inotropic support and immunomodulatory treatment hypotension and hyperlactatemia were persisted and patient was put on V-A ECMO on the 3rd day of hospital admission. Second session of plasma exchange was applied to the patient after initiation of ECMO support. Functions of right and left ventricle were improved and inflammatory parameters were decreased under ECMO support. Patient was weaned from ECMO and decannulated on the 6th day of ECMO support. No ECMO complications occurred. Patient was extubated on the 10th day of admission and the patient was supported with noninvasive mechanical ventilation for 3 days. Physiotherapy was initiated because of critical illness myopathy. The patient was discharged with full recovery on the 25th day of hospitalization. Conclusions: ECMO should always be kept in mind as a support method that can bridge recovery in severe MISC patients.

Covid-19 pneumonia in pediatric patients with tracheostomy

AIMS & OBJECTIVES: We will present the management of three patients with tracheostomies with COVID-19 infection. METHODS: We will present the management of three patients with tracheostomies with COVID-19 infection. RESULTS: The first patient, 13 years old girl, had a diagnosis of osteopetrosis and recurrent osteomyelitis, presented with four days of fever. She had in-house contact and computed tomography was consistent with COVID 19 pneumonia, and PCR was positive. Antibiotic treatment, favipravir, hydroxychloroquine and enoxaparin treatments were began. On the 15th day;ventilator support was given her, after radiological progression and clinical worsening. PCRs were negative on day 13 and 17. Patient was discharged with oxygen support on day 24. The second patient;2-years-old with tracheostomy with BPD admitted for a tracheostomy closure plan. Routine COVID PCR test was positive before the procedure. The patient without complaint had sore throat in her parents, but their COVID 19 PCR test was negative. On the 4th day, she was discharged without any problem. On the 12th day, the COVID PCR test was negative. The third patient, with tracheostomy and gastrostomy, who applied with fever and respiratory distress. In addition to wide antibiotic therapy, favipravir and bemiparin treatments were also began. In the follow-up, mechanical ventilation support was provided. COVID PCR positive taken on the 10th day of treatment;resulted negative on day 17. The patient was discharged on the 20th day. CONCLUSIONS: There is no information about covid 19 pneumonia in pediatric patients with tracheostomy. Followup of these patients will provide insight into the follow-up of patients with future tracheostomy.

Covid 19 frenzy masks the true diagnosis

AIMS & OBJECTIVES: Here we reported three pediatric cases that were misdiagnosed as COVID-19 initially and real diagnosis delayed because of COVID-19 focus of physicians. METHODS: The first case was a 16-year-old male admitted to emergency department because of chest pain and fever (38,5 C). Thorax computed tomography (CT) was evaluated as consistent with COVID-19. During follow up;elevated d-dimer and difference in leg diameters was observed. CT angiography revealed pulmonary thromboembolism. The second case was a 15 years old girl with known asthma presented with cough and fever. Thorax CT was evaluated as consistent with COVID-19 and treatment was started. Hypereosinophlia (eosniphil count: 16370/μL) was remarkable in complete blood count and patient had recurrent sinusitis and asthma history. Bone marrow aspiration was consistent with hypereosinophilic syndrome. The third case was a 10-year-old male patient presented with fever, maculopapular rash and redness of the eyes. Patient was diagnosed as COVID-19 related atypical Kawasaki disease. Because of recurrent abdominal pain abdominal CT was performed and showed multiple cysts and one ruptured cyst in the liver that was consistent with cyst hydatic disease. RESULTS: During pandemic thorax CT became a screening tool for COVID-19 infection. It is known that thorax CT findings are sensitive but not specific for COVID-19. When the current three cases reviewed and analyzed, it can be said that detailed history and/or physical examination provide the right diagnosis. CONCLUSIONS: Even if we are in the COVID-19 pandemic period, all patients should be evaluated in accordance with the order of the diagnostic work up chain.

Multisystem inflammatory syndrome in children (mis-c) associated with COVID-19 infection presenting with steven johson syndrome

AIMS & OBJECTIVES: Multisystem inflammatory syndrome in children (MIS-C) is related to the SARS-CoV-2 Steven Johnson Syndrome (SJS) can also cause multisystem involvement as a result of serious inflammatory reaction. We reported two pediatric cases of COVID-19 associated MIS-C syndrome presenting with SJS. METHODS: We reported two pediatric cases of COVID-19 associated MIS-C syndrome presenting with SJS. RESULTS: Both patient presented with fewer, prominent skin and respiratory findings. Skin punch biopsy showed SJS. Triggering infection agents were H. influenza and COVID-19. Laboratory data showed a leukocytopenia with lymphopenia and eleveated acute phase reactants and impaired liver and kidney function. Broad-spectrum antibiotic therapy and variable teratments including immunomodulators, plasma exchange were given. Despite all treatments, severe hypoxia continued, they were put on the veno-venous extracorporeal membrane oxygenation (VV-ECMO). The first patient died surgical cannula complicaiton on the 17thday of VV-ECMO. Despite effective ECMO support tissue hypoxia became prominent and second patient died on the 40rdday. CONCLUSIONS: It is noteworthy that there are similar immunopathological mechanisms between SJS with COVID 19 infection. This is the first cases of SJS associated with COVID-19. While the cytokine storm of the first patient were benign and under control, our second case had severe multiorgan failure and hyperinflammatory status of the patient could not be controlled with intensive immunmodulatory treatments. The most noticeable difference 2 patients was that the first patient received tocilizumab treatment in the early period. This suggests that tocilizumab therapy should be given early in both MIS-C and SJS-related cytokine storm management.

Effect of COVID-19 lockdown on density of trauma patients in tertiary pediatric intensive care unit

AIMS & OBJECTIVES: It was aimed to investigate whether COVID-19 lockdown has an effect on the density of patients treated for trauma in the pediatric intensive care unit (PICU). METHODS: Patients admitted to PICU because of trauma between March-July 2020 and March-July 2019 were included in the study. Two consecutive years were compared in terms of density of trauma patients. RESULTS: In 2019, 318 patients were admitted to PICU and there were19 trauma patients (6%) among them (7 falls from height, 9 traffic accidents, 1 gunshot wound and 2 burn patients). In 2020 during COVID-19 lockdown 205 patients admitted to PICU and 46 (22.4%) of them were trauma patients (23 falls from height, 17 traffic accidents, 2 gunshot wounds, 3 burn patients and 1 dog attack). The difference is statistically significant (χ2(1) = 31.044, p <0.001). Other demographic features were found to be similar between the two groups. It was found that while number of patients admitted to PICU were decreasing during COVID-19 lockdown period, number and density of trauma patients has been increased. After WHO defined COVID-19 as a pandemic;many countries take measures like lockdown to control spread of new cases. After lockdown and interruption of education in schools children have been started to spend time mostly in house. CONCLUSIONS: Although COVID-19 infection mildly affects children and few child mortalities has been reported we noticed and confirmed that number of patients with trauma requiring PICU admission especially as a home accident increased during COVID-19 lockdown.

Fulminant COVID-19 myocarditis in an infant

AIMS & OBJECTIVES: Herein we describe a 2-yearold previously healthy infant with COVID-19 fulminant myocarditis. METHODS: CASE: A two years old, otherwise healthy boy with the history of COVID-19 positive patient contact was hospitalized with nausea, vomiting and poor oral intake. RESULTS: Physical examination was normal. Chest x-ray (CXR) demonstrated bilateral interstitial infiltration. Investigations including acute phase reactants were in normal range. Multiplex PCR for viruses was negative and no bacterial infection was found. Real-time reverse transcription polymerase chain reaction (RT-PCR) revealed negative for SARS-Cov-2. He swiftly developed respiratory distress with filiform pulse, unmeasurable blood pressure, lethargy and hepatomegaly on the second day, transferred to the pediatric intensive care unit, and promptly intubated. Acute phase reactants remained low with a 30 times elevated troponin-T. CXR revealed cardiomegaly and pleural effusion. Echocardiography was compatible with severe cardiac failure. Cardiogenic shock state did not respond to inotropes, necessitating ECMO. During the preparation of ECMO, cardiac arrest developed and E-CPR procedure was applied with veno-veno-arterial access in a course of 30 minutes CPR. Biopsy specimen of the myocardium driven during ECMO cannulation was compatible with dilated cardiomyopathy secondary to viral myocarditis when evaluated with COVID-19 RT-PCR positivity in the cardiac tissue CONCLUSIONS: This is the first case describing COVID-19 related fatal fulminant myocarditis demonstrated with pathological workup in an infant. The presence of viral genome in myocardial tissue together with local inflammation is worthy. Negative inflammatory indicators suggest the existence of direct damage of the virus.