ABSTRACT
Introduction: Multisystem inflammatory syndrome in children (MIS-C) is a rare complication of SARS-CoV-2 infection, with an incidence of about 1:100'000 children. According to published case series, between 10% and 40% of MIS-C develop coronary artery modifications, mainly hyperechogenicity, with a lower incidence of aneurysm. Evolution and outcome of coronary artery aneurysm post MIS-C is unknown. Methods: We report the case of a 10-year old male with medium left anterior descending coronary artery (LAD) aneurysm (diameter of 6.2 mm, z-score +7.9) and small right coronary artery (RCA) aneurysm (z-score +2.9) detected one week after his hospital admission for hypotensif shock in the context of MIS-C and positive serologies for SARS-CoV-2. He didn't meet diagnosis criteria for Kawasaki disease. He was treated with 2 g/kg immunoglobulin (administered after coronary artery dilatation was observed, as the recognition and definition of MIS-C was contemporary with our case), corticosteroids and anakinra. He rapidly normalized his initial mild LV dysfunction and cardiac enzymes elevation. Results: Since discharge, the patient was treated with antiplatelet therapy (100 mg aspirin daily) and carefully followed up in outpatient cardiology. On echocardiography, coronary artery dimensions progressively regressed, prompting a control computed tomography (CT) 6 months after MIS-C episode. CT confirmed LAD and RCA dimension near-normalization, compared to the fusiform dilatations 6 months ago : LAD maximal diameter of 3.7 mm (z-score +2.3), RAD maximal diameter of 4 mm (zscore +1.8). Moreover, no coronary stenosis was observed. Conclusions: Coronary artery aneurysm in the context of MIS-C probably represents a post-infectious vasculitis. This case illustrates a regression of coronary artery dilatation after a few months. Further research is needed to assess if this finding reflects a generalisable outcome and to study the effect of medical treatment on the evolution of coronary artery dilatation post MIS-C.
ABSTRACT
Introduction: The pandemic of SARS-CoV-2 is a major health issue, and involvement of the cardiovascular system is common amongst adult with acute coronavirus disease 2019 (COVID-19). Since the beginning of the epidemic, children seem relatively spared with a low morbidity and mortality. However, multisystem inflammatory syndrome in children (MIS-C) is a rare but severe complication following SARS-CoV-2 infection. Cardiovascular involvement is reported in about 80% of MIS-C cases, with elevated cardiac enzymes, left ventricular dysfunction, shock, coronary artery dilatation, mitral regurgitation and arrhythmias. Although MIS-C seems to be a post-infectious complication, its pathogenesis has not yet been clearly elucidated. It is unknown whether children with uncomplicated SARS-CoV-2 infection can develop subclinical cardiac implication and coronary artery dilatation. Methods: Children with an acute infection of SARS-CoV-2 confirmed by positive RT-PCR test on nasopharyngeal swab between March and May 2020, who didn't meet MIS-C diagnostic criteria, were proposed an outpatient cardiology appointment. Electrocardiogram and echocardiography were performed in all participants. Results: 35 children (17 female) aged 2 months to 16 years (mean: 9.2 years) were enrolled after informed consent. Cardiology assessment took place 66 days (range 44 to 100 days) after the test. Shortening fraction of the left ventricle was normal in all subjects (mean shortening fraction 35.25%, range 30-43%). Coronary arteries were normal without dilatation in all 35 children. Moreover, there was no valvar abnormalities and no pericardial effusion. ECGs were normal without conduction abnormalities. Conclusions:Wedidn't observe any subclinical cardiac involvement in our cohort of pediatric patients with uncomplicated SARSCoV-2 infection. Cardiac dysfunction and coronary artery dilatations reported in MIS-C, but never or rarely reported in acute pediatric COVID-19 cases corroborate the hypothesis of a postinfectious syndrome. Further researches are necessary to better understand the underlying mechanisms of cardiovascular involvement after SARS-CoV-2 infection.
ABSTRACT
Background: Cardiac injury and myocarditis have been described in adults with coronavirus disease 2019 (COVID-19). Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in children is typically minimally symptomatic. We report a series of febrile pediatric patients with acute heart failure potentially associated with SARS-CoV-2 infection and the multisystem inflammatory syndrome in children as defined by the US Centers for Disease Control and Prevention. Methods: Over a 2-month period, contemporary with the SARS-CoV-2 pandemic in France and Switzerland, we retrospectively collected clinical, biological, therapeutic, and early outcomes data in children who were admitted to pediatric intensive care units in 14 centers for cardiogenic shock, left ventricular dysfunction, and severe inflammatory state. Results: Thirty-five children were identified and included in the study. Median age at admission was 10 years (range, 2-16 years). Comorbidities were present in 28%, including asthma and overweight. Gastrointestinal symptoms were prominent. Left ventricular ejection fraction was <30% in one-third;80% required inotropic support with 28% treated with extracorporeal membrane oxygenation. Inflammation markers were suggestive of cytokine storm (interleukin-6 median, 135 pg/mL) and macrophage activation (D-dimer median, 5284 ng/mL). Mean BNP (B-type natriuretic peptide) was elevated (5743 pg/mL). Thirty-one of 35 patients (88%) tested positive for SARS-CoV-2 infection by polymerase chain reaction of nasopharyngeal swab or serology. All patients received intravenous immunoglobulin, with adjunctive steroid therapy used in one-third. Left ventricular function was restored in the 25 of 35 of those discharged from the intensive care unit. No patient died, and all patients treated with extracorporeal membrane oxygenation were successfully weaned. Conclusions: Children may experience an acute cardiac decompensation caused by severe inflammatory state after SARS-CoV-2 infection (multisystem inflammatory syndrome in children). Treatment with immunoglobulin appears to be associated with recovery of left ventricular systolic function.