Encephalopathy and life-threatening gastrointestinal hemorrhage in a child with mis-c

INTRODUCTION: Multisystem Inflammatory Syndrome in Children (MIS-C) is a recently described phenomenon associated with Coronavirus Disease 2019 (COVID-19). Children typically present with fever and laboratory evidence of systemic inflammation. Additional signs and symptoms can vary widely, leading to diagnostic and management challenges. Given the range of clinical manifestations in children with MIS-C, it is important to report unique cases that represent uncommon but life-threatening complications associated with the disease and its management. DESCRIPTION: A previously healthy 11 year old male was admitted to the pediatric ICU and diagnosed with MIS-C based on clinical appearance, laboratory pattern, and SARS-CoV-2 antibody profile. The patient presented with shock and neurologic symptoms including encephalopathy and dysarthria. The shock was relatively mild and consistent with the hemodynamic profile commonly seen with MIS-C. Brain MRI, obtained to rule out thromboembolic injury, demonstrated cytotoxic edema of the corpus callosum, an imaging finding similar in nature to several previous reports of MRI abnormalities in children with MIS-C. Following administration of intravenous immunoglobulin and pulse dose steroids, the patient convalesced and was discharged home. Medications prescribed at discharge included a steroid taper, aspirin, and proton pump inhibitor. Four days later, he was readmitted with shock and life threatening gastrointestinal hemorrhage. The patient required large scale resuscitation with vasoactive agents and over twice his own circulatory volume in blood products delivered by a rapid infusion system. After extensive evaluation of potential bleeding sources, angiography revealed active bleeding from two arterial vessels supplying the duodenum. The patient demonstrated no further bleeding following successful coil embolization of the two arteries. DISCUSSION: We hypothesize that the vasculitic nature of MIS-C combined with anti-inflammatory and anti-thrombotic therapy placed the patient at risk of hemorrhage. This case highlights unique radiologic features of MIS-C as well as potential complications of treatment and the disease process itself. To our knowledge, this is the first report of a child with life-threatening GI hemorrhage in the setting of MIS-C.

COVID-19 and the Need for Global Critical Care Training. Why Ventilators Alone Are Not the Answer.

The current coronavirus disease (COVID-19) pandemic has unearthed many weaknesses in healthcare systems worldwide. In doing so, it has caused high-income countries to deal with the uncomfortable situation of resource allocation that has long been a daily occurrence in low- and middle-income countries. The shortage of equipment continues to be a major problem in low- and middle-income countries, but there is an even greater shortage of human resources in the form of trained individuals capable of caring for critically ill patients. With physicians being in short supply in many areas throughout Africa, the question becomes where do these human resources come from? In Kenya, clinical officers are the frontline workers and backbone of care in many healthcare settings and outnumber physicians four to one. AIC Kijabe Hospital, located in rural Kenya, recognized this need and identified this cohort of clinicians as a means of ramping up local emergency and critical care. In doing so, the Emergency and Critical Care Clinical Officer training program was created in 2015. Since its inception, the Emergency and Critical Care Clinical Officer program has been training nonphysician clinicians to care for critically ill patients with physician support. In this perspective piece, we outline our attempt at capitalizing on this pool of human resources to advance the care of critically ill patients, describe lessons learned along the way, and try to highlight the utility of their unique skill set in the setting of a pandemic.

Pragmatic Recommendations for Therapeutics of Hospitalized COVID-19 Patients in Low- and Middle-Income Countries.

The therapeutic options for COVID-19 patients are currently limited, but numerous randomized controlled trials are being completed, and many are on the way. For COVID-19 patients in low- and middle-income countries (LMICs), we recommend against using remdesivir outside of a clinical trial. We recommend against using hydroxychloroquine ± azithromycin or lopinavir-ritonavir. We suggest empiric antimicrobial treatment for likely coinfecting pathogens if an alternative infectious cause is likely. We suggest close monitoring without additional empiric antimicrobials if there are no clinical or laboratory signs of other infections. We recommend using oral or intravenous low-dose dexamethasone in adults with COVID-19 disease who require oxygen or mechanical ventilation. We recommend against using dexamethasone in patients with COVID-19 who do not require supplemental oxygen. We recommend using alternate equivalent doses of steroids in the event that dexamethasone is unavailable. We also recommend using low-dose corticosteroids in patients with refractory shock requiring vasopressor support. We recommend against the use of convalescent plasma and interleukin-6 inhibitors, such as tocilizumab, for the treatment of COVID-19 in LMICs outside of clinical trials.

Pragmatic Recommendations for the Management of COVID-19 Patients with Shock in Low- and Middle-Income Countries.

As some patients infected with the novel coronavirus progress to critical illness, a subset will eventually develop shock. High-quality data on management of these patients are scarce, and further investigation will provide valuable information in the context of the pandemic. A group of experts identify a set of pragmatic recommendations for the care of patients with SARS-CoV-2 and shock in resource-limited environments. We define shock as life-threatening circulatory failure that results in inadequate tissue perfusion and cellular dysoxia/hypoxia, and suggest that it can be operationalized via clinical observations. We suggest a thorough evaluation for other potential causes of shock and suggest against indiscriminate testing for coinfections. We suggest the use of the quick Sequential Organ Failure Assessment (qSOFA) as a simple bedside prognostic score for COVID-19 patients and point-of-care ultrasound (POCUS) to evaluate the etiology of shock. Regarding fluid therapy for the treatment of COVID-19 patients with shock in low-middle-income countries, we favor balanced crystalloids and recommend using a conservative fluid strategy for resuscitation. Where available and not prohibited by cost, we recommend using norepinephrine, given its safety profile. We favor avoiding the routine use of central venous or arterial catheters, where availability and costs are strong considerations. We also recommend using low-dose corticosteroids in patients with refractory shock. In addressing targets of resuscitation, we recommend the use of simple bedside parameters such as capillary refill time and suggest that POCUS be used to assess the need for further fluid resuscitation, if available.