ABSTRACT
Case Report: A 4-year-old African American male presented to an outside emergency department (ED) following sudden inability to move left upper extremity. Past medical history was unremarkable and routine vaccinations were up to date. Radiograph of affected extremity ruled out fractures and patient was discharged to follow up with primary care physician. Two days later mother brought him to our ED due to persistent left upper extremity paralysis, poor appetite, and subjective fever. On exam his left arm was warm and tender to dull and sharp touch;he had definite loss of active movement, hypotonia and absence of deep tendon reflexes. The patient had winging of left scapula and could not shrug left shoulder. MRI of cervical and thoracic spine showed enlargement of spinal cord from C2-C6 level with gray matter hyperintensity, slightly asymmetric to the left. Laboratory studies showed leukocytosis (14 000/mcL) and CSF studies showed pleocytosis of 89 WBC/mcL (93.3% mononuclear cells and 6.7% polymorphonuclear cells), 0 RBCs, normal glucose and protein, and a negative CSF meningoencephalitis multiplex PCR panel. Due to high suspicion of demyelinating or autoimmune condition he was treated with high dose steroids and IVIG. Subsequently neuromyelitis optica was ruled out as aquaporin-4 receptor antibodies (AB) and myelin oligodendrocyte glycoprotein AB were normal. CSF myelin basic protein and oligoclonal bands were absent ruling out demyelinating disorders. CSF arboviruses IgM and West Nile IgM were negative. He showed minimal improvement in left upper extremity movement but repeat spinal cord MRI one week later showed improved cord thickness with less hyperintensity. Respiratory multiplex PCR was negative including enteroviruses. Repeat CSF studies after IVIG showed increased IgG index and IgG synthesis suggestive of recent spinal cord infection, consistent with acute flaccid myelitis (AFM). Pre-IVIG blood PCR was invalid for enteroviruses due to PCR inhibitors found in the sample. Blood post-IVIG was negative for mycoplasma IgM, West Nile IgM, and arboviruses IgM. Enterovirus panel titers (post-IVIG) were positive for coxsackie A (1:32), coxsackie B type 4 (1:80) and 5 (1:320), echovirus type 11 (1:160) and 30 (1:80) as well as positive for poliovirus type 1 and 3. These titers could not distinguish acute infection from patient's immunity or false-positives as a result of IVIG. He was discharged with outpatient follow-up visits with neurology, infectious disease, occupational and physical therapy, showing only mild improvement after discharge. Discussion(s):With the anticipated resurgence of AFM after the peak of COVID-19 pandemic, our case illustrates the need to consider this diagnostic possibility in patients with flaccid paralysis. It is important to remember CSF IgG synthesis is not affected by IVIG. In addition when treatment plans include IVIG, appropriate samples should be collected before IVIG to facilitate accurate work-up for infectious diseases. Copyright © 2023 Southern Society for Clinical Investigation.
ABSTRACT
INTRODUCTION: Since the beginning of COVID-19 pandemic in early 2020, we continue to gather more data on various aspects of COVID-19. While many pediatric studies have concentrated on cardio-vascular effects of Multisystem Inflammatory Syndrome of Childhood (MIS-C), very few studies have evaluated the effect on cardiac physiology during the COVID-19 infection. METHOD(S): It is retrospective chart analysis of patients admitted to Pediatric ICU in a tertiary care center of a children's hospital in South Alabama between January 2020 and June 2022. Patients were identified based on International Classification of Disease (ICD-10) code for COVID-19 (U07.1). During the admission the first echocardiogram (Echo) obtained was evaluated. Patients who did not receive the echocardiogram were excluded. Echo findings were read by board certified pediatric cardiologists. The data was analyzed using SPSS software (V25.0) RESULTS: Among 203 children who were hospitalized with COVID-19 infection, 56 (27.5%) patients had an echocardiogram done during the admission. Those who had echocardiogram done were older than those who did not, with Median age [Inter-Quartile Range (IQR)] of 9.83 (2.45 - 14.08) years vs 4.16 (0.68 - 11.7) years, p = 0.003. Patients who had an Echo had a higher median Length of Stay (LOS) 7.03 (4.85 - 11.78) days vs 3.89 (2.20 - 6.03) days, p< 0.001. Race, ethnicity and gender, were not associated with probability of obtaining Echo, adjusted odds ratio (AOR) [95% CI];0.84 (0.21-3.83), p=0.81;1.2 (0.23- 6.28), p = 0.83;1.31 (0.69-2.45), p =0.4, respectively. Median LV ejection fraction (LVEF) and Tricuspid Valve Regurgitation maximum velocity (TR Vmax) were 68 (62-73) % and 1.81 (0 - 2.27) m/s, respectively. The LOS had a positive correlation with TR Vmax but not with LVEF, coefficient of correlation(R) being 0.33, p = 0.01, and 0.49, p = 0.72, respectively. CONCLUSION(S): Echocardiogram on admission in COVID-19 pediatric patients is more likely to be obtained in older children and is associated with longer length of stay. Also, higher the TR Vmax on the initial Echo, longer is the length of stay of these patients. Although further studies including multi-center trials are needed to get better understanding of findings of Echo is COVID-19 pediatric patients and their role in predicting severity of illness.
ABSTRACT
INTRODUCTION: Mental health related concerns have increased as a consequence of the Covid-19 pandemic. Emerging evidence has suggested that adolescents are at a greater risk compared to other age groups. Frequently, it is hypothesized that suicide attempts have increased following the global pandemic;however, inconsistent data currently exists illustrating the pattern of suicide attempts surrounding the pandemic. Therefore, our purpose was to examine the length of stay (LOS) following pediatric suicide attempts across three phases of the pandemic and the potential associated financial burden. METHOD(S): 1,467 patient encounters from the pediatric ED and PICU with a diagnosis of suicide were retrospectively reviewed. A total of 262 patient records (age: 15+/-2 yo, 82% female) were included and grouped based on Covid-19 lockdown (defined as March 2020). Three time periods were demarcated: 1-yr pre-lockdown, 1-yr immediately following lockdown, and 2nd-yr following lockdown. A Pearson correlation was conducted between LOS and total cost of care. A 1-way between group ANOVA was used to examine mean differences in LOS. A p-value < 0.05 was defined as significant. RESULT(S): A positive relationship was found between LOS and total cost of care (n=142;r=.743;CI95%=.658-.808). The number of attempts per time period was 80, 93, and 89, respectively. The between group ANOVA indicated there was a significant (F=3.77, p=0.024) increase in LOS following the lockdown. Specifically, pairwise comparisons showed that LOS was greater during the 2nd-yr of lockdown compared to pre-lockdown (mean+/-SEM: 1.11 +/- .14 vs. 1.63 +/- .13 days;mean difference =.52, CI95% = .15 - .89). CONCLUSION(S): There was a relationship between LOS and total cost of care such that the more time spent hospitalized resulted in higher cost. While it still remains to be determined to what degree the incidence rate of attempt was affected by Covid-19 lockdown, here we suggest that LOS (and perhaps cost) increased following the lockdown date. Interestingly, there was only a difference between pre-lockdown and the 2nd-yr of lockdown. Therefore, future studies should examine factors contributing to greater LOS, such as access to mental health professionals and bed availabilities at inpatient psychiatric facilities.