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Background: Patients with systemic lupus erythematosus (SLE) may have an increased risk of mortality from COVID-19 due to underlying immuno-suppression, comorbidities, and abnormalities in the innate immune system. Studies have shown that autoimmune diseases and some immunosuppres-sive agents are risk factors for hospitalization, ventilation, and mortality from COVID-19. Objectives: To compare the outcomes of patients with or without SLE who were diagnosed with COVID-19 and to identify the factors associated with 30-day hos-pitalization, mechanical ventilation, and mortality. We hypothesized that patients with SLE had a higher risk of adverse outcomes. Methods: This retrospective cohort study used the deidentifed Optum COVID-19 electronic health record dataset to identify adult patients with COVID-19 diagnosis from 1/1/2020-12/31/2020. The SLE cohort was defned as patients who had two or more international classifcation of diseases (ICD) 9 or 10 diagnosis codes of 710.0 or M32.xx but not M32.0 within one year before COVID-19 diagnosis and were on either antimalarial or immunosuppressive therapy. The general cohort excluded patients with SLE. We matched SLE cases with controls at a ratio of 1:10 by age, sex, race and ethnicity, and month of COVID-19 diagnosis via a propensity score matching with exact matching for the latter three variables. Outcomes included 30-day mortality, hospitaliza-tion, and mechanical ventilation after COVID-19 diagnosis. We performed multivariable logistic regression models to estimate the odds of 30-day mortality, hospitalization, and mechanical ventilation after adjusting for age, sex, race and ethnicity, COVID-19 diagnosis quarter, insurance, region, severe obesity, smoking status, and comorbidities. Results: We included 687 SLE cases matched with 6,870 controls. After matching, the 30-day mortality for SLE and control was 3.6% and 1.8% (p <0.001), the 30-day mechanical ventilation was 6.0% and 2.5% (p <0.001), and 30-day hospitalization was 31.0% and 17.7% (p <0.001). After multivariable adjustment (Table 1) for age, sex, race, COVID-19 diagnosis quarter, insurance, region, severe obesity, and smoking status, patients with SLE had higher odds of death (Odds Ratio (OR)=2.09;95% CI 1.31-3.32), mechanical ventilation (OR=2.43;95% CI 1.67-3.54) and hospitalization (OR=2.06;95% CI 1.71-2.49). After additionally adjusting for comorbidities, the OR decreased to 1.39 (95%CI 0.79-2.44), 1.81 (95%CI 1.16-2.82), and 1.32 (95%CI 1.05-1.65) for mortality, mechanical ventilation, and hospitalization respectively. Older age, male sex, Hispanic ethnicity or Black race, severe obesity, and smoking had increased risk of adverse outcomes. Conclusion: Patients with SLE have an increased risks of mortality, mechanical ventilation, and hospitalization within 30 days of COVID-19 diagnosis. The risks decreased after adjustment for comorbidities but remained statistically signifcant for mechanical ventilation and hospitalization.
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Indoor tanning using ultraviolet (UV) radiation increases skin cancer risk. However, there is little objective information on when or where indoor tanning is used. We aimed to evaluate tanning salon geography and patterns of use using objective data rather than self-report. We used data from SafeGraph, a company that combines smartphone location data and proprietary geographic data. Our dataset included aggregate, anonymous data from January 1, 2018-December 31, 2020. We developed and validated an algorithm (positive predictive value 92.6%) to identify businesses offering UV indoor tanning. We evaluated tanning salon locations, number of tanning salons per state population, and foot traffic patterns by visits per month, per day of the week, and per hour of the day. Our algorithm identified 7412 businesses as tanning salons. Of those, 2795 (37.7%) had foot traffic data available. The highest concentrations of tanning salons were in Midwestern states. We found peaks in the spring (April) of 2018 and 2019, a slightly later peak (June) in 2020, and a short-term decrease in tanning salon visits during the early phases of the COVID-19 pandemic (March-May 2020). Visits were most frequent during weekdays (Monday-Friday). Peak times of day were 12pm-3pm. Our study has limitations: it includes only a small portion of the US population (approximately 10% of mobile devices) and we could not account for indoor tanning outside of tanning salons. Indoor tanning is a known carcinogen, but the majority of information on use is based on cross-sectional surveys. Our study represents new information for public health strategies to decrease exposure to this carcinogen.
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The increasing use of pre-operative systemic therapy has resulted in more limited information about axillary lymph node status, both from the impact of systemic therapy itself as well as from less extensive axillary surgery. Decisions about the use of adjuvant endocrine therapy have not been majorly affected, but information on the presence and number of involved lymph nodes can have a significant influence on the use of adjuvant chemotherapy and HER-2 targeted therapies. In addition, lymph node information can also impact decisions around radiation therapy, making multidisciplinary discussions highly relevant when planning therapy. Patients with hormone receptor positive breast cancer may be treated with pre-operative endocrine therapy. This strategy was often used in early stage breast cancer during the COVID pandemic due to delays in surgery. Although an effective approach, pre-operative endocrine therapy may impact nodal status at surgery, information which is important when deciding on the use of OncotypeDX testing in premenopausal women. Similarly, in postmenopausal women, the presence and number of lymph nodes involved is a critical factor in determining the appropriateness of OncotypeDx testing. This nodal information may be lost in the setting of pre-operative therapy and would alter decisions regarding adjuvant chemotherapy. For patients with HER2 positive breast cancer, the presence of nodal disease remains critical for adjuvant decision making. In the situation of small (up to 3 cm) node negative cancers, up front surgery is preferred, because pathologic confirmation of the tumor size and node negative status may make patients eligible for a de-escalated approach of adjuvant paclitaxel and trastuzumab. Patients with more advanced HER2 positive disease are good candidates for preoperative chemotherapy and HER2 targeted therapy. If they have residual disease at surgery, they can be offered trastuzumab emtansine, which was shown in the KATHERINE trial to improve outcomes. In both situations, accurate information about the presence of disease in the axillary lymph nodes determines the most effective treatment approach. Finally, accurate information about nodal status is also relevant to decisions in patients with triple negative breast cancer. Patients who are treated with pre-operative chemotherapy and have residual disease in either the breast or axillary lymph nodes may be offered adjuvant capecitabine, based on the CREATE-X study, which indicated improved survival outcomes in those patients with residual disease who received adjuvant capecitabine. As in HER2 positive breast cancer, the presence of residual disease (including in the lymph nodes) after preoperative therapy will influence the adjuvant therapy recommendation. Thus, when considering de-escalation approaches in axillary management, the impact on systemic therapy decision making must be carefully considered, as these additional adjuvant therapies may improve survival for patients. Conflict of Interest: No significant relationships.
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Introduction: In children, the dermatologic features appear to occur early with other COVID-19 manifestations. Dermatologists play a key role in the early diagnosis of COVID-19. Multi-system inflammatory syndrome in children (MIS-C) shows a presentation mimicking Kawasaki Disease (KD), with mucocutaneous signs. However, late onset dermatological signs are poorly described. Objectives: to evaluate children with MIS-C during the follow-up and to describe late dermatological signs in these patients. Methods: We followed 14 children (3M;11 F) with MIS-C, with clinical, biochemical, imaging data. Autoantibodies, D-Dimer, CRP, ESR, C3, C4, ferritin, serum amyloid, IgA, IgM, IgG were detected 1-2 months after the resolution of the clinical manifestations of MIS-C. Results: 8/14 children (58%) showed livedo reticularis at the legs, arms, trunk. The livedo was more evident at the legs in all the patients. The livedo started at the remission, after normalization of CRP, ESR, D-Dimer;the sign lasted also for 1-2 months after the discontinuation of steroids and the normalization of haematochemical parameters. 4/8 showed low-title positive autoimmune tests (ANA in 2;ENA anti-Sm in 2;anti-cardiolipin IgG in 1;ASCA in 2). Conclusion: In our series, 8/14 patients showed a livedo reticularis, more marked in the legs, however in some cases with a wide distribution to arms and the trunk. Low-title autoantibodies were transiently positive in 50% of these cases, negative in later detections. Livedo reticularis was a late sign, linked to MIS-C related vasculitis, persisting 1-2 months after the resolution of MIS-C. A different treatment regimen (IVIG plus steroids at 1-2 or 30 mg/Kg/day) did not influence the progress of this clinical manifestation. In 50% of children we documented a transient autoimmune response.
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Introduction: Multi-system inflammatory syndrome in children (MISC) shows a presentation mimicking Kawasaki Disease (KD), Toxic Shock Syndrome (TSS), Macrophage Activation Syndrome (MAS). Furthermore, many children show respiratory or abdominal symptoms. Objectives: Intravenous immunoglobulin (IVIG) is recommended as first line treatment as in KD, followed by aspirin, steroids and, in IVIGresistant patients, IL-1 or IL-6 blocking agents. Methods: We describe a cohort of 16 Sicilian children (6M;10F;age:1.4-14 years), with MIS-C, with clinical features compatible with classical or incomplete KD, in some cases with MAS and/or TSS. Demographic, clinical, laboratory, echocardiographic and imaging findings, treatment strategy and outcome were collected. Results: Common presenting symptoms included: fever (94%), abdominal pain or vomiting (50%), mucocutaneous rash (50%), conjunctivitis (44%), latero-cervical lymphadenitis (63%), cheilitis/ pharyngeal hyperaemia (81%), hands and feet oedema (13%). Symptoms started 1-8 days before the hospitalization. Nasopharyngeal swab for SARS-CoV-19 was positive in 12/16 patients, with positive serological IgG, negative or grey zone IgM-type antibodies. 2 patients with negative swab had a history of recent infection and positive IgG-type antibodies;2 patients had parents with positive swab. All the patients showed significant increase of C-reactive protein (CRP). AST, ALT, gamma-GT were increased in 25%. Pancreatic amylase and lipase were increased in 13%, 19% showed lymphocytopenia. Pro-BNP was increased (129-3980pg/ml) in 44% and troponin was increased (27.3-246ng/ml) in 31%. In addition, hyponatraemia was found in 100% of cases. Furthermore, 31 % had proteinuria. 50% showed cardiac involvement (3 pericardial effusion;5 mitral insufficiency;2 mitral and aortic insufficiency;1 coronaritis). Pleural, ascitic, pericardial effusion and abdominal adenitis were found in 19%, 25%, 19% and 31% of cases, respectively. IL-6 levels were evaluated in 9/16 patients and 8/9 showed a significant increase (30.2-285pg/ml) with a rapid normalization after steroids and IVIG treatment. Pro-BNP persisted increased for 7-10 days after IVG and steroids treatment. 25% of patients dramatically and rapidly evolved in a MAS-like form, fulfilling the classification criteria for the diagnosis of MAS (ACR/EULAR 2016). High doses of steroids and IVIG were promptly started with a significant improvement of the clinical course. In all the patients, treatment was started within 72 hours of admission, with IVIG (2 g/ Kg/dose), methylprednisolone (2mg/Kg/day in 56% of patients;30 mg/Kg/day for 3 days, followed by 2 mg/Kg/day in 38% of patients). 2 patients were treated with enoxaparin. TSS was described in 2 patients, who received additionally vasoactive drugs, albumin and diuretics. Conclusion: In our series, most of patients received a prompt treatment with IVIG and steroids. This approach could explain the good outcome in all the cases and the rapid restoring of cardiac function also in patients with MAS or TSS. Patients showed a wide spectrum of presenting signs and symptoms;evidence of inflammation with pathological values of CRP, ESR, D-dimer, ferritin, pro-BNP, troponin, transaminase, pancreatic amylase and albumin;a multi-organ involvement was documented in a high percentage of cases, inducing the clinician to perform a multi-specialistic approach.
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Introduction: MIS-C is a hyperinflammatory syndrome that follows exposure to SARS-CoV-2 by 2-6 weeks. However, some aspects remain unclear, such as cardiac involvement. Objectives: to evaluate the role and effectiveness of cardiac magnetic resonance (CMR) in heart involvement in children affected by MIS-C;to review the expert groups' clinical experience in the field. Methods: we describe a case series of 7 children (age: 2-11 years), admitted to the tertiary care Children Hospital G. Di Cristina, Palermo, between December 2020 and May 2021 with clinical symptoms meeting the criteria for the diagnosis of MISC-C. All the patients showed findings of cardiac involvement without coronary artery lesions. Transthoracic echocardiography demonstrated temporary systolic dysfunction that lasted for 2-5 days. CMR was performed during the recovery phase or after the discharge (the median time to CMR was 10-30 days after the onset of illness). CMR was performed with a 1,5 Tesla scanner (GE Signa Explorer). 5/7 didn't undergo CMR study during the acute phase because they were clinically unstable and needed general anesthesia or sedation. The protocol included, before intravenous contrast media injection, retrospective ECG-Gated fiesta cine sequences (short axis, 4, 3 and 2 chamber views), sequences for edema, and hyperemia T2 -short tau inversion recovery (Stir) (repetition time =1689ms, echo time55.10 ms). Myocardial edema was evaluated by following the Lake Louise criteria. Because normal value in native T1 mapping and T2 relaxation time in children have poor reference, myocardial edema was characterized by increased signal intensity on T2-weighted imaging and myocardial damage by non-ischemic patterns late gadolinium enhancement. Study for evaluating myocyte necrosis and fibrosis: Late gadoliniumenhanced 2D inversion recovery sequences performed at 6 min following intravenous contrast medium administration (0,2 mmol/kg). Results: In 5/7 patients, T2-Stir sequences didn't show myocardial edema and hyperemia. Mean indexed left ventricular end-diastolic volume (iLVEDV), indexed left ventricular end-systolic volume (iLVESV), and indexed left ventricular stroke volume (iLVSV) were within normal range corrected for BSA. In 2 patients CMR showed late gadolinium enhancement in non-ischemic pattern. 1 patient, studied in subacute phase, after steroids and IVIG treatment, showed ventricular apical septum and lateral wall myocardial oedema, without fibrosis and an imaging compatible with focal acute myocarditis. Ventricular systolic function was normal. 1 patient, studied 1 month after the acute phase, and showed myocardial fibrosis. Conclusion: international literature reports that children with MIS-C develop a transitory myocardial impairment, resembling myocarditis, with full recovery in most of them. Until now, the pathophysiology of the event is still object of debate. CMR is an excellent noninvasive diagnostic tool for the diagnosis and follow-up of myocarditis. Furthermore, CMR can predict prognosis and recognize children at high risk to develop arrhythmias and unfavorable events. CMR is a codified method highlighting specific features of myocardial damage: inflammation, edema, necrosis, contractile scar impairment, and pericardial effusion. 6/7 didn't demonstrate myocardial oedema, probably because the CMR was performed during the recovery.
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Introduction: Multisystem Inflammatory Syndrome Associated with COVID-19 Infection (MIS-C) shows many matches with children with Kawasaki disease (KD) and most children with MIS-C have incomplete or complete KD-like phenotype. In these patients cardiologic involvement mimics KD, showing, however, a higher incidence of severe acute manifestations. Objectives: In children with MIS-C and clinical findings related to heart disease, ECG and echocardiography are the first-line imaging. Until now, there are no international guidelines on the management of these patients. We suggest to take inspiration from the recommendations for KD for the significant phenotypic overlap between MIS-C and KD. Methods: We propose a step-by-step cardiologic imaging follow-up: - in all the patients, we recommend ECG and echocardiography at the diagnosis, at the worsening of the clinical and/or blood chemist parameters (CRP, ESR, ferritin;proBNP, troponin, D-Dimer), at any change of treatment supported by clinical worsening, at 8, 30, 45, 60, 90, 180 days since the diagnosis. The time-table may be changed in consideration of the outcome of the patient. -In patients with coronary artery dilatation (CAL), documented by echocardiography, it is advisable to follow-up them, since the diagnosis, with ECG, echocardiography, D-dimer, pro-BNP, troponin. -If CAL are oversized with z-score >- 2,5, according to age and body surface or increase during the follow-up: -it is recommended to perform Coronary Computed Tomography (CT) (CCA) or Cardiac Magnetic Resonance Angiography (CMRA). In fact, echocardiography cannot visualize the whole coronary artery vessels. Results: Both allow visualization of coronary artery aneurysms, vessels thickening, myocardial perfusion defects, permitting risk stratification and handing treatment decisions. CMRA is the first choice, because it is a radiation-free imaging method. It can evaluate the entire coronary artery system and provides details on myocardial function ischemia (detecting areas of inducible myocardial ischemia with pharmacological stress), infarction, inflammation, fibrosis. However, the new generation Multidetector Single -Source CT scanners and Dual Source Ct scanner allow a fast heart CT study with low radiation dose and reduce the need for sedation. CMR is less suitable because it is a lengthy examination and very often requires general anesthesia. If echocardiography demonstrates myocardial dysfunction or valve regurgitation at admission or during hospitalization, we suggest performing CMR. There is no consensus on the right timing. Conclusion: We suggest performing CMR during the acute or subacute phase: it is a step of the relieve in the cardiologic diagnosis to assess ventricular function and myocardial active injuries (oedema, hyperemia, ischemia, necrosis) and to repeat the imaging at the discharge in patients with the first pathological CMR, to evaluate fibrosis by myocardial delayed enhancement. CMR at the discharge is suggested also in cases with the first CMR normal, who showed a worsening of the echocardiographic parameters, the relieve of newinsurance valvulitis, persistent arrhythmia. At 3-6 months since the patient showed the remission, the CMR must be repeated to avoid any fibrotic lesions.
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Introduction: Multisystem inflammatory syndrome in children (MIS-C) is a severe complication of COVID-19 infection, typically evidenced 4-6 weeks after the infection. The debated pathogenesis is a dysregulation of inflammatory response to SARS-CoV-2 infection ad a cytokine hyperexpression. Persistent fever, respiratory and gastrointestinal symptoms are the most common manifestations, associated with typical clinical signs described in Kawasaki Disease (KD). Furthermore, pleiomorphic cardiac manifestations are described, including ventricular dysfunction, coronary artery dilation and aneurysms, arrhythmia, conduction abnormalities and pericardial effusion. These manifestations are a strong link with KD, even if in MIS-C they are more frequently documented. Severe cases can present as Toxyc Shock Syndrome (TSS) with vasodilatory or cardiogenic shock, requiring treatment with plasma expanders, inotropic drugs, diuretics, albumin and -in the more severe patients- extracorporeal membrane oxygenation and mechanical ventilation. KD experience guided the clinicians to treat these children with intravenous immunoglobulin (IVIG), steroids, aspirin (ASA) and, in refractory cases, anti-IL-1 monoclonal antibodies. Objectives: Most patients recover within days to a couple of weeks and mortality is rare, although the medium- and long-term sequelae, particularly cardiovascular complications, are not yet known. Methods: We describe the short-term outcome in a case series of 12 Sicilian children (4M;8F;age: 1.4-14 years) with MIS-C and a documented recent or actual infection by SARS-CoV-2 who showed cardiac involvement. Results: The cardiac features were: 3 patients showed pericardial effusion;1 coronaritis;6 transient mitral valve regurgitation;1 Brugada pattern, evidenced when he was febrile;2 showed associated mitral and aortic valve regurgitation). 7/8 patients with valve regurgitation showed a significant increase of pro-BNP, normalized during the follow-up. TSS was described in 2 patients, showing a significant increase of troponin, promptly treated with high dose of methylprednisolone, IVIG, vasoactive drugs, albumin and diuretics. 3 patients (21%), after the resolution of the acute phase, showed bradycardia (heart rate < 50/min), persisting for 7-10 days. The bradycardia was not associated with first-degree AVB, or a pathological PR. 6 patients (42%) showed an altered ventricular repolarization phase, in association with an increase of pro-BNP (129-3980 pg/ml). 4/12 (33%) had increased troponin levels (27.3-246 ng/ml) in the acute phase, with the normalization of troponin after IVIG and steroids treatment. Pro-BNP persisted increased for a longer time, besides the clinical improvement and the normalization of blood chemistry parameters. Conclusion: Generally, pro-BNP and troponin levels in MIS-C are higher than in KD, reflecting vasculopathy and cardiomyocytes damage extent. Persistence of increased levels of pro-BNP, in patients with a normalization of inflammatory parameters, suggests a mechanism of myocardial oedema, persisting besides the intensive care approach useful, however, to limit effects on cardiac function and normalize inflammatory parameters. Patients admitted with MIS-C require close electrocardiogram monitoring during the acute phase and the recovery, even if they do not manifest dyselectroliteemia, coronary lesions, pericardial effusion, myocarditis, shock. This approach can avoid severe arrythmia.
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OBJECTIVES: To describe clinical characteristics, laboratory tests, radiological data and outcome of pediatric cases with SARS-CoV-2 infection complicated by neurological involvement. STUDY DESIGN: A computerized search was conducted using PubMed. An article was considered eligible if it reported data on pediatric patient(s) with neurological involvement related to SARS-CoV-2 infection. We also described a case of an acute disseminated encephalomyelitis (ADEM) in a 5-year-old girl with SARS-CoV-2 infection: this case was also included in the systematic review. RESULTS: Forty-four articles reporting 59 cases of neurological manifestations in pediatric patients were included in our review. Most (32/59) cases occurred in the course of a multisystem inflammatory syndrome in children (MIS-C). Neurological disorders secondary to cerebrovascular involvement were reported in 10 cases: 4 children with an ischemic stroke, 3 with intracerebral hemorrhage, 1 with a cerebral sinus venous thrombosis, 1 with a subarachnoid hemorrhage, 1 with multiple diffuse microhemorrhages. Reversible splenial lesions were recognized in 9 cases, benign intracranial hypertension in 4 patients, meningoencephalitis in 4 cases, autoimmune encephalitis in 1 girl, cranial nerves impairment in 2 patients and transverse myelitis in 1 case. Five cases had Guillain-Barré syndrome (GBS) and two, including ours, had ADEM. Radiological investigations were performed in almost all cases (45/60): the most recurrent radiological finding was a signal change in the splenium of the corpus callosum. The presence of SARS-CoV-2 viral nucleic acid in the cerebrospinal fluid was proved only in 2 cases. The outcome was favorable in almost all, except in 5 cases. CONCLUSIONS: Our research highlights the large range of neurological manifestations and their presumed pathogenic pathways associated with SARS-CoV-2 infection in children. Nervous system involvement could be isolated, developing during COVID-19 or after its recovery, or arise in the context of a MIS-C. The most reported neurological manifestations are cerebrovascular accidents, reversible splenial lesions, GBS, benign intracranial hypertension, meningoencephalitis; ADEM is also a possible complication, as we observed in our patient. Further studies are required to investigate all the neurological complications of SARS-CoV-2 infection and their underlying pathogenic mechanism.
Subject(s)
COVID-19/complications , Nervous System Diseases/virology , Pneumonia, Viral/complications , Child , Humans , Pneumonia, Viral/virology , SARS-CoV-2ABSTRACT
Introduction: The pandemia of COVID-19 remains a global health alarm with high incidence of lethality, especially in older age groups who suffer from underlying medical conditions. However, children are less likely to manifest severe conditions. Objectives: COVID-19 was correlated to a higher incidence and a suspected increased risk of Kawasaki Disease (KD) in children. Methods: We describe the case of a 2.2-year-old infant admitted for fever (>5 days;> 39°C), pharyngitis, cheilitis, arthralgia, feet oedema, rash, perineal and scrotal region erythema, bilateral lymphadenopathy of the neck, cough, rhinorrhea. He was extremely irritable. Heart rate: 140/min;capillary saturation 99 % in air. Laboratory tests showed: leukocytes 13.4 x 103/μ l (neutrophils: 7.4 x 103/μ l);platelets 502 x 103/μ l;haemoglobin 11.1 g/dl;increased inflammatory markers, with C-reactive protein (CRP) of 14.7 mg/dl (n.v.: < 0.5);hyponatremia (133 mEq/l). The nasal swab for respiratory viruses, IgM and IgG anti-EBV, CMV, Parvovirus, Mycoplasma, Chlamydia were negative. Anamnestic records revealed a previous KD, without coronary artery lesions (CAL), 1 year before. Results: He was treated with antibiotics, intravenous infusion of Immunoglobulins (IVIG) (2 gr/Kg), acetylsalicylic acid (ASA) (50 mg/Kg in 4 doses/day) and reached defervescence into 2 days. Echocardiography excluded CAL. The nasopharyngeal swab for SARS-COV-2 was doubt. The second throat swab done the day after IVIG infusion, was negative;however, the third nasopharyngeal swab for SARS-COV-2, done 4 days after IVIG infusion, was positive. Chest X-ray showed a significant lung interstitial thickening. IL-6 levels were < 6.25 pg/ml (n.v. < 6.25 pg/ml). He continued treatment with antibiotics, ASA (5 mg/Kg/day), with the progressive resolution of the clinical symptoms and of the normalization of laboratory findings. Conclusion: The peculiar outcome of the patient is the correlation of COVID-19 with KD, recently reported as associated. KD is considered as a multifactorial autoinflammatory disease, induced by a cytokine hypersecretion with a systemic vasculitis. COVID-19 is considered a cytokine storm syndrome, with a severe systemic vasculitis. SARS-COV-2 infection could be the trigger that could lead to hyperinflammation of KD. The IVIG infusion could explain the transient negative swab for SARSCOV-2, with the successive positive relieve lasting 7 days, and the normal levels of IL-6, detected after IVIG infusion. Relapsing KD is rare (1.7-3.5%);in our patient this event could be triggered by the documented SARS-COV-2 infection.