Clinical features and laboratory findings of multisystem inflammatory syndrome in children (MIS-C)

Introduction: Children mostly have mild or asymptomatic forms of SARS-CoV-2 infection, but during pandemic a higher incidence of Kawasaki disease, Kawasaki-like syndrome and the emergence of a new clinical entity, multisystem inflammatory post-covid syndrome (MIS-C) has also been observed. Objectives: The aim of this study is to determine clinical features and laboratory findings in patients with MIS-C. Methods: Retrospective analysis of clinical features and laboratory findings of MIS-C patients treated at our tertiary referal center (Clinic of Pediatric, University Clinical Centre Nis, Serbia). Results: From 18th of March 2020 till 30st of April 2021 there were 10 patients diagnosed as MIS-C according to CDC criteria. Eight patients were male and two were female. Patients age was 2 to 13 years (average 7.9 years, median 7 years). All patients had SARS -CoV-2 N-protein IgG antibodies but without history of disease symptoms and had positive contact four weeks prior to the onset of MIS-C symptoms. First symptom of MIS-C was fever (over 38C) which lasted in average for 4.4 days (3-7 days). Muco-cutaneous and gastrointestinal manifestations were most common. All patients had bulbar conjuctivitis, rash was present in 8 patients (80%), hand/foot oedema in 6 cases (60%), anterior cervical lymphadenopathy and cheliitis in 4 cases (40%) and periobital oedema in one case (details presented in Table 1. Clinical features of MIS-C patients). Nine patients (90%) presented with gastrointestinal symptoms while nervous system was affected in 5 patients. Three patients developed heart insuffitiency and one patient developed early signs of right coronary arthery aneurism. All patients had elevated inflammatory markers. Complete blood count showed elevated levels of white blood cells in 9 patients. Hypoalbuminemia and hypoproteinemia, low levels of serum potassium and sodium were present during ten days after the onset of symptoms. Troponines were elevated in 4 cases, proBNP in 5 cases. Abdominal ultrasound was performed and 6 patients presented with hepatoplenomegaly, 3 with enlarged spleen, one with enlagred liver and 4 had ascites. All patients were treated with combination of two antibiotics till cultures were proven negative, corticosteroid therapy and antiaggregation therapy. Three patients received a IVIG in a single dose (2gr/kg). All patients had good response to corticosteroid therapy (2mg/kg). Corticosteroid therapy was continued for four weeks (tapering). Conclusion: MIS-C can be a life-threatening condition in children. Early diagnosis and timely adequate treatment are of paramount importance. In children less than 5 years of age, the distinction between Kawasaki (Kawasaki shock) syndrome and MIS-C might be difficult, influencing the decision to use IVIG or steroids alone.

Kawasaki-like syndrome associated with COVID-19: clinical characteristics of mild to moderate forms of a disease

Introduction: In setting of global pandemic of coronavirus disease 19 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), cases resembling Kawasaki disease (KD) were repeatedly reported. Soon afterwards it began to be considered as separate entity named multisystem inflammatory syndrome in children (MIS-C). In addition to this newly recognized syndrome which has overlapping features with KD and is still occasionally described as its from, during COVID-19, a high incidence of Kawasaki-like syndrome (KLS) with mild to moderate symptoms was also noted. Recently, it was proposed that even such cases should, in clinical context, be treated as MIS-C if appropriate criteria are met. On the other hand, clear distinction of the two entities can help researchers to answer the question of its etiology and pathogenesis and could direct the clinicians what to expect during the course of the disease. Objectives: The aim was to describe main epidemiologic and clinical characteristics of KLS during the first year of COVID-19 pandemic. Methods: This retrospective study included analysis of medical documentation of patients treated for KLS at Clinic of Pediatrics, University Clinical Center Niš, between March 2020 and 2021. Inclusion criteria was fulfillment of KD or KLS criteria, based on CDC1 or WHO2 recommendation. Severe form of the disease with signs of a shock was exclusion criteria. The results were elaborated with the statistical method of descriptive and quantitative analysis. Results: A total of 21 subjects fulfilled the criteria for KLS during the study period. The cumulative incidence was 8.48 per 105 minors. Male to female ratio was 2:1 and mean age at diagnosis was 6.5 years (min. 8 months;max. 17 years). In fourteen cases current or recent COVID-19 infection or confirmed COVID-19 exposure was observed. When only these patients are analyzed average age was 8.2 years. Antibodies against SARS-CoV-2 were confirmed in seven patients, three had positive PCR test for COVID-19 and one had close contact with someone who has COVID-19 but COVID-19 was not proved. Interestingly, three patients that were antigen positive had respiratory organ involvement. In the reaming seven cases all the other possible causes of symptoms were ruled out and possible contact with SARS-CoV-2 was assumed. In addition to prolonged fever, that was present in all patients, polymorphous rash (95%) was the most common clinical feature flowed by bilateral nonpurulent conjunctivitis (47%). Gastrointestinal tract involvement was the most common internal organ manifestation. Treatment included corticosteroids (15 patients), intravenous immunoglobulin (1 patient) and two patients received nonsteroidal anti-inflammatory drug in anti-inflammatory dose, while the rest were only treated symptomatically. Favorable outcome was achieved in all patients with no morphological changes observed on echocardiography during the hospitalization and 2 weeks after discharge. Conclusion: Our findings suggest connection between infection and occurrence of the disease in susceptible children. Yet, a large portion of the population had contact with SARS-CoV-2, thus the exact role of infectious agent and pathophysiological mechanisms have to be determined. Gender distribution with male dominance among our patients is expected. Still, average age at diagnosis was bit higher than what is usually observed in classic KD and is more in line with characteristics of MIS-C. Further research are to be done in order to define what determine progression of the disease and are there any signs that may point in which way it will develop. Only in that way the clinicians would made right choices regarding the patients treatment.

Impact of COVID-19 outbreak on hospital admissions and outcome of acute coronary syndromes in a single high-volume centre in southeastern Europe.

BACKGROUND: As coronavirus disease 2019 (COVID-19) has reached pandemic status, authors from the most severely affected countries have reported reduced rates of hospital admissions for patients with acute coronary syndrome (ACS). AIM: The aim of the present study was to investigate the influence of the COVID-19 outbreak on hospital admissions and outcomes in ACS patients in a single high-volume centre in southeastern Europe. METHODS: This retrospective observational study aimed to investigate the number of hospital admissions for ACS, clinical findings at admission, length of hospitalisation, major complications and in-hospital mortality during the COVID-19 outbreak and to compare the data with the same parameters during an equivalent time frame in 2019. For the ST-elevated myocardial infarction (STEMI) subgroup of patients, changes in ischaemic times were analysed as well. RESULTS: There was a significant reduction of 44.3% in the number of patients admitted for ACS during the COVID-19 outbreak when compared with the same period in 2019 (151 vs 271; 95% confidence interval 38.4-50.2, p < 0.01) with a higher mortality rate (13.2% vs 7.2%, p = 0.03). In 2020, patients with non-ST-elevated myocardial infarction presented more often with acute heart failure (3.3% vs 0.7%, p = 0.04). During the COVID-19 outbreak, we observed increases in the total ischaemic time (303 ± 163.4 vs 200.8 ± 156.8 min, p < 0.05) and door-to-balloon time (69.2 ± 58.4 vs 50.5 ± 31.3 min, p < 0.01) in STEMI patients. CONCLUSIONS: These findings should increase the awareness of morbidity and mortality related to missed or delayed treatment of ACS among the public and the healthcare services.