ABSTRACT
Background. Kawasaki disease (KD) and Multisystem Inflammatory Syndrome in Children (MIS-C) associated with Coronavirus Disease 2019 present similarly with mucocutaneous symptoms and fever. Both syndromes can progress to shock. Successful treatments for MIS-C are largely based on proven KD management. As more patients with MIS-C are treated, protocols are adjusted. Infectious Diseases (ID) specialists are often early consultants in these cases. Understanding differences in how body systems are affected in MIS-C versus KD is essential for management. Methods. This is a single hospital comparison of 25 cases of MIS-C with mucocutaneous presentation and symptoms of shock and 25 consecutive cases of KD Shock Syndrome (KDSS). Cases were compared for demographics, symptoms, cardiac abnormalities, medical treatments, and cardiac recovery. Results. Patients with MIS-C develop symptoms of shock including sustained hypotension and tachycardia at 3 times the rate of patients with KD (45% vs 13%;p< 0.001). On echocardiogram, left ventricular myocardial dysfunction, assessed by ejection fraction, is more commonly noted in cases of MIS-C than KDSS (fig 1). About half of patients with MIS-C show left ventricular myocardial dysfunction initially with normalization by 6 months post-presentation in the majority (96%). Conclusion. Cardiac changes and shock events related to KD and MIS-C are thought to be caused by differing inflammatory mediators. By comparing these two syndromes, we can determine ways to manage each optimally. MIS-C often results in left ventricular myocardial dysfunction, which is rarer in KD cases. Fluid resuscitation with multiple fluid boluses followed by inotropes to treat hypotension in cases of in MIS-C puts increased strain on the already weakened myocardium. Early intravenous immunoglobulin (IVIG) administration, even in the presence of mild hypotension, can simultaneously provide the patient with additional fluid and decrease the underlying inflammatory process. This prompt treatment might reduce the need for pressor support while protecting the myocardium from further damage. As early consultants in MIS-C, ID providers should be educated regarding the unique cardiac challenges of MIS-C and avoid delay in IVIG treatment and cardiologist and intensivist consultation.
ABSTRACT
Background: Pediatric providers have been caring for two new and similar respiratory illnesses: E-cigarette or vaping use associated lung injury (EVALI) beginning in 2019 and Coronavirus Disease 19 (COVID-19) in 2020. Similarities include prodrome, presentation, imaging, and laboratory testing. While EVALI often improves with steroid treatment, steroids can be detrimental early in the course of COVID-19. Although a positive SARS CoV-2 polymerase chain reaction (PCR) test is helpful, this result does not definitively identify SARS CoV-2 as the primary cause of symptoms in patients with a history of vaping, as both processes may be coexistent. Coinfection with other infectious agents is commonly found in children with COVID-19 infection, and the majority of children with PCR positive SARS CoV-2 are asymptomatic or mildly symptomatic. Methods: In hopes of better defining EVALI versus COVID-19 clinical syndromes, we reviewed charts of pediatric patients admitted to a freestanding children's hospital in Texas diagnosed with EVALI over a year period from June 1, 2019 and June 1, 2020. Cases were identified through a local patient registry. We compared findings in these cases with literature regarding pediatric patients with acute COVID-19 and EVALI. Variables included presenting symptoms, timing of symptoms, vital signs, imaging, and laboratory results. Results: Twelve patients with EVALI diagnosis were included. Clinical presentation, imaging, and laboratory findings were similar to those described with acute COVID-19 and are included in figures 1 and 2. Repeated interviewing regardingvaping revealed a history of vaping in all EVALI cases;frequency reported varied from multiple times daily to remote use. Some cases with EVALI also had a significant psychiatric history, positive urine drug screen, or significant weight loss prior to hospitalization. Cases with EVALI and steroid treatment improved within days of treatment. In a review of literature, BAL sampling often reveals lipoid pneumonia in EVALI cases, which would not be expected in COVID-19. Of note, the single case in our group tested did not have lipoid pneumonia on bronchoalveolar lavage (BAL) cytology. Conclusion: Presence of prolonged preceding weight loss, or BAL cytology could help differentiate these clinical states.