ABSTRACT
Multisystem inflammatory syndrome in children (MIS-C), emerged from late April to early May 2020 and affected clusters of children in Europe and North America. In dengue-endemic regions like Malaysia, MIS-C is likely to cause a diagnostic dilemma with dengue fever due to overlapping clinical and laboratory features, especially in the Emergency Department (ED). A healthy 10-year-old boy, who completed vaccination for COVID-19 presented to the ED with a 3 days history of fever associated with vomiting and loose stool. The patient was lethargic with skin rash, buccal mucosa redness and dry lips. Dengue virus antigen detection (NS-1) antigen test was positive. Subsequently, he was diagnosed with dengue fever with warning signs. Laboratory investigation shows White blood cells 4.0 x 10-9/L, Hemoglobin 10.5g/dL, Hematocrit 34 % , Platelet 198 x10-9/L and CRP 19 . Serial electrocardiogram shows ischemic changes, Q wave and U wave on lead II and III, T inversion V1-V4. Thorough bedside echocardiography by a paediatrician discovered mild pericardial effusion and dilated both left coronary artery and right coronary artery with perivascular cuffing. The patient was diagnosed with MIS-C with gastrointestinal and cardiovascular involvement. COVID-19 antibody screening was positive for Immunoglobulin (IgG) N protein. However, dengue serology was negative. He was treated with intravenous immunoglobulin for two days and started on a tapering dose of steroids. Finally, he improved and was discharged well after seven days in the hospital. Oral mucosal findings, raised inflammatory parameters, anaemia and bedside echocardiography findings can differentiate MIS-C from dengue fever in the emergency department. This case highlights the need for Emergency Department doctors to have vast knowledge and patience to do a meticulous clinical evaluation, correctly interpret laboratory investigation and do thorough bedside echocardiography in febrile children with suspicious evidence of MIS-C.
ABSTRACT
Background and objectives: Malaysia first announced Movement Control Order (MCO) in March 2020 following escalation of COVID-19 outbreak and declaration of pandemic, leading to nationwide partial lockdown. Fear of virus spread and MCO directives were presumed to markedly affect trends in visits to the emergency department (ED). This study aims to observe the trend in ED utilization among hybrid hospitals in Malaysia following the MCO period. Methods: This retrospective, observational, cross-sectional study involved COVID-19 hybrid hospitals under Ministry of Health Malaysia. Hybrid hospitals are institutions that manage both confirmed and non-COVID-19 patients and were included in the study. Full COVID-19 and screening hospitals were excluded. Data were taken from January to October 2020 and compared with 2019 data of same months. Primary outcome is monthly trend of total ED utilization by adult and pediatric population, and secondary outcome observes the trend of ED attendance according to triage categories. Changes in attendance were calculated in percentage. Descriptive analysis was reported in median and interquartile range. Mann-Whitney U test was used to compare the difference between two medians in each month. Results: A total of 25 hospitals were included in the study. Total attendance to ED has dropped significantly nationwide from March 2020 onward after MCO was initiated. Reduction in total attendance between March and October 2020 ranges between 36.4% and 63.4% with significant difference compared to 2019. Higher percentage of reduction was seen in the pediatric population between 56.2% and 76.1% compared to the adult population which ranged between 32.5% and 60.9%. These differences were significant from April to October 2020 (p<0.05). Comparing the triage categories, no significant difference was seen in utilization of critical zone despite reduction in number of cases. Attendance to semi-critical zones showed significant differences in April to June 2020 with reduction of 47% (p<0.001), 33% (p=0.029), and 29.5% (p=0.021), respectively. Non-critical zone saw significant difference in its utilization from April to October 2020 compared to preceding year Conclusions: This study showed Malaysian perspective of COVID-19 effects on ED utilization during the first outbreak wave. Despite general reduction in total attendance, ED still receives substantial number of critical patients with high-acuity presentations.