ABSTRACT
Introduction/Background Paediatric inflammatory multisystem syndrome temporally associated with COVID-19 (PIMS-TS) is a novel condition with poorly understood pathophysiology. Acute presentation varies, with some children acutely unwell in systemic shock, whereas others may have features of Kawasaki disease. This study reports on the presence of gastrointestinal (GI) symptoms and subsequent investigations in children with PIMS-TS at presentation and follow-up, in a large cohort from a tertiary/quaternary paediatric centre. Aim The aim of this prospective observational cohort study is to characterise the gastrointestinal impact of children with PIMS-TS at presentation and at first follow-up. Subjects and Methods Patients from one paediatric centre within the multidisciplinary PIMS-TS service were identified, meeting the following inclusion criteria: under 18 years old, satisfying RCPCH criteria for PIMS-TS, admitted during their acute presentation between 25/4/20-01/12/20. Clinical presentation, symptom profile and initial management were recorded. Investigations including biochemical and inflammatory profiles, stool calprotectin and abdominal imaging (US-Small bowel and CT- Abdomen) were documented. On discharge, GI symptoms and investigations were monitored on subsequent assessments using a standardised template. Results 54 children were identified (35 male), with a median age of 10.3 years (x = 10.0, range 0.75-17.2y). 48/54 (94%) of children had GI symptoms on presentation to admitting hospital (abdominal pain 76%, vomiting 59%, diarrhoea 57%, nausea 35% and ascites 22%). See figure 1. Faecal calprotectin was not a recommended investigation in the UK National PIMS-TS consensus (Delphi process), as such was only performed on 3/54 children at presentation. All of which were within normal range Elevated ALT, AST and/or GGT were seen in 63% of children. Abdominal imaging was performed in 36/54 (67%) of total cohort. On CT abdomen 22/36 (61%) had abnormal abdominal findings (ileocolitis [5/8, 63%], hepatobiliary abnormalities [2/8, 26%]). On abdominal ultrasound (ascites [13/32, 40%], hepatobiliary abnormalities [10/32, 31%], ileocolitis [10/32, 31%], mesenteric adenitis [4/32, 13%], appendicitis [2/32, 6%]) were seen. All patients were reviewed following discharge. On first review (mean: 54 days from discharge), there was resolution of GI symptoms in 96% of the total cohort, however 19% continued to have abnormal abdominal imaging (predominately hepatobiliary abnormalities) and 15% had persistently raised transaminases. 23/54 (43%) children had a faecal calprotectin analysed during the follow-up period - 48% (11/23) had an elevated calprotectin >50mug/g (range 55-399). Summary and Conclusion PIMS-TS has predominately been characterised as a rare condition that effects the cardiovascular system and/or is signified by symptoms of fever and circulatory shock. This study demonstrates the high incidence of GI symptoms at presentation. Abnormalities in transaminases and abdominal imaging and are seen in significant numbers, notably inflammation in the distal ileum and proximal colon and hepatobiliary abnormalities which persist in 19% at their first review. Increased faecal calprotectin levels seen at follow-up, suggest utility at testing at admission. The prevalence of abdominal symptoms may aid the differentiation between Kawasaki disease and PIMS-TS. The persistence of abdominal symptoms, abnormal abdominal imaging and biochemical markers indicate follow-up is required to better understand the long-term GI implications and prognosis of this condition.