Features of Gastrointestinal Disorders in Children with Multisystem Inflammatory Syndrome Associated with Covid-19

Gastrointestinal tract damage is a part of the course of multisystem inflammatory syndrome in children (MVS-D) associated with the new COVID-19 coronavirus infection. According to the results of a retrospective study, gastrointestinal tract damage was detected in 77% of patients with MVS-D and is represented by signs such as abdominal pain, vomiting, diarrhea and peritoneal symptoms. In children with gastrointestinal tract lesions, significant differences were noted in the frequency of occurrence of the following signs: hepatomegaly, splenomegaly, hypotension/shock, as well as conjunctivitis and facial swelling. Among laboratory abnormalities, hypoalbuminemia is more characteristic, but the level of CRP and troponin is higher. The article shows that gastrointestinal tract damage is an important early predictor of the severity of MVS-D.

Multisystem Inflammatory Syndrome in Children (Clinical Observation)

Multisystem inflammatory syndrome is the most severe manifestation of a new coronavirus infection in children. The article presents the clinical case of the multisystem inflammatory syndrome features associated with COVID-19 in a teenager. The purpose of the work is to provide information on this topical clinical problem.

MONITORING OF CHILDREN WITH KAWASAKI-LIKE (MULTISYSTEM INFLAMMATORY) SYNDROME IN THE EAST SIBERIAN AREA OF RUSSIA

The pathogenetic basis for Pediatric Multisystem Inflammatory Syndrome (PMIS) associated with SARS-CoV-2 is systemic vasculitis resulting from hyperproduction of pro-inflammatory cytokines associated with dysregulation of the immune response. Clinical manifestations of PMIS include fever with features of Kawasaki Syndrome (KS) and multi-organ dysfunction coupled with frequent unusual heart involvement, ranging from mild with minimal ECG changes or elevated troponin to fulminant myocarditis or Takotsubo syndrome (TTS). The purpose of the research was to study the characteristics of cardiovascular disorders in Kawasaki-like multisystem inflammatory syndrome associated with COVID-19 in children observed in the East Siberian area of Russia. A single-center retrospective cohort study was carried out on the basis of the Irkutsk Oblast Regional Children's Clinical Hospital (Irkutsk, Russia): 36 patients with PMIS associated with COVID-19 in Nov. 18, 2020 - Dec. 31, 2021, including 21 boys (M/F ratio 1.4:1) at the average age of 7.5 years old (1.5 months to 17 years old). The diagnostic signs of KS were observed in 34 (94%) children, including the complete set of diagnostic signs in 21 (58%). Refractory fever and a sharp increase in inflammatory biomarkers were detected in all 36 (100%) children;multiorgan dysfunction in 31 (86%);thrombocytopenia in 24 (67%);gastrointestinal syndrome in 25 (69%);cerebral dysfunction in 24 (66)%;various cardiovascular disorders in 30 (83%), including: dilatation of the left ventricle (LV) and a decrease in myocardial contractility in 3 (8%);moderate coronary dilatation in 5 (14%);thickening of the posterior LV walls in diastole in 5 (13%);thickening of the interventricular septum in diastole in 6 (16%). According to the MRI results performed in 15 children the signs of myocardial damage were found in 6 (40%). LV dilatation and decreased myocardial contractility were noted in 3 (8%) children, clinically apparent thrombotic complications in 3 (8%) children as well, and severe neurological deficit in one patient (3%). An increase in the level of D-dimer was observed in 26 (72%) patients, thrombocytopenia in 24 (67%), a statistically significant correlation between thrombocytopenia and myocardial damage was found (R=-0.506, p=0.001). The treatment measures were given as follows: inotropic support (dobutrex/dobutamine) was received by 8 (22%), artificial lung ventilation - by 8 (22%), intravenous human immunoglobulin 1.5-2.0 g/kg/course - by 28 (77%), dexamethasone - by 24 (67%), tocilizumab - by 2 (5%) patients. All 36 (100%) patients have survived. Conclusion(s): the Kawasaki-like multisystem inflammatory syndrome associated with COVID-19 was accompanied by the cardiovascular disorders (pericarditis, arrhythmias, abnormal ECG changes, elevated troponin and/or natriuretic peptide, LV thickening on echocardiography, coronary dilatation) in most patients, although LV dilatation and decreased myocardial contractility were observed in a few cases only. A negative correlation between thrombocytopenia and myocardial damage was found, which may indicate the involvement of thrombotic microvascular inflammation in the genesis of myocardial disorders. Copyright © 2022, Pediatria Ltd. All rights reserved.

Heart injury in patients with multisystem inflammatory syndrome associated with sars-cov-2: A description of a series of clinical cases

Multisystem inflammatory syndrome in children and adolescents associated with SARS-CoV-2 (MBS-D) is a new challenge for pediatricians around the world. Scientific data is updated daily and patient treatment regimens are developed. The involvement of the heart in the inflammatory process complicates the course of the disease and further rehabilitation of patients. The article describes 12 patients with heart disease in the structure of MVS-D, who underwent laboratory tests and instrumental studies, including MRI of the heart, and also provides detailed descriptions of three clinical cases and a review of literature data. © 2021, Pediatria Ltd.. All rights reserved.

safety of antibodies to measles, mumps, rubella and diphtheria in patients with juvenile idiopathic arthritis

Introduction. The issue of protection against vaccine-preventable diseases has acquired new urgency in connection with the decrease in the vaccination rate established by WHO against the background of the COVID-19 pandemic. This creates the conditions for outbreaks and puts patients with immunopathological diseases at particular risk, who are most often not vaccinated from the moment of diagnosis Purpose of the study – to assess the safety of specific antibodies to measles, mumps, rubella and diphtheria in children with JIA, depending on the duration of vaccination, the duration of the disease and the therapy received. Materials and methods. The vaccination rate of 171 children with juvenile idiopathic arthritis (JIA) aged (11,31±0,31 years) with the duration of the disease at the time of examination was 4,69±0,29 years, who had previously received 1-2 vaccinations against measles, mumps, rubella and 3-6 vaccinations against diphtheria. Antibodies to these infections were determined by ELISA. Results. 42.1% of children had no protective titers of antibodies to measles, 19,9% – to mumps, 9,4% – to rubella and 16,4% – to diphtheria. Among 93 vaccinated and revaccinated patients, there were no protective titers of antibodies to measles – 40,9% (38 children), mumps – 13,9% (13 people), rubella – 5,4% (5 children), and among 78 vaccinated once, respectively: measles – 43.6% (34 children), mumps – 25.6% (20 children), rubella – 14,1% (11). The level of protection against diphtheria was comparable for those who received 3-5 vaccinations. Depending on the therapy, 3 groups were identified: group 1-71 children received metatrexate and glucocorticosteroids, 2-82 children received modifying anti-rheumatic drugs (DMARD) and 18 children without this therapy (Group 3). Children of the 2nd group were on average older (12,48±0,42 years) than in the 1st and 3rd groups (10,04±0,48 and 10,96±0,96 years, respectively), they had significantly more frequent systemic variant and polyarthritis (64,6% compared to 36,6% and 16,7%, px2<0,001). The number of vaccine doses received by children in all groups before the onset of the disease did not significantly differ. The average level of antibodies to measles in children of group 2 (0,32±0,07 IU/ml) was 2,8 times less than in group 3 and significantly less than in group 1 (0,78±0,16, Pt=0.009), the average value of antibodies to rubella was also significantly less in group 2 (84,48±7,34 IU/ml) than in group 1 (109,73±8,09, Pt=0,022) and in group 3 (120,01±15,42, Pt=0,042). The analysis showed that the safety of antibodies to antigens of live vaccines, especially against measles, is negatively affected by the duration of the disease and the nature of therapy. Children who received combined therapy with anti-TNF, anti-IL-6 and anti-CD-80 drugs had a longer duration of the disease (7,5±0,97 years)=0,00082 compared to those who received only anti-IL-6 (2,9±0,7 years) and anti-TNF therapy (6,1±0,5 years) and with a comparable number of vaccine doses received, significantly lower average values of antibodies and a larger number of unprotected ones. Conclusions. The duration of the disease, the lack of timely age-related revaccinations, as well as the presence of combination therapy aimed at suppressing various mechanisms of the immune response in children with JIA are factors that lead to an increase in the number of unprotected from controlled infections. Immunity to measles suffers the most – 40.9% of revaccinated people are unprotected.

Pediatric multisystem inflammatory syndrome associated with a new coronavirus infection: unresolved issues

Since March 2020, the first reports have appeared about the increasing, almost everywhere, number of children who have undergone a new coronovirus infection caused by SARS-Cov-2 with a symptom complex resembling the manifestations of Kawasaki disease. A special feature of the clinical manifestations of this syndrome, which is called “Pediatric multisystem inflammatory syndrome associated with COVID-19”, is the high incidence of life-threatening conditions caused by the sharp development of arterial hypotension against the background of cardiogenic or vasogenic shock. In St. Petersburg, since the end of November 2020, there has been a sharp surge in admissions of children to the ICU of various hospitals with the clinic of Pediatric multisystem inflammatory syndrome, who have laboratory confirmation of the transferred COVID-19. The purpose of this article is to attract the attention of doctors of various profiles, to combine efforts to study this pathology, to determine the criteria for verifying the diagnosis, optimal treatment regimens and dispensary monitoring of patients who have been ill. © 2021 Interregional public organization Association of infectious disease specialists of Saint-Petersburg and Leningrad region (IPO AIDSSPbR). All rights reserved.

Kawasaki disease and multisystem inflammatory syndrome in children with COVID-19 infection

During the COVD-19 pandemic, some pediatric patients in many countries around the world experienced a syndrome resembling a severe Kawasaki disease (KD), often accompanied by shock. Due to the incomplete signs of the classic KD in the era before the present pandemic, in many publications from European countries and the United States, this condition was called «multisystem inflammatory syndrome in children - MIS-C» or «hyperinflammatory shock» or «Kawasaki-like syndrome». This syndrome with a new coronavirus infection is characterized by refractory fever, frequent gastrointestinal symptoms, heart damage (including coronary dilation in some patients, and acute left ventricular failure in the majority), increased ESR and CRP levels, neutrophilia, extremely high troponin levels, increased ferritin, AST, ALT, lactate dehydrogenase, creatine phosphate kinase, interleukin-6 and interleukin-10, coagulopathy with an increase in D-dimer and fibrinogen, thrombocytopenia, sometimes procalcitonin increase. The manifestations of a cytokine storm may meet the criteria for secondary hemophagocytic syndrome. The mechanism of myocardial damage remains unclear. Treatment with high-dose intravenous immunoglobulin is effective, and in the presence of signs of hemophagocytic syndrome, dexamethasone or methylprednisolone. Further research is needed to understand the pathogenesis, resemblance and differences of this syndrome with classic KD, understanding of heart injuiry and early recognition for the need of urgent care. В ходе пандемии COVD-19 у части пациентов детского возраста во многих странах мира отмечен синдром, напоминающий тяжелый вариант болезни Кавасаки (БК), часто сопровождаемый шоком. Ввиду неполного его соответствия классической БК в эру до настоящей пандемии во многих публикациях из европейских стран и США это состояние получило название «мультисистемный воспалительный синдром», либо «гипервоспалительный шок», либо «Кавасаки-подобный синдром». Для данного синдрома при новой коронавирусной инфекции характерны рефрактерная лихорадка, частые гастроинтестинальные симптомы, поражение сердца (включая коронарную дилатацию у части больных и острую левожелудочковую недостаточность у большинства), повышение уровня СОЭ и СРБ, нейтрофилез, экстремально высокий уровень тропонина, рост ферритина, АСТ, АЛТ, лактатдегидрогеназы, креатинфосфаткиназы, интерлейкина-6 и интерлейкина-10, коагулопатия с увеличением Д-димера и фибриногена, тромбоцитопения, иногда рост прокальцитонина. Проявления цитокинового шторма могут отвечать критериям вторичного гемофагоцитарного синдрома (ГФС). Механизм поражения миокарда остается неясным. Эффективно лечение высокодозным внутривенным иммуноглобулином, при наличии признаков ГФС - дексаметазоном либо метилпреднизолоном. Дальнейшие исследования необходимы для понимания патогенеза, сходства и различия данного синдрома с классической БК, механизма поражения сердца, раннего распознавания для оказания ургентной помощи.

Features of current and intensive therapy of new coronavirus infection in children with comorbidities (clinical cases)

The risk of a severe course of new coronavirus infection (COVID-19) due to the development of acute respiratory distress syndrome is extremely high, which is especially true for patients with comorbidities. The aim of the study is to demonstrate the peculiarities of the course and intensive care measures in new coronavirus infection COVID-19 in children with comorbidities. Patients and methods: On the example of clinical cases, the characteristics of the course of a new coronavirus infection of COVID-19 in children with systemic lupus erythematosus and bronchopulmonary dysplasia are considered. Results: The main data from the history and clinical laboratory examination are reflected, which made it possible to identify a cytokine storm in a timely manner, a high risk of adverse course and begin timely specific pathogenetic therapy, including immunoglobulins for intravenous administration, hydroxychloroquine, ritonavir in combination with lopinavir, azithromycin and dexamethasone. Particular attention is paid to the need to limit infusion therapy, maintain a negative water balance and optimal blood oxygen capacity, ambiguity of opinions on the need for routine use of albumin and dexamethasone solutions in patients with COVID-19 has been demonstrated. Conclusion: Children with comorbidities are characterized by a severe course of a new coronavirus infection CO-VID-19, which requires timely pathogenetic therapy taking into account the individual characteristics of the patient.