ABSTRACT
Objective: To present paediatric cases of unusual neuroinflammatory conditions encountered during the COVID-19 pandemic in Trinidad & Tobago. Methods: Retrospective study design. Inpatient paediatric patients (aged 0-16 years) hospitalized for neurological complaints from June 2020 - August 2021 at EWMSC. Outcome measures were age at presentation, sex, ethnicity, diagnosis, radiological findings, blood/CSF findings, COVID-19 PCR and antibodies testing, treatment, outcomes and other systems involved. Results: Twenty (20) patients (aged 4-months-old to 15-years-old) had documented neurological involvement. 50% had a diagnosis of ADEM/ADS/AHNE;45% had a diagnosis of either CNS vasculitis (n=3), autoimmune encephalitis (n=3) or GBS (n=3);5% had a diagnosis of acute COVID-19 encephalitis. 70% were of African descent. The youngest age group (0-4 years) (n=11) constituted more males (82%) whereas the eldest age group (10-15 years) (n=3) were all females. Neuroimaging findings were corpus callosal lesions;deep white matter T2 hyperintensities;cerebellar involvement;area postrema and brainstem/C-spine involvement;microhaemorrhages and necrotizing/haemorrhagic lesions (peripheral/central). 70% of patients were either SARS-CoV-2 PCR or COVID-19 antibodies positive. Other systems were involved in 40% to 62.5% (n=5) had cardiac involvement (myocarditis, coronary arteries dilatation, valve regurgitation) and 37.5% (n=3) had pancreatic involvement (autoimmune pancreatitis, type 1 diabetes mellitus). Treatment modalities for CNS manifestations (n=17) were clinically based - 24% (n=4) 3rd line treatment, 29% (n=5) 2nd line treatment, 41% (n=7) 1st line treatment and 6% (n=1) requiring no treatment. All 3 patients with a diagnosis of GBS responded appropriately to IVIG. Developmental outcomes were worst in patients with a diagnosis of autoimmune encephalitis. Conclusion: We have had an explosion of neuro-inflammatory cases since the COVID-19 pandemic began. The range of neuroradiological diagnoses and other systemic involvement (including criteria for PIMS) are interesting, alluding to a neuroinflammatory mechanism. Effects on long-term sequelae and developmental outcomes are concerning in some cases, however, still unknown at this stage.
ABSTRACT
Clinical findings: NC, a 20-month-old male presented in July 2020 with new-onset focal motor seizures, drowsiness and developmental regression. There was a preceding history of fever, vomiting and diarrhoea about 1 to 2 weeks prior to presenting. On examination, he was noted to have erythema nodosum over his shins, unable to fix and follow even to light stimulus, no head nor trunk control with generalized increased tone, hyperreflexia and upgoing plantar responses bilaterally. Investigations: Blood investigations: lymphopenia, mild increase in ESR 16mm/hr, transaminases elevated, CK elevated. CSF investigations: CSF protein 143mg/dL, glucose 88mg/dL, CSF cell count 28 white cells, 17 red cells. EEG: background slowing right > left. MRI brain (initial): transient lesions along corpus callosum, petechial haemorrhages within superior aspect of cerebellar vermis Treatment: He was treated with 5 days IV methylprednisolone 30mg/kg/day followed by oral prednisolone. He was treated as a protracted ADEM illness with IVIG (2g/kg over 2 days) when he clinically deteriorated. Steroids were slowly tapered over 8 weeks. Progress: 2 weeks post IVIG-speech and language milestones improved to baseline, started cruising. 6 weeks post IVIG-able to walk independently however, not able to climb/run. Follow-up investigations: 2 months post admission: 2019-CoV IgM Antibodies (blood): 1.123 (range 0-1). Of note, we have had a total of 4 patients managed for ADEM within the past 3 months. 3 presented with preceding viral GE symptoms. Most recently the other was initially managed for Kawasaki disease and is also COVID 19 IgM positive. We are awaiting COVID-19 antibody testing for these patients to determine whether they are linked. Unfortunately, in our resource-limited setting, PCR testing was initially only performed on patients with a travel history and respiratory symptoms.