ABSTRACT
Background and Aim: Cardiac involvement is seen in the majority of cases with multisystem inflammatory syndrome in children (MIS-C). Various rhythm and conduction disturbances, as well as repolarization abnormalities, have been described by more than 50% of the patients, while there are few cases with complete heart block or with asystole. Method(s): Case report Results: 8-year old girl presented with a 5-day history of fever, cough, headache, and abdominal pain. Because of the critical con-dition, with respiratory insufficiency and heart failure symptoms, the child was intubated and started on inotropic support. ECG showed complete AV-block with a ventricular rate of 75/min and with ST-T changes;echocardiography revealed dilated left ventricle with reduced contractility, CT-scan of the lungs showed bilateral pneumonia, the inflammatory markers were elevated, in combination with high troponin levels, and positive SARS-CoV2-IgG antibodies. The diagnosis MIS-C was made and treatment with immunoglobulins, antibiotics, corticosteroids, and anticoagulants was initiated. During the next 2 days, the cardiac function deteriorated further, and while still on mechanical ventilation and inotropic support, extreme bradycardia with a ventricular rate of 35/min was regis-tered, and the patient was indicated for temporary emergency pac-ing. Upon induction of anesthesia, the child became asystolic, requiring extensive resuscitation. After circulation recovery, the ECG showed nodal tachycardia with a heart rate of 140-170/min. A temporary transvenous pacemaker (PM) was inserted, and the patient was started on intravenous amiodarone which resulted in a slower ventricular rate of 70/min. 3 days later sinus rhythm was restored, with first-degree AV-block, which allowed removal of the PM 5 days after its insertion. Left ventricular dimensions were normalized and contractility remained low-normal (EF 56%). During the 6-month follow-up, the ECG and the Holter-monitoring showed sinus rhythm with first-degree AV-block. Magnetic resonance imaging (MRI) on day 15 of the hospital stay demonstrated scattered areas of myocarditis and ischemia predominantly in the left ventricle, as well as thickening of the basal septum. Six months later the MRI changes were reduced but still persistent. Conclusion(s): MIS-C can present with serious and life-threatening rhythm and conduction disturbances in children;this is why extensive cardiac monitoring is obligatory by all patients.
ABSTRACT
Symptoms of acute Covid-19 infection are less common in children than in adults. In most cases, the symptoms are mild or absent. However, after contact with SARS-CoV-2, children may develop post-infectious hyperinflammatory syndrome - multisystem inflammatory syndrome in children (Multisystem Inflammatory Syndrome in Children MIS-C). We present 6 children with MIS-C, observed in November and December 2020 during the peak incidence of Covid-19 infection in Bulgaria. Patients have a mean age of 9.7 years. Four of the children had a history of contact with Covid-19. Clinically, they presented with fever and gastrointestinal symptoms. SARSCoV2 IgM and IgG serology was positive in all patients. Troponin and pro-BNP (B-type natriuretic peptide) levels were elevated in all six children. Cardiac ultrasound revealed systolic dysfunction of the left ventricle (reduce ejection fraction) in all of them. When cardiac MRI was performed, limited areas of left ventricular myocardial edema, as well as areas of late non-ischemic gadolinium amplification involving up to 25% of the myocardium, were founded. Treatment in all patients includes a broad-spectrum antibiotic, intravenous immunoglobulin, corticosteroids, diuretic, ACE inhibitor, and low molecular weight heparin. At discharge, all patients were in good overall condition, with no signs of heart failure, normal echocardiographic findings, and laboratory tests. In children the mortality from MIS-C is not high, despite significant increase in inflammatory markers and multisystem symptoms. In our patients, the short term outcome of MIS-C is favorable. However, long-term follow-up is needed for late complications. © 2021 Academy of Medicine. All rights reserved.