Post-COVID-19 paediatric inflammatory multisystem syndrome: association of ethnicity, key worker and socioeconomic status with risk and severity.

OBJECTIVES: Patients from ethnic minority groups and key workers are over-represented among adults hospitalised or dying from COVID-19. In this population-based retrospective cohort, we describe the association of ethnicity, socioeconomic and family key worker status with incidence and severity of Paediatric Inflammatory Multisystem Syndrome Temporally associated with SARS-CoV-2 (PIMS-TS). SETTING: Evelina London Children's Hospital (ELCH), the tertiary paediatric hospital for the South Thames Retrieval Service (STRS) region. PARTICIPANTS: 70 children with PIMS-TS admitted 14 February 2020-2 June 2020. OUTCOME MEASURES: Incidence and crude ORs are presented, comparing ethnicity and socioeconomic status of our cohort and the catchment population, using census data and Index of Multiple Deprivation (IMD). Regression is used to estimate the association of ethnicity and IMD with admission duration and requirement for intensive care, inotropes and ventilation. RESULTS: Incidence was significantly higher in children from black (25.0 cases per 100 000 population), Asian (6.4/100 000) and other (17.8/100 000) ethnic groups, compared with 1.6/100 000 in white ethnic groups (ORs 15.7, 4.0 and 11.2, respectively). Incidence was higher in the three most deprived quintiles compared with the least deprived quintile (eg, 8.1/100 000 in quintile 1 vs 1.6/100 000 in quintile 5, OR 5.2). Proportions of families with key workers (50%) exceeded catchment proportions. Admission length of stay was 38% longer in children from black ethnic groups than white (95% CI 4% to 82%; median 8 days vs 6 days). 9/10 children requiring ventilation were from black ethnic groups. CONCLUSIONS: Children in ethnic minority groups, living in more deprived areas and in key worker families are over-represented. Children in black ethnic groups had longer admissions; ethnicity may be associated with ventilation requirement.This project was registered with the ELCH audit and service evaluation team, ref. no 11186.

Systemic Inflammation Is Associated With Neurologic Involvement in Pediatric Inflammatory Multisystem Syndrome Associated With SARS-CoV-2.

OBJECTIVE: Pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) is a severe immune-mediated disorder. We aim to report the neurologic features of children with PIMS-TS. METHODS: We identified children presenting to a large children's hospital with PIMS-TS from March to June 2020 and performed a retrospective medical note review, identifying clinical and investigative features alongside short-term outcome of children presenting with neurologic symptoms. RESULTS: Seventy-five patients with PIMS-TS were identified, 9 (12%) had neurologic involvement: altered conciseness (3), behavioral changes (3), focal neurology deficits (2), persistent headaches (2), hallucinations (2), excessive sleepiness (1), and new-onset focal seizures (1). Four patients had cranial images abnormalities. At 3-month follow-up, 1 child had died, 1 had hemiparesis, 3 had behavioral changes, and 4 completely recovered. Systemic inflammatory and prothrombotic markers were higher in patients with neurologic involvement (mean highest CRP 267 vs 202 mg/L, p = 0.05; procalcitonin 30.65 vs 13.11 µg/L, p = 0.04; fibrinogen 7.04 vs 6.17 g/L, p = 0.07; d-dimers 19.68 vs 7.35 mg/L, p = 0.005). Among patients with neurologic involvement, these markers were higher in those without full recovery at 3 months (ferritin 2284 vs 283 µg/L, p = 0.05; d-dimers 30.34 vs 6.37 mg/L, p = 0.04). Patients with and without neurologic involvement shared similar risk factors for PIMS-TS (Black, Asian and Minority Ethnic ethnicity 78% vs 70%, obese/overweight 56% vs 42%). CONCLUSIONS: Broad neurologic features were found in 12% patients with PIMS-TS. By 3-month follow-up, half of these surviving children had recovered fully without neurologic impairment. Significantly higher systemic inflammatory markers were identified in children with neurologic involvement and in those who had not recovered fully.

The value of a paediatric rheumatology virtual ward round during COVID

BackgroundWe aim to provide high value care through optimum patient outcomes with limited resource. As our service has grown rapidly, we identified need for managing complex cases in a different way. To avoid admissions yet allow our team to consider each case in depth and carefully monitor patients remotely over time. We undertook a service redesign project to optimise management of our complex high risk patients through a weekly virtual ward round. This was chaired by the Rheumatology CNS with attendance from Clinical Fellows and Consultants. Consequently, we were able to avoid loss to follow up and potential undesirable events including admissions to local hospitals, loss of schooling or parental work absence. Here we describe the process and value of the virtual ward round.ObjectivesActive monitoring of high risk, high need complex patientsReduce admission ratesRemotely manage/avoid unnecessary appointmentsReduce unnecessary GP contactsMethodsRetrospective reviews of the weekly minutes with both qualitative and quantitative data collected. The CNS team generated a list of patients with clinical or social concerns, complex disease, frequent contact, upcoming transition, regular infusions and inpatients. Patients were divided into three categories;red, amber and green to highlight the concern level. Patients moved between groups as required and were taken off the list once concerns were dealt with.ResultsAn average of 58 patients were listed each week from a database of 791 and 16 decisions made on average. Discussions focussed on areas of concern therefore not all patients were discussed at each meeting. These decisions included new requests for day unit treatment/assessment, medication changes, changing appointments, referral to other specialties and whether patients can be removed from the list. There were no unexpected outpatients admitted. Patient conditions included Juvenile Idiopathic Arthritis, Systemic Lupus Erythematosus, Juvenile Dermatomyositis, Vasculitis, Scleroderma and Mixed Connective Tissue Disease with decisions leading to involvement from our colleagues in the dermatology and renal departments for many. A significant proportion of patients were added to the list due to social concerns or poor engagement.ConclusionsThis project identified the high level of productivity possible by continuing a weekly virtual ward round during a very difficult year. It is a reliable and resilient method for the team to keep track of a complex patient cohort. Data collection also highlighted the valuable learning for individuals and the team as a whole by sharing knowledge, discussing treatment plans and problem solving difficult cases. Limitations to this project include limited prospective data collection for contemporaneous analysis and the use of very basic computer systems to record outcomes. Going forward we plan to develop this meeting with the potential to upscale and use similar formats for other patient groups. It would also be important to assess technology options available to assist more detailed documentation and analysis of the outcomes. Through this low cost implementation there has been highly valuable output with overall improvement of patient care quality and consistency.

PIMS or not? Alternative diagnoses in the febrile child during the COVID-19 pandemic

BackgroundThe majority of children and young people affected by COVID-19 have remained asymptomatic or suffered mild illnesses. However throughout the pandemic patients with a novel rare but severe disease phenotype, Paediatric Inflammatory Multisystem Syndrome Temporally associated with SARS-CoV-2 (PIMS-TS)1 continue to need hospital admission. The importance of considering the wider differential such as malignancies should be highlighted.ObjectivesTo establish the range of diagnoses of children admitted to a tertiary London children’s hospital presenting with a history of fever and high CRP, in whom PIMS-TS was considered as a diagnosis, during the COVID-19 pandemic.MethodsClinical records from 1st March 2020 to 30th June 2020 (inclusive) were retrospectively analysed to identify patients under the age of 18 years admitted to a tertiary London children’s hospital with a history of fever and CRP >60. Electronic notes were reviewed to determine final diagnosis.Results140 patients were admitted with a history of fever and CRP >60 during the study period. 58% (n=81) had PIMS-TS and 42% (n=59) had alternative diagnoses. Of those with an alternative diagnosis 81% (n=48) had infective diagnoses and of these 46% (n=22) had upper or lower respiratory tract infections;25% (n=12) had sepsis;13% (n=6) had urinary tract infections or pyelonephritis;10% (n=5) had gastroenteritis;4% (n=2) had lymphadenitis and 2% (n=1) had meningitis. 10% (n=5) had surgical diagnoses most commonly appendicitis (n=3). 5% (n=3) had inflammatory diagnoses;2 with an exacerbation of Crohn’s disease and 1 with vasculitis. 3% (n=2) had autoimmune diagnoses, 1 with juvenile idiopathic arthritis and 1 with Still’s disease who developed macrophage activation syndrome. 2% (n=1) had Burkitt leukaemia.ConclusionsIn the midst of a pandemic there is a high suspicion of PIMS-TS in unwell febrile children. The high numbers of patients with PIMS-TS admitted to this hospital reflects the regional referrals pathway for the PIMS-TS patients during the first wave of COVID-19. However infections remain a major cause of children presenting with fever and a high CRP. The range of alternative diagnoses outlined in our cohort is not surprising, when one considers that PIMS-TS is a disease with a subjective and broad case definition, with signs and symptoms overlapping with other serious diagnoses – infectious, surgical, inflammatory, autoimmune and malignant.The wider differential diagnoses should always be considered when children present with fever and a thorough history and examination is paramount. Alternative diagnoses may have indolent or more chronic symptoms. Our experience has shown that discussion within a multidisciplinary team has helped to ensure alternate diagnoses are not missed.ReferenceHealth Service Journal. National alert as ‘coronavirus-related condition may be emerging in children. April 2020. Available from: https://www.hsj.co.uk/acute-care/exclusive-national-alert-as-coronavirus-related-condition-may-be-emerging-in-children/7027496.article (Last accessed 5th March 2021).

Spectrum of Imaging Findings at Chest Radiography, US, CT, and MRI in Multisystem Inflammatory Syndrome in Children Associated with COVID-19.

This case series examines the spectrum of imaging findings at chest radiography, US, CT, and MRI in 35 children admitted to a tertiary pediatric hospital in April and May 2020 with a post-coronavirus disease 2019 inflammatory condition known as multisystem inflammatory syndrome in children. The constellation of findings includes airway inflammation and rapid development of pulmonary edema on thoracic images, coronary artery aneurysms, and extensive right iliac fossa inflammatory changes on abdominal images. Awareness of this emerging condition and the expected multi-organ imaging findings will aid radiologists in the assessment of these complex cases.

Adaptations to the current ECCO/ESPGHAN guidelines on the management of paediatric acute severe colitis in the context of the COVID-19 pandemic: a RAND appropriateness panel.

OBJECTIVE: Paediatric acute severe colitis (ASC) management during the novel SARS-CoV-2/COVID-19 pandemic is challenging due to reliance on immunosuppression and the potential for surgery. We aimed to provide COVID-19-specific guidance using the European Crohn's and Colitis Organisation/European Society for Paediatric Gastroenterology, Hepatology and Nutrition guidelines for comparison. DESIGN: We convened a RAND appropriateness panel comprising 14 paediatric gastroenterologists and paediatric experts in surgery, rheumatology, respiratory and infectious diseases. Panellists rated the appropriateness of interventions for ASC in the context of the COVID-19 pandemic. Results were discussed at a moderated meeting prior to a second survey. RESULTS: Panellists recommended patients with ASC have a SARS-CoV-2 swab and expedited biological screening on admission and should be isolated. A positive swab should trigger discussion with a COVID-19 specialist. Sigmoidoscopy was recommended prior to escalation to second-line therapy or colectomy. Methylprednisolone was considered appropriate first-line management in all, including those with symptomatic COVID-19. Thromboprophylaxis was also recommended in all. In patients requiring second-line therapy, infliximab was considered appropriate irrespective of SARS-CoV-2 status. Delaying colectomy due to SARS-CoV-2 infection was considered inappropriate. Corticosteroid tapering over 8-10 weeks was deemed appropriate for all. After successful corticosteroid rescue, thiopurine maintenance was rated appropriate in patients with negative SARS-CoV-2 swab and asymptomatic patients with positive swab but uncertain in symptomatic COVID-19. CONCLUSION: Our COVID-19-specific adaptations to paediatric ASC guidelines using a RAND panel generally support existing recommendations, particularly the use of corticosteroids and escalation to infliximab, irrespective of SARS-CoV-2 status. Consideration of routine prophylactic anticoagulation was recommended.