Medium-Term Cardiac Outcomes in Young People with Multi-system Inflammatory Syndrome: The Era of COVID-19.

Multi-system inflammatory syndrome in children (MIS-C) causes widespread inflammation including a pancarditis in the weeks following a COVID infection. As we prepare for further coronavirus surges, understanding the medium-term cardiac impacts of this condition is important for allocating healthcare resources. A retrospective single-center study of 67 consecutive patients with MIS-C was performed evaluating echocardiographic and electrocardiographic (ECG) findings to determine the point of worst cardiac dysfunction during the admission, then at intervals of 6-8 weeks and 6-8 months. Worst cardiac function occurred 6.8 ± 2.4 days after the onset of fever with mean 3D left ventricle (LV) ejection fraction (EF) 50.5 ± 9.8%. A pancarditis was typically present: 46.3% had cardiac impairment; 31.3% had pericardial effusion; 26.8% demonstrated moderate (or worse) valvar regurgitation; and 26.8% had coronary dilatation. Cardiac function normalized in all patients by 6-8 weeks (mean 3D LV EF 61.3 ± 4.4%, p < 0.001 compared to presentation). Coronary dilatation resolved in all but one patient who initially developed large aneurysms at presentation, which persisted 6 months later. ECG changes predominantly featured T-wave changes resolving at follow-up. Adverse events included need for ECMO (n = 2), death as an ECMO-related complication (n = 1), LV thrombus formation (n = 1), and subendocardial infarction (n = 1). MIS-C causes a pancarditis. In the majority, discharge from long-term follow-up can be considered as full cardiac recovery is expected by 8 weeks. The exception includes patients with medium sized aneurysms or greater as these may persist and require on-going surveillance.

Myocardial involvement in children with post-COVID multisystem inflammatory syndrome: a cardiovascular magnetic resonance based multicenter international study-the CARDOVID registry.

BACKGROUND: Recent evidence shows an association between coronavirus disease 2019 (COVID-19) infection and a severe inflammatory syndrome in children. Cardiovascular magnetic resonance (CMR) data about myocardial injury in children are limited to small cohorts. The aim of this multicenter, international registry is to describe clinical and cardiac characteristics of multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19 using CMR so as to better understand the real extent of myocardial damage in this vulnerable cohort. METHODS AND RESULTS: Hundred-eleven patients meeting the World Health Organization criteria for MIS-C associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), having clinical cardiac involvement and having received CMR imaging scan were included from 17 centers. Median age at disease onset was 10.0 years (IQR 7.0-13.8). The majority of children had COVID-19 serology positive (98%) with 27% of children still having both, positive serology and polymerase chain reaction (PCR). CMR was performed at a median of 28 days (19-47) after onset of symptoms. Twenty out of 111 (18%) patients had CMR criteria for acute myocarditis (as defined by the Lake Louise Criteria) with 18/20 showing subepicardial late gadolinium enhancement (LGE). CMR myocarditis was significantly associated with New York Heart Association class IV (p = 0.005, OR 6.56 (95%-CI 1.87-23.00)) and the need for mechanical support (p = 0.039, OR 4.98 (95%-CI 1.18-21.02)). At discharge, 11/111 (10%) patients still had left ventricular systolic dysfunction. CONCLUSION: No CMR evidence of myocardial damage was found in most of our MIS-C cohort. Nevertheless, acute myocarditis is a possible manifestation of MIS-C associated with SARS-CoV-2 with CMR evidence of myocardial necrosis in 18% of our cohort. CMR may be an important diagnostic tool to identify a subset of patients at risk for cardiac sequelae and more prone to myocardial damage. CLINICAL TRIAL REGISTRATION: The study has been registered on ClinicalTrials.gov, Identifier NCT04455347, registered on 01/07/2020, retrospectively registered.

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).

A dual-site trauma system during COVID-19 pandemic - Our experience in a high-risk area with 60-day mortality report.

AIM: We set up a COVID-free trauma site due to the high rates of COVID-19 infections within our hospital. We aimed to determine the incidence of post-operative COVID-19 infection within the first two weeks post-treatment at the COVID-free site and the postoperative mortality rate. We analysed data for non-hip fracture and fragility hip fracture patients separately. METHOD: Data was collected for 138 patients presented during the study period, having 147 operations in total. 103 were non-hip fracture patients and 35 were hip fracture patients. RESULTS: All patients were followed up and none of the non-hip fracture cohort developed symptoms of COVID-19 infection. Postoperative 60-day mortality rate for this cohort was 0.97%. Of the 35 hip fracture patients, none were tested positive for COVID-19. However, two patients were treated as suspected COVID cases due to their symptoms. CONCLUSION: Establishing a separate site with screening for COVID-19 infection can allow safe emergency surgery.

Coronary aneurysms, myocardial dysfunction, and shock in a COVID-19 child, role of ECMO, immunomodulation, and cardiac CT.

Coronary artery aneurysms in children were observed as a rare complication associated with coronavirus disease 2019 (COVID-19). This case report describes the severe end of the spectrum of the new multisystem inflammatory syndrome in a 12-year-old child with coronary aneurysms, myocardial dysfunction, and shock, managed successfully with extracorporeal membrane oxygenation support and immunomodulation therapy. This report also highlights the additional benefits of cardiac CT in the diagnosis and follow-up of coronary aneurysms.

Electrocardiographic Changes in Children with Multisystem Inflammation Associated with COVID-19: Associated with Coronavirus Disease 2019.

OBJECTIVE: To analyze findings and trends on serial electrocardiograms (ECGs) in multisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease taken during the course of illness and at follow-up. STUDY DESIGN: We included all children presenting with MIS-C at a single center with 3 or more ECGs taken during the course of their illness. We measured ECG intervals (PR, QRSd, and QTc) and amplitudes (R-, S-, and T-waves) on each ECG and documented any arrhythmias and ST-segment changes. RESULTS: A majority of children (n = 42, 67%) showed ECG changes. The most common findings were low QRS amplitudes and transient T-wave inversion. ST changes were uncommon and included ST-segment elevation consistent with pericarditis in 1 child and acute coronary ischemia in 1 child. Arrhythmias were seen in 13 children (21%) but were benign with the exception of 1 child who was compromised by an atrial tachycardia requiring support with extracorporeal membrane oxygenation. No children were found to have high-grade atrioventricular block. CONCLUSIONS: MIS-C is associated with electrocardiographic changes over the course of the illness, with low amplitude ECGs on presentation, followed by transient T-wave inversion, particularly in the precordial leads. There was a low prevalence of ST-segment changes and tachyarrhythmias.

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.

Multimodality cardiac evaluation in children and young adults with multisystem inflammation associated with COVID-19.

AIMS: Following the peak of the UK COVID-19 epidemic, a new multisystem inflammatory condition with significant cardiovascular effects emerged in young people. We utilized multimodality imaging to provide a detailed sequential description of the cardiac involvement. METHODS AND RESULTS: Twenty consecutive patients (mean age 10.6 ± 3.8 years) presenting to our institution underwent serial echocardiographic evaluation on admission (median day 5 of illness), the day coinciding with worst cardiac function (median day 7), and the day of discharge (median day 15). We performed cardiac computed tomography (CT) to assess coronary anatomy (median day 15) and cardiac magnetic resonance imaging (CMR) to assess dysfunction (median day 20). On admission, almost all patients displayed abnormal strain and tissue Doppler indices. Three-dimensional (3D) echocardiographic ejection fraction (EF) was <55% in half of the patients. Valvular regurgitation (75%) and small pericardial effusions (10%) were detected. Serial echocardiography demonstrated that the mean 3D EF deteriorated (54.7 ± 8.3% vs. 46.4 ± 8.6%, P = 0.017) before improving at discharge (P = 0.008). Left main coronary artery (LMCA) dimensions were significantly larger at discharge than at admission (Z score -0.11 ± 0.87 vs. 0.78 ± 1.23, P = 0.007). CT showed uniform coronary artery dilatation commonly affecting the LMCA (9/12). CMR detected abnormal strain in all patients with global dysfunction (EF <55%) in 35%, myocardial oedema in 50%, and subendocardial infarct in 5% (1/20) patients. CONCLUSIONS: Pancarditis with cardiac dysfunction is common and associated with myocardial oedema. Patients require close monitoring due to coronary artery dilatation and the risk of thrombotic myocardial infarction.

Beware the corona diet

Plenty of diets promise to boost your immune system to help protect you from covid-19, but do their claims stack up, asks James Wong