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INTRODUCTION. The aetiology of Kawasaki disease (KD) remains unknown. Changes in infectious exposure during the COVID-19 pandemic owing to infection prevention measures may have affected the incidence of KD, supporting the pathogenic role of an infectious trigger. The purpose of this study was to evaluate the incidence, phenotype and outcome of KD before and during the COVID-19 pandemic in Denmark. METHODS. This was a retrospective cohort study based on patients diagnosed with KD at a Danish paediatric tertiary referral centre from 1 January 2008 to 1 September 2021. RESULTS. A total of 74 patients met the KD criteria of whom ten were observed during the COVID-19 pandemic in Denmark. Alof these patients were negative for SARS-CoV-2 DNA and antibodies. A high KD incidence was observed during the first six months of the pandemic, but no patients were diagnosed during the following 12 months. Clinical KD criteria were equally met in both groups. The fraction of intravenous immunoglobulin (IVIG) non-responders was higher in the pandemic group (60%) than in the in the pre-pandemic group (28.3%), although the rate of timely administered IVIG treatment was the same in both groups (>= 80%). Coronary artery dilation was observed in 21.9% in the pre-pandemic group compared with 0% in KD patients diagnosed during the pandemic. CONCLUSION. Changes in KD incidence and phenotype were seen during the COVID-19 pandemic. Patients diagnosed with KD during the pandemic had complete KD, higher liver transaminases and significant IVIG resistance but no coronary artery involvement.Copyright © 2023, Almindelige Danske Laegeforening. All rights reserved.
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Objectives: As of March 5th, 2022, around 1.585 cases of MIS-C and 98 deaths (6,4%) were reported in Brazil. The state of Rio de Janeiro State (RJ) having 94 cases (5,9%) and 4 deaths (4,2%)1.Our aim was to evaluate clinical and laboratory features, and management of MIS-C in seven pediatric hospitals in RJ, Brazil. Method(s): Multicenter, observational, ambidirectional cohort study in seven tertiary hospitals in RJ(Brazil), assessing medical charts of pediatric inpatients (0-18 years) diagnosed with MIS-C according to WHO/CDC criteria, from August, 2020 to February, 2022. Descriptive statistics were used to analyze distributions of continuous variables, frequencies, and proportions. Result(s): A total of 112 cases of MIS-C were enrolled. The mean age was 4.2 years and thre was male predominance (59,8%). All cases had a SARS-CoV-2 contact (29.5% close contact;31.3%:positive PCR;serology:43.8%).Only 12.5% had comorbidities. Length of stay (LOS) was 7 days.Median duration of fever was 8 days. Most common symptoms were: rash(67%);gastrointestinal (67%);conjunctivitis (42%);neurological(39.6%);cardiovascular(37.5%);cervical lymphadenopathy (36.6%), and shock/hypotension(28.6%).Co-infection occurred in 3 patients. Forty-four patients fulfilled criteria for Kawasaki disease. Most patients were admitted to PICU(12;62,5%) for amedian of 2 days. Respiratory distress was seen in 18,7%;hypotension:28,6%, and shock in 23,2%. Main laboratory findings were: high C-reactive protein in 95%;D-dimer:77%, anemia:77%, thrombocytosis:63%;transaminitis:43.8%, lymphopenia:38%;hypoalbuminemia:34%;thrombocytopenia: 29%;hypertriglyceridemia:28%, and high pro-BNP in 27%. Echocardiogram was performed in 91/112 patients;abnormal in 70,3%;exhibiting myocardial dysfunction( 25%);pericardial effusion(21%);coronary dilation/aneurysms(11%) and, valvulitis (14.5%). IVIG+corticosteroids (CTC) were administered in 59.8%(67/ 112);18.6%(18/112) IVIG only;10.7%(12/112) CTC only;3.4%(4/112)biologics, and 15(13.3%) received no treatment. ASA low dose in 77.7% (87/112) and moderate/high dose in 34.8%. Oxygen support was needed in 27,7%;vasoactive amines:18,7%;dialysis:5,3%, and transfusion:18,7%.One patient died from a cytokine storm syndrome. Conclusion(s): Our study reports a higher number of MIS-C cases in RJ than the number reported to Brazilian authorities, highlighting underreporting. Our patients were younger, had fewer comorbidities, cardiovascular/gastrointestinal/renal involvement, shortest LOS in ICU, and a higher frequency of myopericarditis.
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Purpose of Study Treatment outcomes of children diagnosed with MIS-C are unclear and warrant investigation. The purpose of this study is to investigate the characteristics of pediatric patients diagnosed with MIS-C and their treatment outcomes with an emphasis on fatalities associated with MISC. Methods Used A literature review using Google Scholar and Pubmed using keywords such as 'Multisystem Inflammatory Syndrome in Children', 'Pediatric Inflammatory Multisystem Syndrome', and 'Coronavirus Disease 2019' was conducted. We included studies of hospitalized MIS-C patients with a sample size of more than 15. Summary of Results Of ten studies published before August 2020, five reported hospitalized MIS-C cases in the United States and five in Europe. A total of 514 hospitalized patients were reported with a sample size of 15 to 186 in various studies. Of 514 patients, 431 (84%) tested positive for SARS-CoV-2 via RT-PCR or serology. In different studies, 50% to 100% of MIS-C patients required PICU admission, 10% to 54% were intubated, and up to 80% required vasopressors. In studies that reported echocardiogram results, coronary artery dilations or aneurysm were noted in up to 93%, and depressed cardiac function was reported in 51- 100% of MIS-C patients. Treatment of MIS-C patients included intravenous immunoglobulins (IVIG) 388/514 (75%) plus steroids 288/514 (56%), along with anticoagulants and Anakinra 26/514 (5%). In total, 23 patients were put on ECMO, and of those, 16 (70%) survived. The larger studies reported fatality rate of 2% to 3% in hospitalized MIS-C patients. A total of 10 deaths were reported. Of the fatality causes that were described, 3 were associated with cerebral infarction after ECMO, 2 had not received IVIG, systemic glucocorticoids, or immunomodulators, and another 2 had co-morbidities. Conclusions Our review suggests that children with MIS-C who are hospitalized typically have a severe disease course. The outcome in vast majority of patients is favorable but death can occur, most likely as a result of cardiac dysfunction or cerebral infarction. Larger studies are needed to identify clinical features as well as laboratory and diagnostic parameters that predict disease severity and outcome.
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Case Report:We present a 5-year-old male with two days of fever, cough, vomiting, and loose stools. His history is significant for premature birth (35 weeks gestational age) and shunted hydrocephalus. A ventriculoperitoneal (VP) shunt was placed 6 days prior to presentation. Parental report included episodes of post-tussive, nonbloody, non-bilious emesis, poor oral intake, tachypnea, and increased work of breathing. Physical examination demonstrated a dehydrated infant with sunken fontanelles. He had no notable rash, no lymphadenopathy, and clear conjunctiva. His VP shunt site appeared normal without swelling or erythema. Initial evaluation showed elevated inflammatory markers -ESR 51 and CRP 12.32 mg/dL. A viral respiratory PCR panel returned positive for coronavirus (not SARS-CoV-2). A head CT scan and shunt radiography series showed no abnormalities with his shunt. The following morning, Radiology reported an incidental retropharyngeal fluid collection on a re-read of the patient's initial CT scan. A neck CT was obtained and demonstrated a fluid pocket with secondary mass effect in addition to bilateral cervical lymphadenopathy. Screening blood cultures were negative. The patient remained febrile (tmax 103.6F) and developed a transaminitis (ALT 264.9, AST 654), elevated fibrinogen 476, elevated INR 1.4, and low albumin 2.1. Abdominal ultrasound showed a normal the liver and biliary tract. His transaminitis resolved without treatment. The next day, the patient developed lip erythema and conjunctival injection. An echocardiogram showed a dilated right coronary artery (z-score of 3.59) and his inflammatory markers (ESR 26, CRP 9.63) remained elevated. Treatment was initiated with IVIG and moderate-dose aspirin. The patient defervesced, and he remained afebrile for over 48 hours prior to discharge. A repeat echocardiogram 2 days later showed a slight reduction in coronary artery dilatation (z-score 3.39). Hewas discharged on lowdose aspirin, and followed up with cardiology as an outpatient. Kawasaki's Disease (KD) is most common in children from ages 1 to 4 years and is classically characterized by persistent fever with a constellation of symptoms including limbal sparing conjunctivitis, cervical lymphadenopathy, polymorphous rash, strawberry tongue, oral changes, and extremity changes. Our patient presented at a younger age with a concurrent diagnosis of coronavirus upper respiratory tract infection. His atypical hospital course and incidental finding of retropharyngeal edema and transaminitis increased the clinical suspicion for KD. His symptoms rapidly improved after administration of IVIG. Younger patients are at an increased risk for severe complications of KD including coronary aneurysm. KD has been shown in the literature to have an association with coronavirus infection as well as presentation with retropharyngeal edema. Clinicians should consider KD in their differential even if patients do not meet all criteria for diagnosis on initial presentation. Copyright © 2023 Southern Society for Clinical Investigation.
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BACKGROUND AND AIM: The clinical spectrum and management of Multi-system Inflammatory Syndrome in Children (MIS-C) is evolving with each wave of COVID-19. This study aims to compare the clinical spectrum and immunomodulatory management of children with MIS-C between first and second wave in a tertiary care hospital in south India. METHOD(S): This prospective observational comparative study included children satisfying CDC MIS-C criteria admitted during 1st and 2nd wave of COVID 19 (total period from September 2019 to January 2022). We compared the clinical presentation, severity of illness, inflammatory biomarker profile, immunomodulatory therapy, need for inotropic support, duration of stay and outcome. RESULT(S): Study population included 27 during 1st wave and 75 during 2nd wave. Median age (IQR) of patients was 4.4years (3.15, 7.95) and 5.6 years (3.25, 8.8) during 1st and 2nd wave respectively. Males preponderance was seen in both waves (69% VS 65%). Clinical presentation was similar in both waves. 37% patients presented with shock during 1st wave while 36% in 2nd wave. Gastrointestinal symptoms were predominant (78% VS 82%) followed by cardiac manifestations (44% VS 45%), while a higher incidence of coronary artery dilatation was seen in 2nd wave (35% VS 26%). Comparison of immunomodulatory therapy is depicted in table 1. IVIG and pulse Methylprednisolone requirement was more during 2nd wave. 3 patients during 2nd wave needed additional immunomodulatory therapy with Anakinra (table 1). No patient required 2nd dose of IVIG. There was no mortality. CONCLUSION(S): Clinical presentation was similar in both waves. Requirement of immunomodulatory therapy was more during 2nd wave.
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BACKGROUND AND AIM: The clinical spectrum and management of Multi-system Inflammatory Syndrome in Children (MIS-C) is evolving with each wave of COVID-19 and emerging literature. This study aims to describe the clinico-pathological spectrum and immunomodulatory management of MIS-C in a tertiary care hospital in south India. METHOD(S): This prospective observational study included children satisfying CDC MIS-C criteria admitted from September 2019 to January 2022. We studied the characteristics of patients receiving immunomodulatory therapy with respect to need for inotropic support, duration of stay, mortality, escalation of immunomodulation, time to defervescence and persistence of coronary abnormalities at 2 weeks. RESULT(S): 102 children were included with median (IQR) age of 5.5 (3.2-8.5) years with male: female ratio of 1.84. Gastrointestinal symptoms were seen in 85 (84%), cardiac manifestations in 48 (47%) and coronary artery dilatation was seen in 33 (32%). Methylprednisolone and intravenous immunoglobulin were used as first line therapy in 31 (30.4%), and 25 (24.5%) patients, respectively. 46 (45.1%) children received both IVIG and IV Methylprednisolone. 30 (29%) presented with shock and 28 (27%) required inotropic support. Defervescence at 48hrs was observed in 30 (96%) in steroids alone group, 18 (72%) in IVIG group and 26 (57%) in IVIG+steroid group. 4 needed additional immunomodulatory therapy with Anakinra (table 1). None of them required 2nd dose of IVIG. There was no mortality. At 2 weeks follow-up coronary artery dilatation persisted in 9 children. CONCLUSION(S): Immunomodulator therapy was based on severity at presentation and all combinations of therapy were effective.
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BACKGROUND AND AIM: To describe the cardiovascular and laboratory manifestations among children presenting with the multisystem inflammatory syndrome associated with SARS-CoV-2 infection (MIS-C). METHOD(S): Data obtained from the database of our PICU complemented by a review of the clinical records. Children from 1 month to 15 years of age, admitted to the hospital between August 1, 2020 and December 31, 2021 with a diagnosis of MIS-C were included. RESULT(S): A total of 8 children, represent 6% of our admissions during the study period, were included. Median age 5.7 years (IQR 1.5-10), 100% males, weight 10 to 59 kg, PICU LOS 1 to 11 days, median 2.6 days (IQR 1-7.5). PIM-3 median 1.75 (IQR 1.17- 2.54). Symptoms were persistent fever, gastrointestinal symptoms, polymorphic rash, conjunctivitis, and mucosal changes.The cardiovascular complications were shock, cardiac arrhythmias, pericardial effusion and coronary artery dilatation. Reduced left ventricular ejection fraction and elevated troponin were present in half of them. The biochemical markers of inflammation were raised in most patients: elevated C-reactive protein, serum ferritin, procalcitonin, N-terminal pro B-type natriuretic peptide, interleukin-6 level, and D-dimers. Polymerase chain reaction for SARS-CoV-2 virus was negative in all patients, whereas immunoglobulin (Ig) M antibodies were positive in 50% and IgG in 87.5% cases. CONCLUSION(S): The children have significantly raised levels of biochemical markers of inflammation.Cardiac involvement, including ventricular dysfunction, coronary artery dilation or aneurysm, and arrhythmias, is common in children with SARS-CoV-2-associated multisystem inflammatory syndrome and needs to be carefully identified and monitored over time due to uncertain prognosis and risk of progression of cardiac manifestation. (Figure Presented).
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BACKGROUND AND AIM: Severe Multi Inflammatory Syndrome in Children (MISC) is known to cause high morbidity and mortality. Cardiac dysfunction is the main debilitating organ affected by MISC post COVID 19 infection and often requires the use of ECMO for survival. ECMO service is not widely available in Malaysia. We describe the use of Continuous Renal Replacement Therapy (CRRT) and Plasma Exchange (PLEX) in severe MISC our case series. METHOD(S): All paediatric patients with MISC from April 2021 to January 2022 in Paediatric High Dependency Unit Hospital Selayang, Malaysia was included. Case definition as per CDC and WHO guideline. Clinical presentation divided to Kawasaki-like, shock, undifferentiated fever-like and severe refractory MISC. Analysis includes length of stay, length of ventilation, inflammatory markers (CRP, ESR, IL-6, IL-1, IL-10), cardiac markers (Trop-I, NT-ProBNP), treatment with IVIG and steroids, CRRT, Plex, morbidity and mortality. RESULT(S): Total patients were 25 (age 1month to 17 years). Thirty six percent are school-going age (5years to less than 9 years old), Average length of ICU stay was 5 days (median). Cardiac complications include coronary dilatation (n=3), pericardial effusion (n=4), perivascular cuffing (n=7), IVS dyskinesia (n=2), poor contractility (n=3) and low ejection fraction <55% (n=6). Six required CRRT and 2 required PLEX, with age range from day 24 of life to 11 years. All patient survived with 4 required anti-failure medications upon discharge. CONCLUSION(S): MISC is a newly described disease during the COVID 19 pandemic. Our patients with severe refractory were successfully treated with IVIG, high dose steroids and CRRT and PLEX.
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INTRODUCTION: Multi-system Inflammatory Syndrome (MIS-C) is a hyperinflammatory state involving two or more organs associated with a previous diagnosis of SARSCoV- 2. Cardiac dysfunction is described in 80-85% of cases. Currently, there is a knowledge gap regarding long-term cardiac and functional outcomes in children diagnosed with MIS-C. METHOD(S): We conducted a retrospective chart review of children < 21 years admitted to our hospital for MIS-C between January 2020 and January 2022. We collected demographic, clinical, laboratory, imaging data [left ventricular ejection fraction (LVEF), coronary artery dilation (CAD)], and functional status score (FSS) during hospital stay and long-term (up to 6 months) follow up. Using a student t-test and chi-square test, we compared the outcomes of children admitted to the pediatric intensive care unit (PICU) vs outside the PICU. RESULT(S): Out of the 40 children admitted to the hospital with MIS-C during the study period, 16 (40%) were admitted to the PICU while 24 (60%) were admitted outside the PICU. Of the PICU patients, 13.33% showed CAD and 31.25% had a LVEF <=55% on at least one echocardiogram during their hospital stay. Of the echocardiograms completed on the non-PICU patients (n=22), 18.18% showed CAD and 9.09% had a LVEF <=55% on at least one echo during admission. Between PICU and non-PICU patients, there was a significant (p <= 0.05) difference in mean length of stay (13.56 vs. 6.16 days respectively), lowest LVEF (56.14% vs 62.58%), and change in Functional Status Score (DELTAFSS) (0.5 vs 0.0). Of the 16 PICU patients, 11 had follow-up echocardiogram and none had persistent CAD and/or LVEF <=55%. Of the 20/24 (83.33%) non-PICU patients with echocardiograms at follow-up, 10% displayed persistent coronary artery dilation while none had LVEF <=55%. At follow-up, a significant proportion of non-PICU patients had persistent CAD as compared to PICU patients (p<=0.0001), but there was no difference in LVEF and DELTAFSS amongst the two cohorts. CONCLUSION(S): A significant proportion of children admitted outside the PICU had persistent coronary abnormalities at up to 6 month follow up compared to patients admitted in the PICU. However, none of the patients had persistent low LVEF (<=55%) or functional disability at up to 6 month follow up (DELTAFSS).
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Background. Multisystem Inflammatory Syndrome (MIS-C), a new entity in children which developed 2-4 weeks after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, is a severe condition. It can affect the multisystem, while the most severe manifestation is cardiac involvement. Left ventricular dysfunction, cardiogenic shock, coronary artery dilatation/aneurysm, valvulitis, pericardial effusion, arrhythmia, and conduction abnormalities were reported in approximately 80% of children with cardiovascular system involvement. It is still unclear the duration of the cardiac symptoms, and even they are permanent or persistent. Few studies evaluated persistent cardiac abnormalities by cardiac magnetic resonance imaging (MRI). Therefore, we aimed to assess persisting cardiac abnormalities with MIS-C by cardiac MRI and compare them with echocardiograms. Methods. A retrospective study was conducted at a tertiary-level University Hospital between June 2020-July 2021. Thirty-four children diagnosed with MIS-C according to the criteria defined by the Centers for Disease Control and Prevention were retrospectively evaluated. Results. The study included 17 males and 17 females with a mean age of 9.31 +/-4.72 years. Initial echocardiographic evaluation showed cardiac abnormality in 18 (52.9%) patients;4 (11.8%) pericardial effusion, 4 (11.8%) left ventricular ejection fraction (LVEF) < 55%, 5 (14.7%) LV fractional shortening < 30%, 5 (14.7%) coronary artery dilatation. Echocardiography showed normal LV systolic function in all patients at follow-up;coronary dilatation persisted in 2 of 5 (40 %) patients at the 6th-month visit. Cardiac MRI was performed in 31 (91.2%) patients. We didn't detect abnormal T1 levels, whereas 9 (29%) had isolated elevated T2 values. 19 (61.3%) of 31 patients had at least one of the followingfindings: pericardial effusion, right ventricular dysfunction, LVEF abnormality. Conclusion. Cardiac involvement persisted at a higher rate which was shown by cardiac MRI in the late period, particularly pericardial effusion. Cardiac MRI may be suggested for all MIS-C patients at a later phase. Prospective studies with larger sample sizes are needed to determine long-term cardiac effects.
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INTRODUCTION: Since the recognition of Multisystem Inflammatory Syndrome in Children (MIS-C), different immune therapies have been utilized as monotherapy (MT) or combination therapy (CT). Currently there is a lack of sufficient literature examining the long-term cardiac and functional outcomes in children following MT versus CT for MIS-C. METHOD(S): We conducted a retrospective chart review of children < 21 years old admitted to our tertiary care children's hospital for MIS-C from January 2020 to January 2022. We collected clinical data, especially cardiac imaging data [left ventricular ejection fraction (LVEF), coronary artery dilation (CAD)], and functional status scores (FSS) during hospital stay and long-term (up to 6 months) follow up. We then compared the long-term outcomes of children who received three different treatment regimens during hospitalization: Steroid only (S), Steroid and IVIg (S + IVIg), and Steroid, IVIg, and Anakinra (S + IVIg + Ana), using a student t-test and Fisher's exact test. RESULT(S): Of the 40 children admitted with MIS-C during the study period, one who did not receive any immune therapy was excluded and of the remaining 39, the number of patients in each treatment group (S, S+IVIg, S+IVIg+Ana) was 13 (33%), 14 (36%) and 12 (31%) respectively. During hospitalization, among the S, S+IVIg, and S+IVIg+Ana groups, the mean (SD) LVEF were 63.9 (4.9)%, 60.0 (7.2)%, 55.9 (9.1)% respectively and CAD was documented in 1/11 (9.1%), 3/14 (21.4%) and 2/11 (18.2%) patients, respectively and at up to 6-month follow-up, the mean (SD) LVEF were 63.9 (2.8)%, 63.5 (4.0)%, and 66.3 (3.1)%, respectively, and CAD was documented in 0/11 (0%), 0/10 (0%), 2/10 (20%) patients, respectively. There was no significant difference in the proportion of patients with persistent low (<= 55%) LVEF or CAD across the groups at long-term follow-up (p>0.05). There was no significant difference in DELTAFSS across the 3 groups at discharge [mean (SD): S 0 (0), S+IVIg 0.3 (1.1), and S+IVIg+Ana 0.3 (0.9)] as well as at follow-up [mean (SD): S 0 (0), S+IVIg 0 (0), and S+IVIg+Ana 0.3 (0.7)]. CONCLUSION(S): In our cohort of MIS-C patients, cardiac and functional outcomes were favorable at follow-up irrespective of combination of immune therapies offered during hospitalization.
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Coronavirus disease 2019 (COVID-19) is usually mild in children. Rarely, children are severely afected. Multisystem infammatory syndrome in children (MIS-C) is an uncommon complication of COVID-19 often involving previously healthy older children and adolescents. It is thought to be the result of an abnormal immune response to the infection. Most afected children have negative polymerase chain reaction (PCR) and positive serology for SARS-CoV-2. Clinical presentation may include persistent fever, gastrointestinal symptoms and features like Kawasaki disease (KD) followed by shock or multisystem involvement. Infammatory markers (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], D-dimer and procalcitonin) and cardiac biomarkers (Troponin, brain natriuretic peptide [BNP] or N-terminal proBNP [NT-proBNP]) are often elevated. Evidence of infection (PCR, antigen test or positive serology) or likely contact with COVID-19 patients should accompany. Myocardial injury, identifed by the presence of cardiac troponin above the 99th percentile upper reference limit, is common. Possible causes include viral myocarditis, infammation, hypoxia, stress cardiomyopathy and ischemia. Combinations of these mechanisms could be responsible for cardiac dysfunction. A minority of patients present cardiac symptoms or nonspecifc symptoms. ST-segment and T-wave changes, arrhythmia or heart block may occur on electrocardiography (ECG) although most patients have non-specifc ECG. Depressed left ventricular (LV) function, Coronary artery (CA) dilation or aneurysm, mitral valve regurgitation or pericardial efusion may occur on echocardiographic evaluation. Management depends on the clinical presentation and severity. All patients should receive empiric antibiotic and also antiviral therapy if evidence of active infection exists. Patients presenting shock are treated with intravenous fuid and vasoactive agents. Signifcant LV dysfunction necessitates supportive care to maintain hemodynamics, intravenous immune globulin (IVIG), diuretics and inotropes and rarely mechanical hemodynamic support. For patients with KD features, standard therapies are applied. Glucocorticoid therapy is recommended for severe or refractory shock, KD-like features with risk of IVIG resistance risk and persistent fever. Systemic anticoagulation is used for moderate to severe LV dysfunction and also older children and adolescents with moderate to severe MIS-C. The mortality rate is approximately 1 to 2 percent for MIS-C patients. Most children with cardiac involvement have recovery of ventricular function and resolution of arrhythmias at the time of hospital discharge, although mildly diastolic ventricular dysfunction usually persists in 20%.
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Background and Aim: Multi-system inflammatory syndrome in chil-dren (MIS-C) causes widespread systemic inflammation including a pancarditis in the weeks following a COVID infection. Further coronavirus surges appear inevitable and with vaccination rates lower in young people an understanding of the medium-term car-diac impacts of this condition is important for planning further treatment and understanding the impacts on their health. Method(s): A retrospective single-center study of 67 consecutive patients with MIS-C was performed. Three time points were determined as the point of worst cardiac dysfunction during the acute admission, then at intervals of 6-8 weeks and 6-8 months. Echocardiographic findings were used to evaluate both 2D and 3D measures of cardiac function. Coronary artery measurements were recorded. Corresponding serial ECG findings were evaluated. Result(s): The worst cardiac function arose 6.8 +/- 2.4 days after the onset of fever. The mean M mode-derived FS was 30.9 +/- 8.1% during the acute phase. The mean 3D left ventricle (LV) ejection fraction (EF) was borderline at 50.5 +/- 9.8%. A pancarditis was typ-ically present: 46.3% showed cardiac impairment;31.3% had some pericardial effusion;26.8% had moderate (or worse) valvar regur-gitation and;26.8% had coronary dilatation. Cardiac function returned to normal in all patients by 6-8 weeks (mean 3D LV EF 61.3 +/- 4.4%, plt;0.001 compared to admission). Coronary dila-tation normalized in all but one patient who initially developed large aneurysms at presentation;these continued 6 months later. ECG findings mainly featured T-wave changes resolving at fol-low-up. There were a small number of adverse events: need for ECMO (2), death as an ECMO-related complication (1), suben-docardial infarction (1), LV thrombus formation (1). Conclusion(s): MIS-C causes a pancarditis with decreased cardiac function and almost a quarter of patients showing coronary changes. In most, discharge from long-term follow-up can be con-sidered as full cardiac recovery is expected by 8 weeks. The excep-tion includes patients with medium sized aneurysms or greater or those with more of a Kawasaki disease phenotype as these require on-going surveillance for persistence of coronary changes.
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Background and Aim: Pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) is a postim-munological reaction after SARS-CoV-2 infection. Various car-diac manifestations of PIMS-TS have been reported, namely pericardial effusion, ventricular arrhythmia, myocarditis, valvular regurgitation, and pericarditis. The aim of this study was to analyze clinical and laboratory features to distinguish any possible predic-tion for cardiac involvement in children with PIMS. Method(s): The PIMS patients under 18 years old treated in our center between July 2020 and December 2021 were included. Data of the patients were retrospectively obtained from their medical records. Result(s): A total of 46 patients with PIMS were examined during the study period. The mean age of study group was 9.4 +/- 4.6 years, 18/46 were female and 3 groups were formed according to their age ranges. Among them, seventeen patients (37%) had cardiac involvement with mean age was 8.7 years. Impaired cardiac func-tions were seen more in male patients (n: 10/17). Coronary artery dilatation seen in seven patients especially with mean age of 5.2 years (Age group 1,2,3;%36.4,%14.3,%0;p = 0.033;respectively) and especially related to high troponin T levels (p = 0.006). In our study group, cardiac involvement was shown more related to ProBNP and Troponin T (p = 0.008;p = 0.003). The cut-off val-ues of proBNP and troponin T for predicting in cardiac dysfunc-tion were 2759 pg/mL (95% confidence interval (CI), 0,83-1;sensitivity, 0.86;specificity, 0.93;AUC:0.92, p lt;0,001). Conclusion(s): Although there is a wide variability of symptoms, MIS-C is a rare, severe, less understood complication of COVID-19 that may cause multisystemic involvement in the patients. Clinicians should be aware of this condition in children with persistent fever and a family history of COVID-19. Cardiac involvement in chil-dren with PIMS may strongly be predicted by levels of Troponin T and ProBNP. Further more younger age and high Troponin T levels are the independent predictors for the coronary artery dila-tation among children with PIMS.
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Background and Aim: MIS-C is a hyperinflammatory syndrome caused by Sars-CoV-2 virus. Cardiovascular system impairment is observed up to 100 % of all MIS-C patients with a wide spectrum and severity of symptoms. It is important to identify the course of the disease and its outcome, which could significantly improve public health. Method(s): A single-centre study, prospective cohort study, con-ducted in the Children's Clinical University hospital in Latvia from January to December 2021. Patients between the ages of one to seventeen years who met the MIS-C criteria were included in the study. We evaluated blood pressure, left ventricular heart func-tion, size of coronary arteries and hospital course. Result(s): Thirty-one patients were included who met the MIS-C criteria. The median age was 8.0 years, 52% were boys. Of all patients 77% initially presented with hypotension of whom 42% required inotropic support. Treatment in PICU was required in 58% of all patients. Reduced left ventricular ejection fraction was observed in 35% of all patients. Mildly decreased ventricular ejection fraction (lt;55%) was observed in 19% of cases but mod-erate dysfunction (ejection fraction lt;45%) was observed in 16% of patients. Twelve percent of patients received milrinone to improve left heart function. Left heart function significantly improved in all patients during the hospitalisation. In 6 % of all patients coronary artery dilations was observed. All patients had dilations resolution at the time of discharge. Median length of hospitalisation was twelve days and median length of PICU stay was three days. Conclusion(s): All patients cardiovascular symptoms had resolved at the time of discharge. Whether patients will have chronic cardiac impairment is unknown therefore it is crucial to perform long-term follow-up.
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Background and Aim: Multisystem inflammatory syndrome in chil-dren (MIS-C) is a late manifestation of SARS-CoV-2 infection. Cardiac involvement is common and presents as ventricular dys-function, shock, and coronary anomalies. The aim of the study is evaluate the influence of cardiac disfunction on clinical presen-tations and outcomes in a single center. Method(s): A retrospective study on patients diagnosed with MIS-C and referred to Buzzi Children's Hospital in Milan from November 2020 to February 2021. Patients were treated with intravenous immunoglobulins, corticosteroids and anti-throm-botic prophylaxis, in respect to our approved multidisciplinary protocol. According to the admission cardiac left ventricular ejec-tion fraction (LVEF), the patients were divided into group A (LVEF lt;45%) and group B (LVEF >=45%). Result(s): We collected 32 consecutive patients. Group A included 10 patients (9M/1F, aged 13 years [IQR 5-15]), and group B included 22 patients (15M/7M, aged 9 years [IQR 7-13]). At the presentation, significant differences were observed among shock (group A 6/10 vs group B 2/22, plt;0.01), gastrointestinal involvement (9/10 vs 11/22, p = 0.04) and duration of fever (5.3 vs 6.9 days, p = 0.02). All patients in group A required inten-sive care hospitalization (10/10 vs 12/22, p = 0.01). Interestingly, despite good cardiac function, two patients in group B presented with shock, probably due to vasoplegic/distributive cardiocircula-tory impairment secondary to the inflammatory state. Among biochemistry parameters, leukocytes, neutrophils, and CRP were significantly worse in group A (p = 0.001, p = 0.001 and p = 0.008, respectively). Pathological level of troponin T and NTproBNP were detected in all patients in group A and also in 33% and 77% of group B;with statistically significant higher median values in group A (Troponin T 72 [40-243] ng/L vs 22 [8-49] ng/L, p = 0.01;NTproBNP 14825 [11340-17810] ng/L vs 5921 [1114-11243] ng/L, p = 0.01). In group A, mitral regurgitation was more frequent (plt;0.01) and one patient had transient left main coronary dilation (Boston z-score +2.39). At the discharge, cardiac function normalized in all patients. Total length of hospital stay and cardiac recovery time were not statistically different between groups. Conclusion(s): If correctly diagnosed and early treated, all the MIS-C patients completely recovered, regardless of the initial cardiac involvement.
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Background and Aim: Cardiovascular manifestations are common (35-100%) in multisystem inflammatory syndrome in children (MIS-C), including ventricular dysfunction, shock, coronary artery dilation, pericardial effusion and conduction abnormalities. Our study aimed to analyse cardiovascular involvement in our patients with MIS-C treated in our hospital. Method(s): The retrospective cohort study included all patients with MIS-C treated from April 2020 to December 2021 in the Mother and Child Health Institute of Serbia. In every case, cardiovascular manifestations were analysed: ventricular dysfunction, coronary artery dilatation, pericardial effusion, shock and ECG changes. Result(s): The study included 77 patients, 45 boys and 32 girls, aver-age years of age 9.3 +/- 4.8. Elevated cardiac troponin I and pro-BNP were observed in 35.9% and 87.8% of patients, respectively. Myocardial dysfunction was observed in half of our patients (50.6%), with an average ejection fraction of 50.5 +/- 8.9%. Children older than 10 years had 4 times higher chances for myo-cardial dysfunction (OR 4.3, 95%CI 1.6-10.8;p = 0.003). Shock syndrome had 21.1% of children on admission, while 5.3% devel-oped shock during the in-hospital stay. Transient coronary artery (CA) dilatation was observed in 6.5% of patients;left CA in 3 pts (Z score +2,95 +/- 0.3), right CA in one patient (Z score +2), and in one LCA and RCA (RCA Z score 2.6). Transient CA dilatations were observed only in patients with KD-like clinical presentation (5/54 pts). Mild pericardial effusion with spontaneous resolution was detected in 28.6% of children, while one female adolescent had severe pericardial effusion with threatening cardiac tamponade. On the standard ECG, 53% of children had negative T wave in inferior or/and precordial leads averagely on day 2 (IQR 1-3 day);transient QTc prolongation was registered in 46% of patients, averagely on day 7 (IQR 5-9). Sinus bradycardia and coronary rhythm were registered in 42.1% of patients, while premature ven-tricular beats were observed in 2.7% of pts. left ventricle thrombus was detected in one patient with normal echocardiography find-ing. In this patient, increased activity of Factor VIII and XII was proven. Conclusion(s): Cardiac manifestations are common and potentially life-threatening in MIS-C and should be assessed for at presenta-tion and during the clinical course as indicated.
ABSTRACT
Background and Aim: Multisystem Inflammatory Syndrome in Children (MIS-C) associate with Coronavirus disease-19 is a life-threatening clinical condition in which cardiovascular system is frequently affected. Shock, cardiac arrhythmias, myocarditis, reduced left ventricular ejection fraction (LVEF), pericardial effu-sion, and coronary artery dilatation are amongst the most common cardiac complications. In this study, we aim to assess myocardial status in patient with cardiac involvement in MIS-C. Method(s): Over a 14-month period, we retrospectively collected clinical, biological, echocardiographic data in children who were admitted to our hospital with a diagnosis of MIS-C and cardiac involvement. WHO criteria for clinical case definition of MIS-C were adopted. Elevation in brain-natriuretic-peptide and troponin-I, electrocardiographic abnormalities, echocardio-graphic evidence of pericarditis, myocarditis, reduced LVEF, valvular disease, and coronary artery dilatation were including cri-teria. LV indexed end-diastolic (EDVi), end-systolic (ESVi), stroke volumes were measured with Cardiac Magnetic Resonance (CMR). T2 mapping, Cine-RM and late gadolinium enhance-ment studies were performed. Result(s): 14 children were identified and included in the study, 71% of which were male. Median age at disease onset was 7 years old (IQR 5 to 9 years). All patients underwent cardiological evaluation in the first 48 hours of hospital staying. LVEF was lt;45% in 28.6% and lt;35% in 14.3% of patients. Myocarditis was detected in 78.6%, pericarditis in 28.6%, valvular damage in 35.7%, coronary abnormalities in 42.9%. All patients underwent CMR after on average 4 months (median: 3.87, IQR 2 to 4) from disease onset, after full clinical and biological recovery. ESVi and stroke volumes resulted within normal range in 100%. CMR abnormalities were observed in 21%. Particularly, left ventricular EDVi resulted elevated in 7%, delayed washout in T2 was described in 7%, and increased T2 mapping in 7%. Conclusion(s): Despite complete clinical and biological resolution, increased EDVi, delayed washout in T2 and increased T2 mapping at follow-up CMR in patient with cardiac involvement due to MIS-C may be signs of myocardial remodeling.
ABSTRACT
Background and Aim: Multi-system inflammatory syndrome in chil-dren (MISC) associated with COVID-19 has been described as a potentially life-threatening disease. In this study, we aimed to evaluate cardiovascular findings in children diagnosed with MISC at initial presentation and follow up. Method(s): Between November 2020 and November 2021, 35 children diagnosed with MISC based on WHO criteria were evaluated in this retrospective study.Cardiac markers, electrocardi-ography and echocardiography were performed in all cases at pre-sentation. Cardiac evaluation were repeated at the mean of 10th week after discharge(range:5 to 33weeks). Result(s): At this period, 633 children had positive PCR test of Covid-19. The freguency of MISC was 5.5% in our cohort. The median age was 9 years at diagnosis. Comorbid diseases were found in 20% cases, but none had preexisting heart disease. All patients had high grade fever and laboratory evidence of hyperin-flammation. Most cases had mild form disease, however 12 patients had been hospitalized in ICU median 6 day. 27 cases (77%) had cardiovascular involvement.Kawasaki-like findings were found in 10 patients and 5 cases were presented with shock(Figure-1) Echocardiography;Left ventricular (LV)systolic dysfunction (EFlt;57%) was detected in 11 cases (31.4%) and coronary artery (CA) dilatation(z scoregt;2)was found in five(14.2%) cases. Pericardial effusion was seen in 12 cases. Electrocardiography: Sinus tachycardia was the most common finding. 2 cases had pro-longed QTc interval and four cases had T wave alterations. Four cases had experienced complex ventricular arrhythmia. Cardiac markers:24 cases had high Pro-BNP level. 18 cases also had high Troponin T levels. Pro-BNP and Troponin T levels were not found to be correlated with LVEF. Only one adolescent boy who had severe cardiac dysfunction died during the acute period. Followup:There were two cases with persistent cardiac symptom, but no case had LV systolic dysfunction. The mean PR intervale was significantly lower than initial measurements. The mean of QT and QTc at follow up were not different from basal measurements.The mean LVEF was significantly higher than the initial levels. The basal CA z scores normalized at followup. Conclusion(s): MISC is characterized predominantly by cardio-vascular system involvement, but the children with MISC have good cardiac outcomes at short term follow up.
ABSTRACT
Background and Aim: Cardiac involvement in multisystem inflam-matory syndrome in children (MIS-C) associated with Coronavirus 2019 disease (COVID-19) is often observed with high risk of hearth failure. Early diagnosis and treatment are man-datory for a good outcome. The aim is to describe cardiovascular involvement, management and early outcome for patients with MIS-C and to analyze the differences in cardiovascular manifesta-tions between two groups: younger and older than 6 years old. Method(s): This retrospective observational study describes cardio-vascular clinical manifestations, laboratory findings, cardiac imag-ing, according to different age groups, and treatment in patients with diagnosis of MIS-C admitted to the Pediatric Istitute Giannina Gaslini between March 2020 and September 2021. Result(s): We collected 25 patients. Median age at onset of symptoms was 5 years old (interquartile range IQR, 3-12 y), 12 boys (56%). Immunoglobulin G antibodies were positive in 70% cases, Polymerase chain reaction (PCR) nasal/throat swab test for COVID-19 was positive in 15% cases, at the admission. The remaining cases had close contacts of COVID-19 positive cases. Predominant coronary artery abnormalities were observed in age group up to 6 years old (n.13) with development of small and medium aneurysms in half of cases and low rate of mild ventricular dysfunction. While children between 7-18 years of age present myopericardial involvement with ventricular dysfunction in 67% cases, from mild to moderate. Only two cases of transient coronary dilatation. Frequent electrocardiogram abnormalities: ventricular repolarization anomalies and reversibile QTc prolon-gation interval. Laboratory findings showed rised inflammatory markers and only mild elevation of cardiac enzymes compared to an early and significant NT-pro-BNP increase. All patients were treated with intravenous immunoglobulin and corticosteroids. Some cases needed anakinra. Aspirin and heparin was adminis-trated. No inotropes requied but only cardioprotective therapy. No need of Intensive Care Unit. Conclusion(s): This case-series shows the frequent cardiovascular involvement in MIS-C with a peculiar distribution, according to differents age's group: coronary artery anomalies in young ones, myopericardial disease in old ones. Prompt multi target anti-inflammatory therapy could have an effect to favorable outcome.