ABSTRACT
Background: The COVID-19-associated multisystem infammatory syndrome in children (MIS-C) is characterized by Kawasaki disease (KD)-like features and circulatory shock [1]. The genesis of SARS-CoV-2 variants triggered successive waves of mass infections followed by MIS-C outbreaks. Objectives: To compare MIS-C phenotypes across the waves of the COVID-19 pandemic. To identify predictors of pediatric intensive care unit (PICU) admission and treatment with biologic agents. Methods: Youth aged 0-18 years, fulflling the WHO case defnition of MIS-C, and admitted to the Alberta Children's Hospital during the COVID-19 pandemic (May 2020-December 2021) were included. Clinical, laboratory, imaging, and treatment data were captured (KD-like manifestations, signs of shock and/or hypotension, peak C-reactive protein (CRP) and ferritin, platelet count nadir, peak NT-proBNP and troponin, liver enzyme abnormalities, sodium and albumin nadir, echocardiogram fndings, biologic agents). Results: 57 consecutive MIS-C patients (median age 6 years, IQR 4-6;72% males) were included. 31 patients (54%) required PICU admission. All received immunoglobulins, 44 (77%) received corticosteroids, 8 patients (14%) were treated with biologic agents. Patients presenting during the third (mainly driven by Alpha variant) or fourth wave (mainly driven by Delta variant) presented with higher ferritin and NT-proBNP levels, and more liver enzyme abnormalities, hypoalbuminemia and thrombocytopenia compared to those presenting during the frst or second wave (Table 1, Figure 1). PICU admission was associated with the presence of shock/hypotension, higher CRP, ferritin, and NT-proBNP levels, lower albumin levels, and the presence of ventricular dysfunction on echocar-diogram (Table 1). A logistic regression model combining peak NT-proBNP, tro-ponin and ferritin levels explained 70% (Nagelkerke R2) of the variance in PICU admission and correctly classifed 91% of the cases. NT-proBNP was the sole signifcant contributor (p=0.017). Treatment with biologic agents was associated with higher CRP (mean 148.8 mg/l versus 251.7 mg/l;p=0.024) and ferritin (797 μg/l versus 1280 μg/l;p=0.049) levels. Conclusion: A shift in MIS-C phenotype was identifed across the successive COVID-19 waves, including the predominance of features associated with macrophage activation syndrome in later stages. These fndings may refect the impact of distinct SARS-CoV-2 variants. NT-proBNP emerged as the most important MIS-C feature predicting PICU admission, underscoring the importance of monitoring.
ABSTRACT
Background: The 2019 novel coronavirus (COVID-19) has been associated with elevated liver enzymes, which has seen to be associated with a higher mortality rate in COVID-19 infected patients. With a global vaccination rate under 50%, as of November 2021, we will continue to see patients admitted for COVID-19 infection. We have done this study to further evaluate the relationship between development of transaminitis and its relation to vaccination status and to see if vaccination prevented liver injury in COVID-19 patients. Methods: A retrospective study was performed between October 2019 and October 2021 on patients infected with COVID-19. A total of three hundred and fifty patient charts were included in the study. Patient data regarding age, sex, comorbidities, vaccination status, vaccine manufacturer, mortality, and length of stay data were reviewed. Patients were then divided into two groups (Vaccinated vs Unvaccinated ), data was then matched for their age, sex, and comorbidities using propensity score matching. Results: Each group had thirty-nine patients after propensity score matching. The average age in both groups was 58.4±13.3. Twenty-one females were in a non-vaccinated group and twenty females in the vaccinated group. The average number of days to infection from the last COVID-19 vaccine was 132±57. The vaccinated group showed a significant reduction in the incidence of liver injury with respect to AST (42±13 vs. 93.3±35, P< 0.02, 95% CI), ALT (50±10 vs. 97.4±45.5 P<0.04), and ALP 65±15.2 vs. 93±35.6 P<0.01) compared to unvaccinated patients. The vaccinated patient group showed a reduced length of stay compared to the unvaccinated group ( 10.6 ± 4.8 vs. 18.1 ± 8.1, P<0.05). The vaccinated patient group showed a decrease in mortality as compared to the unvaccinated group (17 vs. 8, P<0.05). Conclusion: After a thorough review of COVID infected patients, liver enzyme abnormalities were evaluated in vaccinated and unvaccinated patients. ALT, AST, and ALP in vaccinated patients were found to be significantly lower in as compared to unvaccinated patients. Hospital length of stay and mortality rate were both found to be lower in vaccinated patients compared to unvaccinated patients. Recent vaccination status leading to decreased infection severity may relate to the lack of significant and dramatic increase in liver enzyme levels and may present as confounding factors. Major limitation in the study was the small sample size and future studies with a larger sample size can deliver a better perspective.
ABSTRACT
Background and aim. Gastrointestinal manifestations in COVID-19 have been frequently acknowledged by clinicians and scientists. However, their clinical significance and potential influence on the disease outcome is not entirely elucidated. In this study we aim to evaluate gastrointestinal involvement, both digestive symptoms and liver-related changes in hospitalized COVID-19 patients in correlation to the presence or absence of underlying liver disease and rate of mortality. Methods. We performed a retrospective cohort study of COVID-19 patients, consecutively admitted in a hospital from Chisinau, between September 3, 2020 and May 31, 2021. Data on clinical symptoms and laboratory findings were collected from electronic clinical records. The cohort was divided into two groups, with and without pre-existing liver disease. The Fisher exact, Pearson Chi-square tests were used to compare groups. Results. A total of 1835 patients were included, 108 (5.9%) with pre-existing liver disease and 1727 (94.1%) without this comorbidity. Digestive symptoms were reported by 331(18%) of the patients, diarrhea being the most common symptom 11.8% (217) and being encountered more in patients with underlying chronic liver disease. No statistical difference was identified between the groups in regard to other symptoms, comorbidities and rate of mortality. But patients with chronic liver disease had significant (P < 0.001) lower ferritin, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in comparison with the other group. At admission, 341 (19.2%) had increased aspartate aminotransferase level (AST) and 317 (17.8%) alanine aminotransferase. The enzyme abnormalities were predominantly mild and transitory. Abnormal AST level at admission and during follow up, higher ESR, CRP, ferritin, lactate dehydrogenase (LDH) was found to correlate with higher rates of mortality. Conclusion. Digestive implications, especially diarrhea in COVID-19 patients is frequent, but do not appear to be associated with mortality. Elevated liver enzymes during hospitalization, age, high ferritin, CRP, LDH might be interpreted as risk factors for mortality in COVID-19 but further studies are needed to address this topic
ABSTRACT
Background: Interstitial lung disease (ILD) is an umbrella term used for a large group of diseases that cause scarring of the lung. Description of the case: We describe the case of a 57-year-old woman who has been hospitalized for dyspnea, fever and dry cough. Objectively she presented late inspiratory bibasilar crackles, periungual erythema, hyperkeratosis of the fingers and oral ulcers. Baseline complete blood count, liver and kidney function, as well as creatine kinase and lactate dehydrogenase were normal. The chest-X-ray showed a diffuse reticulonodular pattern and high resolution computed tomography confirmed diffuse ground glass opacities. Four nasal and oropharyngeal swabs for SARS-CoV-2 molecular detection, bacterial and viral serology and blood cultures were all negative. Antinuclear antibodies and myositis specific autoantibodies were negative, excepted for the melanoma differentiation associated gene 5 antibodies (MDA5). The diagnosis was of MDA5+ amyopathic dermatomyositis with ILD. Conclusions: Dermatomyositis (DM) and polymyositis (PM) are classified as idiopathic inflammatory myopathies. Among patients with DM or PM, interstitial lung disease is a major cause of morbidity and mortality. Anti MDA5 antibodies are often associated with a rapidly progressive course of ILD and cutaneous vasculitis. Skin lesions include digital and palmar papules and ulcerations, alopecia and oral ulcers. Anti MDA5 disease can be present in the absence of muscle enzyme abnormalities or other autoantibodies and portends a worse prognosis.