Cytokine elimination in suspected COVID-19 perymyocarditis

Background: Only recently studies have been able to demonstrate the safety and efficacy of purification therapies in inflammatory diseases. Here we present the management of a young (21y) male patient in severe cardiogenic shock due to COVID-19 perymyocarditis admitted to the ICU at Bolzano Central Hospital. November 30th 2020 the patient developed high fever (>40 C) and diarrhea. After unsuccessfully being treated orally with a macrolide he was admitted to a peripheral hospital the 4th of December. The day after he deteriorated, required transfer to the ICU, endotracheal intubation and pharmacological cardiovascular support (Norepinephrine, Levosimendan). Antimicrobial treatment was started with piperacillin/tazobactam, linezolid and metronidazole. Despite multiple radiological and microbiological diagnostic attempts the origin of this severe septic shock remained unclear. December 6th the patient was transferred to Bolzano Central Hospital for VA-ECMO evaluation. Method(s): The transesophageal echocardiography revealed 15-20% of EF, lactate (5,2 mmol/l), cardiac enzymes (TropT 1400 mcg/l) and inflammatory parameters (PCT 35 ng/ml, IL-6 685 pg/ml) were elevated. We performed cardiac monitoring via Swan-Ganz catheter. The cardiac index was 1,6 l/min/m2. The peak dosage for Norepinephrine reached 7,5mg/h (1,47 mcg/kg/min). At Bolzano ICU we facilitate the pharmacological therapy with milrinone, vasopressin and low dose epinephrine. Furthermore, we impost continuous hemodiafiltration with CytoSorb filter. Result(s): Only hours after the start of filtration therapy the patient improved and we were able to gradually reduce catecholamine therapy, lactate values decreased. A VA-ECMO implantation was no more necessary. December 10th, we saw a stable patient without ventilatory or cardiovascular support, at echocardiography we revealed a normal EF. Conclusion(s): Clinically we saw a young patient in severe septic/cardiogenic shock due to perimyocarditis. Yet diagnostic attempts (CT-scan, multiple blood/urinary/liquor cultures) remained negative. Despite multiple negative PCR tests for SARS-CoV2 infection we performed specific immunoglobulin analysis and received a positive result for IgM. We therefore conclude on a COVID-19 associated perymyocarditis. Furthermore, this case illustrates the potential benefit of cytokine filtration and elimination in COVID-19 patients with altered IL6 levels.

Complications Of A Severe Case Of Multisystem Inflammatory Syndrome In Children

Case Presentation: A 10 year old male with prior COVID-19 exposure presented with 7 days of fever, rash, cough, vomiting, and hypotension. Laboratory evaluation was notable for SARS-CoV2 antibodies, elevated cardiac enzymes, BNP, and inflammatory markers. Initial echocardiogram showed normal cardiac function and a small LAD coronary aneurysm. He was diagnosed with Multisystemic Inflammatory Syndrome in Children (MIS-C) and given methylprednisolone and IVIG. Within 24 hours, he developed severe LV dysfunction and progressive cardiorespiratory failure requiring VA-ECMO cannulation and anticoagulation with bivalirudin. Cardiac biopsy demonstrated lymphocytic infiltration consistent with myocarditis. On VA-ECMO, he had transient periods of complete AV block. With immunomodulator treatment (anakinra, infliximab) and 5 days of plasmapheresis, inflammatory symptoms and cardiac function improved. He weaned off ECMO, and anticoagulation was transitioned to enoxaparin. He had left sided weakness 5 days later, and brain MRI revealed an MCA infarct. Ten days later, he had focal right sided weakness and repeat MRI showed multiple hemorrhagic cortical lesions, thought to be thromboembolic with hemorrhagic conversion secondary to an exaggerated inflammatory response to an MSSA bacteremia in the setting of MIS-C. Enoxaparin was discontinued. After continued recovery and a slow anakinra and steroid wean, he has normal coronary arteries, cardiac function, and baseline ECG but requires ongoing neurorehabilitation. Discussion(s): COVID-19 infection in children is often mild, but MIS-C is an evolving entity that can present with a wide range of features and severity. This case highlights two concepts. While first degree AV block is often reported in MIS-C, there is potential for progression to advanced AV block. Close telemetry monitoring is critical, especially if there is evidence of myocarditis. MIS-C shares features with Kawasaki disease, with a notable difference being a higher likelihood of shock and cardiac dysfunction in MIS-C. In MIS-C patients with cardiovascular collapse requiring ECMO, there is a risk for stroke. There should be a low threshold for neuroimaging and multidisciplinary effort to guide anticoagulation in these complex cases.

COVID-19 and Spontaneous Coronary Artery Dissection: Association or Causality

Clinical Information Patient Initials or Identifier Number: JS Relevant Clinical History and Physical Exam: A 55-year old woman was brought to emergency department complaining of sudden onset squeezing chest pain radiating to her arm and jaw and associated with giddiness. She had flu like illness a day prior to her presentation associated with malaise, arthralgia and dry cough. She had history of hypertension. Physical examination revealed dual heart sounds and clear lung fields to auscultation. Relevant Test Results Prior to Catheterization: Electrocardiogram (ECG) showed normal sinus rhythm and the cardiac enzymes were elevated;high sensitivity troponin-I, 23000 ng/L (range0-10 ng/L). RNA PCR was positive for SARS-CoV-2 (COVID-19). D-Dimer was 303microgram/L (normal <500). Transthoracic echocardiogram showed severe hypokinesis of the mid inferolateral wall with left ventricular ejection fraction (LVEF) 52%. Chest X-ray showed no focal consolidation. [Formula presented] [Formula presented] Relevant Catheterization Findings: Invasive coronary angiogram showed tortuous coronary arteries with abrupt narrowing of mid- distal Ramus Intermiedius and discrete lesion of mid PDA. SCAD (spontaneous Coronary dissection) of Ramus Intermedius and mid PDA (posterior descending artery) was suspected, and patient was treated conservatively. Repeat coronary angiography, few months later showed complete resolution of SCAD with normal appearance of affected vessels. [Formula presented] [Formula presented] [Formula presented] Interventional Management Procedural Step: After obtaining an informed consent right Radial access was achieved with 6F Terumo sheath using over the wire technique. 1% lignocaine was used as local anaesthetic. 5F JL 3.5 (Judkin's) and JR 4 catheters were used to engage left main stem (LMS) and right coronary artery (RCA) and selective coronary angiography was performed. No percutaneous coronary intervention was performed. After the procedure hemoband (TR band) was applied to access site. Patient remained hemodyanamically stable throughout the procedure. [Formula presented] [Formula presented] [Formula presented] Conclusion(s): SCAD is a potential cause of type II myocardial infarction in patients with COVID-19, but more studies are needed to establish causality. Infection-related SCAD may occur at any time during index events and could be difficult to diagnose. Conservative management seems like a safe strategy.Copyright © 2023

Myocardial Injury Is Not Associated with Mortality in Severe Covid-19

Background Biochemical markers of cardiac injury and strain are proven indicators of severe COVID-19. Whether enzyme elevation is a product of cardiopulmonary strain versus myocardial viral injury is not well defined. CARDIO-COVID is a registry designed to study COVID-19 patients admitted to ICUs with evidence of cardiac injury. Methods Inclusion criteria for the CARDIO-COVID registry are PCR positive test for SARS-CoV2, ICU admission and either elevated troponin, elevated NT-proBNP/BNP, or new onset heart failure. Registry contains 1328 cases from 16 centers in the US, Canada, and Europe. 838 cases were included for analysis. Cases were collected between March 2020 - May 2021. Multivariate regression analyses were performed. Results Patients were 51.3% male, average age of 67.4 years and 32% Caucasian. 63% had pre-existing cardiovascular disease. Morbidity and mortality were common: 40% died, 50% underwent intubation, 20% required renal replacement therapy, and 5% had cardiac arrest requiring CPR. New onset arrhythmias were common (26%), but VT/VF was rare (4.8%). Cardiovascular complications were minor drivers of morbidity: 4.8% had ACS requiring catheterization, 8.0% had new onset heart failure (median EF 43% (IQR 31 - 47.75%), 4.4% had a CVA, and 6.7% had PE. Of patients who died, 65% died from hypoxemic respiratory failure, 10.5% from septic shock, 9.3% from PEA, and 3.1% from cardiogenic shock. Modeling showed insignificant increased odds of death in patients with MACE (p-value 0.22, OR 1.94 CI 0.67 - 5.82). Age (p-value 0.005) and intubation (p-value 0.001, OR 5.8 CI 2.1 - 18) were strongest predictors of death. Every increase in age by one year was associated with 5% increase in odds of death. Degree of cardiac enzyme elevation was not associated with MACE, death, or intubation. Conclusion While elevated cardiac enzymes are common in severe COVID-19, cardiac complications are not common drivers of mortality. Respiratory failure and septic shock are leading causes of death. These findings suggest that in severe COVID-19 cardiac enzyme elevation usually reflects cardiopulmonary strain from respiratory distress rather than myocardial injury portending cardiac failure or death.Copyright © 2023 American College of Cardiology Foundation

The arrhythmic events and short-term cardiovascular outcomes in patients hospitalized with COVID-19 infection in Taiwan

Objective: The aim of this study is to investigate the arrhythmic events and short-term cardiovascular (CV) outcomes in patients hospitalized with COVID-19 infection in a single Taiwan tertiary center. Method(s): A retrospective study was carried out on 186 confirmed COVID-19 infection patients admitted to our hospital between May, 2021 and September, 2021. We investigate their CV symptoms, vital signs, laboratory examinations, arrhythmic events, and major adverse cardiovascular events (MACE), including ischemic stroke or systemic embolism, myocardial infarction, CV death, and heart failure (HF) during hospitalization. Result(s): During the hospitalization, 29.6% of patients had an elevation of cardiac enzymes, 67.2% had an elevation of d-dimer level, and 7.5% had abnormal NT-pro BNP level. The most common recorded arrhythmia is sinus tachycardia (22%), followed by atrial arrhythmia (12.4%, including atrial fibrillation 7.0%), sinus bradycardia (3.2%), ventricular arrhythmia (1.6%), and paroxysmal supraventricular tachycardia (1.1%). A total of 68 patients (36.6%) had arrhythmic events during hospitalization. During the mean follow-up of 2.8 months, 17 patients (9.1%) developed MACE, including 6 ischemic strokes, one pulmonary embolism, one peripheral artery occlusive disease, 3 HF, and 7 CV death. The total mortality rate is 19.9%. The hospitalized patients with arrhythmic events were associated with a higher incidence of intubation (32% vs 15%, p = 0.0062), MACE (22% vs 2%, p < 0.001), and mortality (37% vs 10%, p < 0.001) than those without arrhythmic events. Conclusion(s): The patients hospitalized with COVID-19 infection were associated with higher CV manifestations and arrhythmic events in Taiwan. Those patients with arrhythmic events were associated with higher morbidity and mortality.

Cardiovascular manifestations in multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19

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.

THROMBUS IN TRANSIT CAPTURED BY BEDSIDE ULTRASOUND: A LIFE-SAVING TOOL

SESSION TITLE: Thrombosis Jamboree: Rare and Unique Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Point of care ultrasound used by the provider is rapidly expanding in internal medicine. Thrombus in transit (TIT) is defined on ultrasound as mobile echogenic material temporarily present in the right heart chambers to the pulmonary circulation via the tricuspid valve or systemic circulation via an atrial septal defect. In this case, we were able to identify echogenic material traversing the tricuspid valve into the pulmonary circulation, which confirmed the diagnosis of pulmonary embolus [1] CASE PRESENTATION: This is a 71-year-old female with a history of hypertension who presented to the emergency room with 4-day pleuritic chest pain, productive cough, fever, and exertional dyspnea. She was hemodynamically stable, afebrile, tachycardic, and tachypneic. Initial diagnostic workup demonstrated elevated cardiac enzymes and creatinine, ground-glass opacities on chest CT, positive COVID PCR, and sinus tachycardia with nonspecific T wave abnormalities. Given her renal insufficiency, CTA was initially held off. The patient was found to have right lower extremity deep venous thrombosis, and a heparin infusion was started while waiting for a V/Q scan. Shortly after admission, she had a syncopal episode after using the bathroom. CPR was initiated for suspected cardiac arrest, and a bedside ultrasound demonstrated a sizeable mobile thrombus in the right atrium traversing the tricuspid valve into the right ventricle. Given this finding, we elected to move forward with CTA chest, and this study confirmed extensive bilateral PE with right heart strain. DISCUSSION: TIT is a rare emergency in PE (4%) with a staggering mortality rate twice as high as PE without TIT [2]. The gold standard for diagnosis of PE is CT angiogram, and early echocardiography is a cornerstone in diagnosis and risk stratification. However, patients similar to the one discussed in this care may present with conditions preventing timely utilization of these tools. POCUS allows for the rapid assessment and implementation of time-sensitive treatments. Historically, it has been a must-have skill set among ER and critical care physicians. Only 35% of internal medicine residency programs have fully integrated formal diagnostic POCUS within the past decade despite increasing interest among trainees. The expeditious medical decision made for our patient was possible following a focused echocardiogram performed by an internal medicine resident. In patients with massive PE, only 35% of echocardiograms obtained within 24 hours were done in the ER, and still, 1 in 6 happened after 6 hours [3]. CONCLUSIONS: As with any operator-dependent skill, proficiency in POCUS is a prerequisite for reliable findings and time-sensitive medical decision-making. POCUS only becomes a lifesaving tool in experienced hands. Hence, it is imperative that internal medicine residency programs consider this tool an essential component of resident training. Reference #1: Arboine-Aguirre L, Figueroa-Calderón E, Ramírez-Rivera A, et al. Thrombus in transit and submassive pulmonary thromboembolism successfully treated with tenecteplase. Gac Med Mex. 2017;153(1):129–33. Reference #2: Casazza F, Bongarzoni A, Centonze F, Morpurgo M. Prevalence and prognostic significance of right-sided cardiac mobile thrombi in acute massive pulmonary embolism. Am J Cardiol. 1997;79(10):1433-1435. doi:10.1016/s0002-9149(97)00162-8 Reference #3: Torbicki A, Galié N, Covezzoli A, et al. Right heart thrombi in pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry. J Am Coll Cardiol. 2003;41(12):2245-2251. doi:10.1016/s0735-1097(03)00479-0 DISCLOSURES: No relevant relationships by Varinder Bansro No relevant relationships by Olayiwola Bolaji No relevant relationships by clarence findley No relevant relationships by Faizal Ouedraogo

Cardiac Manifestations in Pediatric COVID-19

Myocarditis is usually diagnosed clinically by electrocardiograms, echocardiography, and increased cardiac enzymes since troponin is also defined as a marker of cardiac injury in children and adolescents. Myocarditis and pericarditis have been found in up to 40% and 25% of patients, respectively. Pericardial effusion occurred in up to 32% of patients. Together with the myocardial dysfunction findings, these characterize the pancarditis associated with COVID-19. Myocardial involvement may also be related to the presence of arrhythmias. In COVID-19, hypoxia, neurohormonal or inflammatory stress, and metabolic disorders contribute to changes in the cardiac rhythm. Some of the current drug therapies used in this disease can also induce arrhythmia, adversely affecting cardiac electrophysiology. Patients with COVID-19 have an increased risk of developing venous thrombosis, reaching 25%, with the highest risk in those with increased Ddimer and inflammatory markers, decreased fibrinogen, and those with the severe acute respiratory syndrome. There is suspicion mainly in patients who develop refractory hypoxemia or asymmetric edema of the lower limbs. Coronary thrombosis, in addition to the one being characterized, may correspond to one of the pathophysiological mechanisms of cardiovascular complications. Because of the systemic inflammatory response and imbalance in the oxygen supply, there is also an increased risk of coronary ischemia.

MIS-CM imicking Acute Appendicitis

Introduction: Abdominal pain is one of the most common complaints seen in the pediatric acute care setting. SARS-CoV-2 disease in children includes a hyperinflammatory syndrome called Multisystem Inflammatory Syndrome in Children (MIS-C). Gastrointestinal symptoms are most common in pediatric acute SARS-CoV-2 infection as well as in MIS-C. Case Description: A 13- year-old female presented with diffuse lower abdominal pain for 3-days. Pain was 10/10 in intensity, worsened with movement, and had associated constipation, anorexia, nausea, and vomiting. Exam showed an ill-appearing female with labile vitals and generalized lower abdominal tenderness with good bowel sounds. Ultrasound suggested features of acute appendicitis but a follow-up CT did not visualize the appendix. She was admitted to the inpatient unit after routine screening revealed positive SARS-CoV-2 antibody but negative PCR. She received IV fluid bolus, narcotic analgesics, and ampicillin-sulbactam preoperatively. Within hours, she spiked high-grade fevers (101.4F), sustained hypotension, and tachycardia with concern for sepsis secondary to a possible ruptured appendix. She underwent emergency diagnostic laparoscopy which revealed bile-tinged fluid in the lower quadrant, a mildly inflamed appendicular tip without perforation, and thickened mesenteric nodes within the inflamed distal ileum. Intra-operatively, she had persistent hypotension requiring fluid boluses and vasopressors. Her admission labs revealed elevated inflammatory markers, deranged coagulation profile, and elevated cardiac enzymes. Her differential diagnosis was then revised to include MIS-C and severe sepsis. Antibiotic coverage was broadened to Vancomycin and Meropenem. An Echocardiogram showed mitral regurgitation with moderately to severely decreased right and left ventricular systolic dysfunction with an ejection fraction of 32.8% The patient was then transferred to the pediatric cardiac critical unit where she received treatment with IVIG, steroids, and anticoagulants. Her clinical status and lab studies improved with EF > 50%. She was discharged from the intensive care unit after 7 days and has had an uneventful follow-up. Discussion: Differential diagnosis for acute lower abdominal pain in an adolescent female is broad. Similar cases with predominant GI symptoms and later generalized multisystem involvement have been reported, however, most were managed conservatively. Two reports have been published on MIS-C presenting as acute appendicitis, but neither had significant cardiac involvement. Our patient's presentation can easily be confused with an acute surgical abdomen but the pathology report confirmed a congested appendix without any fecoliths supporting either inflammation or vasculitis as the cause for her presentation, which is in concordance with the hyperinflammatory state that has previously been described in patients presenting with a history of past SARS-CoV- 2 infections. Conclusion: MIS-C can mimic serious pediatric illnesses including sepsis, acute abdomen, and Kawasaki disease. Clinicians should have a low threshold for suspecting MIS-C, as prompt treatment can be lifesaving. Universal screening for COVID-19 infection with PCR and antibody tests can expedite the diagnostic evaluation of severely ill children. Showing reactive wall thickening of the cecum and small bowel loops (red arrow) and enlarged mesenteric lymph nodes (yellow arrow). The appendix could not be visualized here.

Multisystem Inflammatory Syndrome in Children (MIS-C)- A Case Report with severe Cardiac Involvement

We present the case and course of a 10-year-old girl with a multisystem inflammatory syndrome in children (MIS-C) following SARS CoV-2 infec-tion. The previously healthy girl was referred to our emergency department due to persistent fever, reduced general condition, thrombocytopenia and elevated CRP. Clinical exanimation confirmed a reduced condition and revealed bilateral conjunctivitis, palmar, facial and thoracal ery-thema, sinus tachycardia and fever. Diagnostics, including a negative SARS-CoV-2 test, showed pancytopenia, elevated liver enzymes and CRP. Initial echocardiography and ECG were normal. Based on history, clinical presentation and laboratory results reflecting a multisystem affection we considered sepsis, Kawasaki disease and as a result oft the SARS-CoV-2 pandemic MIS-C despite negative test. Treatment included antibiotics, in-travenous immunoglobulins (IVIG) and systemic corticosteroids. The condition worsened on the third day of hospitalization with clinical signs of heart failure due to new-onset myocarditis. Echocardiography showed a reduced biventricular function. There were repolarization ab-normalities in ECG and elevated cardiac enzymes. The patient was then referred to ICU of a tertiary hospital for further treatment. Meanwhile SARS-CoV-2 infection was proven via positive antibodies. The girl was sta-bilized with high-flow therapy, catecholamines, diuretics, low-dose ace-tylsalicyl acid (ASA) and high-dose corticosteroids. Due to persistent fever, antibiotic therapy was extended and immune-modulating medication (Anakinra) was prescribed. Within a few days, cardiac function improved, cardiac enzymes normalized and there were no signs of coronary dilation. After 6 days and a second course of IVIG, the patient was transferred from ICU to the hospital ward. The patient was discharged in good general condition after 13 days of hos-pitalization with low dose ASA for 8 weeks and Prednisolon for 2 weeks in total. Regular outpatient controls showed normalized cardiac function. After 6 months, a cardiac MRI was performed showing no signs of myocardial damage and normal coronary arteries. The patient was suffering from breathlessness and general weakness for several months. Six months af-ter primary diagnosis of MIS-C she was allowed to participate in normal physical exercise again. Summarized, pediatricians need to be aware of MIS-C as a serious condi-tion whenever children present with persistent fever, rash and clinical signs of multiorgan affection.

Real time case of cardiac and vascular complications of COVID -19 infection from the State of Jharkhand

As of December 2021, India has over 34.8 million cases of COVID 19, an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It has been a massive problem to society with variable manifestations in human, and there has been numerous reported cases of covid 19 patients presenting with broad spectrum of cardiovascular (CV) manifestations. This case presented 3 patients with CV complication of COVID 19 leading to vascular ischemia, cardiac tamponade and ST elevated myocardial infarction All patients presented with chief complaint of high grade fever and shortness of breath. The first patient was a healthy and young 24-year-old male having pain in the right thigh with swelling. Doppler ultrasound of limbs showed poor venous flow indicating vascular ischemia. 2nd patient was 60-year-old women with upper respiratory symptoms diagnosed with Covid 19 and had progressive dyspnoea. She was found to have a hemorrhagic pericardial effusion with echocardiographic signs of tamponade and grade 2 cardiomegaly. Third patient was a 59 years old diabetic male diagnosed with ST elevated myocardial infraction represented by elevated cardiac enzymes, raised troponin I, ST elevation in anterior and septal leads and akinesia in the region of left anterior descending coronary artery (LAD). Covid 19 infection has common respiratory foot prints identified by knowledge of clinical presentation however, it has also extra- pulmonary cardiac and Vascular Stigmas which can be of serious consequences.

Regression of coronary arteries dilatation 6 months after multisystem inflammatory syndrome in children (MIS-C)

Introduction: Multisystem inflammatory syndrome in children (MIS-C) is a rare complication of SARS-CoV-2 infection, with an incidence of about 1:100'000 children. According to published case series, between 10% and 40% of MIS-C develop coronary artery modifications, mainly hyperechogenicity, with a lower incidence of aneurysm. Evolution and outcome of coronary artery aneurysm post MIS-C is unknown. Methods: We report the case of a 10-year old male with medium left anterior descending coronary artery (LAD) aneurysm (diameter of 6.2 mm, z-score +7.9) and small right coronary artery (RCA) aneurysm (z-score +2.9) detected one week after his hospital admission for hypotensif shock in the context of MIS-C and positive serologies for SARS-CoV-2. He didn't meet diagnosis criteria for Kawasaki disease. He was treated with 2 g/kg immunoglobulin (administered after coronary artery dilatation was observed, as the recognition and definition of MIS-C was contemporary with our case), corticosteroids and anakinra. He rapidly normalized his initial mild LV dysfunction and cardiac enzymes elevation. Results: Since discharge, the patient was treated with antiplatelet therapy (100 mg aspirin daily) and carefully followed up in outpatient cardiology. On echocardiography, coronary artery dimensions progressively regressed, prompting a control computed tomography (CT) 6 months after MIS-C episode. CT confirmed LAD and RCA dimension near-normalization, compared to the fusiform dilatations 6 months ago : LAD maximal diameter of 3.7 mm (z-score +2.3), RAD maximal diameter of 4 mm (zscore +1.8). Moreover, no coronary stenosis was observed. Conclusions: Coronary artery aneurysm in the context of MIS-C probably represents a post-infectious vasculitis. This case illustrates a regression of coronary artery dilatation after a few months. Further research is needed to assess if this finding reflects a generalisable outcome and to study the effect of medical treatment on the evolution of coronary artery dilatation post MIS-C.

Absence of cardiac involvement in children with uncomplicated SARS-CoV-2 infection

Introduction: The pandemic of SARS-CoV-2 is a major health issue, and involvement of the cardiovascular system is common amongst adult with acute coronavirus disease 2019 (COVID-19). Since the beginning of the epidemic, children seem relatively spared with a low morbidity and mortality. However, multisystem inflammatory syndrome in children (MIS-C) is a rare but severe complication following SARS-CoV-2 infection. Cardiovascular involvement is reported in about 80% of MIS-C cases, with elevated cardiac enzymes, left ventricular dysfunction, shock, coronary artery dilatation, mitral regurgitation and arrhythmias. Although MIS-C seems to be a post-infectious complication, its pathogenesis has not yet been clearly elucidated. It is unknown whether children with uncomplicated SARS-CoV-2 infection can develop subclinical cardiac implication and coronary artery dilatation. Methods: Children with an acute infection of SARS-CoV-2 confirmed by positive RT-PCR test on nasopharyngeal swab between March and May 2020, who didn't meet MIS-C diagnostic criteria, were proposed an outpatient cardiology appointment. Electrocardiogram and echocardiography were performed in all participants. Results: 35 children (17 female) aged 2 months to 16 years (mean: 9.2 years) were enrolled after informed consent. Cardiology assessment took place 66 days (range 44 to 100 days) after the test. Shortening fraction of the left ventricle was normal in all subjects (mean shortening fraction 35.25%, range 30-43%). Coronary arteries were normal without dilatation in all 35 children. Moreover, there was no valvar abnormalities and no pericardial effusion. ECGs were normal without conduction abnormalities. Conclusions:Wedidn't observe any subclinical cardiac involvement in our cohort of pediatric patients with uncomplicated SARSCoV-2 infection. Cardiac dysfunction and coronary artery dilatations reported in MIS-C, but never or rarely reported in acute pediatric COVID-19 cases corroborate the hypothesis of a postinfectious syndrome. Further researches are necessary to better understand the underlying mechanisms of cardiovascular involvement after SARS-CoV-2 infection.

Pediatric COVID-19-associated hyper-inflammation score: The virus registry predictive analytic study

INTRODUCTION: Several adult and pediatric studies demonstrate a correlation between elevated inflammatory markers and COVID-19 disease severity. The Society of Critical Care Medicine (SCCM) Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS) COVID-19 registry was used to develop Pediatric COVID Hyperinflammation Syndrome (PcHIS) score and evaluate the association between PcHIS and severe COVID illness in children. METHODS: Children under 18 years of age hospitalized due to COVID-19 were filtered from VIRUS registry (NCT 04323787). Neonates and children incidentally positive for COVID were excluded. For the development of PcHIS score we used 7 variables: fever, hematologic dysfunction (platelet, leucocyte count), elevated ferritin, elevated D-dimer, cytokinemia (CRP, procalcitonin, IL-6), hepatic injury (ALT, AST, albumin) and elevated cardiac enzymes (BNP, Troponin). ROC curves were generated for each variable to choose the best discriminatory (J point of Youden Index) value for identification of severe disease (anyone requiring respiratory support more than O2 by NC, vasoactive meds, ECMO, or dialysis). Each abnormal value got one point and the additive PcHIS score was calculated for the best discriminatory score for identification of severe disease (using ROC). RESULTS: Out of a total of 1123 patients aged < 18 years with COVID-19 in the registry, 722 were included for PcHIS development;rest had missing data. A 1/3rd in the cohort had severe COVID disease. Odds of severe disease were higher with fever > 39°C (OR1.5;CI1.05-2.14), presence of any hematologic dysfunction (platelets < 250k/μL or WBC > 6650/μL) (OR 7.12;CI 2.52-20.05), cytokinemia (CRP >6.7 mg/dL or procalcitonin > 3.4) (OR 4.99;CI 3.05-8.17), ferritin level > 270 mg/dL (OR 3.87;CI 2.38-6.28), elevated cardiac enzymes (BNP > 685 or Troponin > 0.03) (OR 3.08;CI1.96-4.85), hepatic injury (AST >50 or ALT >40 or albumin< 3.5 g/dL) (OR 3.25;CI 2.16-5.0), D-dimer > 2000 ng/ml (OR 2.46;CI1.59-3.8). A PcHIS score of 2.5 had a sensitivity of 69.2% and a specificity of 62.1% with ROC area under curve of 0.70 (95% CI: 0.66-0.74;p< 0.001). CONCLUSIONS: PcHIS score may be calculated from early laboratory data and is useful in predicting severe disease in children with COVID-19. Its role in clinical practice needs to be determined in a prospective study.