RESUMEN
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%.
RESUMEN
Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can involve children of all ages, although less frequently and with a milder presentation than adults. Cardiovascular abnormalities (myocardial injury, acute myocarditis, cardiomyopathy, heart failure, arrhythmias, pericarditis, cardiogenic shock, pulmonary embolism, myocardial infarction) may accompany, especially with the multisystem inflammatory syndrome in children and adolescents (MIS-C). Severe disease is managed in the hospital setting. Supportive care is the mainstay of therapy. Antiviral therapy, immune-mediated therapies, empiric antibiotics, and therapy for influenza infection are used in selective patients. Cardiac management focuses on maintaining hemodynamic stability and providing adequate systemic perfusion. Children presenting with shock should be resurrected according to standard protocols. Vasoactive agents such as epinephrine or norepinephrine and, if possible, milrinone is used in fluid-refractory shock. Children with Kawasaki disease (KD) features should receive standard therapies for KD, including intravenous immune globulin (IVIG), aspirin, and glucocorticoids. Patients with severe LV dysfunction, intravenous diuretics and inotropic agents, such as milrinone, dopamine, and dobutamine are suggested. Continuous cardiac monitoring is essential. In cases of the fulminant disease, mechanical hemodynamic support may be necessary. For moderate or severe manifestations (shock, left ventricular systolic dysfunction, elevated troponin or brain natriuretic peptide, arrhythmia, coronary artery aneurysm, or presentations requiring PICU care), therapy with combined IVIG plus a glucocorticoid is suggested. Patients may be at risk for venous thromboembolism due to COVID- 19 associated hypercoagulability. Patients with MIS-C and those with severe LV dysfunction or CA aneurysms are at increased risk. It is suggested that all patients with MIS-C receive low-dose aspirin, and severe cases requiring PICU care receive prophylactic-dose anticoagulant therapy. Patients with current or prior VTE, severe LV dysfunction, large or giant CA aneurysms, markedly elevated D-dimer should receive therapeutic anticoagulation (low molecular weight heparin) plus aspirin. Most children with cardiac involvement have recovery of function by hospital discharge. The overall mortality rate for MIS-C is approximately 1 to 2 percent. Cardiology follow-up after discharge is recommended.