Systemic Inflammation Is Associated With Neurologic Involvement in Pediatric Inflammatory Multisystem Syndrome Associated With SARS-CoV-2.

OBJECTIVE: Pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) is a severe immune-mediated disorder. We aim to report the neurologic features of children with PIMS-TS. METHODS: We identified children presenting to a large children's hospital with PIMS-TS from March to June 2020 and performed a retrospective medical note review, identifying clinical and investigative features alongside short-term outcome of children presenting with neurologic symptoms. RESULTS: Seventy-five patients with PIMS-TS were identified, 9 (12%) had neurologic involvement: altered conciseness (3), behavioral changes (3), focal neurology deficits (2), persistent headaches (2), hallucinations (2), excessive sleepiness (1), and new-onset focal seizures (1). Four patients had cranial images abnormalities. At 3-month follow-up, 1 child had died, 1 had hemiparesis, 3 had behavioral changes, and 4 completely recovered. Systemic inflammatory and prothrombotic markers were higher in patients with neurologic involvement (mean highest CRP 267 vs 202 mg/L, p = 0.05; procalcitonin 30.65 vs 13.11 µg/L, p = 0.04; fibrinogen 7.04 vs 6.17 g/L, p = 0.07; d-dimers 19.68 vs 7.35 mg/L, p = 0.005). Among patients with neurologic involvement, these markers were higher in those without full recovery at 3 months (ferritin 2284 vs 283 µg/L, p = 0.05; d-dimers 30.34 vs 6.37 mg/L, p = 0.04). Patients with and without neurologic involvement shared similar risk factors for PIMS-TS (Black, Asian and Minority Ethnic ethnicity 78% vs 70%, obese/overweight 56% vs 42%). CONCLUSIONS: Broad neurologic features were found in 12% patients with PIMS-TS. By 3-month follow-up, half of these surviving children had recovered fully without neurologic impairment. Significantly higher systemic inflammatory markers were identified in children with neurologic involvement and in those who had not recovered fully.

PIMS or not? Alternative diagnoses in the febrile child during the COVID-19 pandemic

BackgroundThe majority of children and young people affected by COVID-19 have remained asymptomatic or suffered mild illnesses. However throughout the pandemic patients with a novel rare but severe disease phenotype, Paediatric Inflammatory Multisystem Syndrome Temporally associated with SARS-CoV-2 (PIMS-TS)1 continue to need hospital admission. The importance of considering the wider differential such as malignancies should be highlighted.ObjectivesTo establish the range of diagnoses of children admitted to a tertiary London children’s hospital presenting with a history of fever and high CRP, in whom PIMS-TS was considered as a diagnosis, during the COVID-19 pandemic.MethodsClinical records from 1st March 2020 to 30th June 2020 (inclusive) were retrospectively analysed to identify patients under the age of 18 years admitted to a tertiary London children’s hospital with a history of fever and CRP >60. Electronic notes were reviewed to determine final diagnosis.Results140 patients were admitted with a history of fever and CRP >60 during the study period. 58% (n=81) had PIMS-TS and 42% (n=59) had alternative diagnoses. Of those with an alternative diagnosis 81% (n=48) had infective diagnoses and of these 46% (n=22) had upper or lower respiratory tract infections;25% (n=12) had sepsis;13% (n=6) had urinary tract infections or pyelonephritis;10% (n=5) had gastroenteritis;4% (n=2) had lymphadenitis and 2% (n=1) had meningitis. 10% (n=5) had surgical diagnoses most commonly appendicitis (n=3). 5% (n=3) had inflammatory diagnoses;2 with an exacerbation of Crohn’s disease and 1 with vasculitis. 3% (n=2) had autoimmune diagnoses, 1 with juvenile idiopathic arthritis and 1 with Still’s disease who developed macrophage activation syndrome. 2% (n=1) had Burkitt leukaemia.ConclusionsIn the midst of a pandemic there is a high suspicion of PIMS-TS in unwell febrile children. The high numbers of patients with PIMS-TS admitted to this hospital reflects the regional referrals pathway for the PIMS-TS patients during the first wave of COVID-19. However infections remain a major cause of children presenting with fever and a high CRP. The range of alternative diagnoses outlined in our cohort is not surprising, when one considers that PIMS-TS is a disease with a subjective and broad case definition, with signs and symptoms overlapping with other serious diagnoses – infectious, surgical, inflammatory, autoimmune and malignant.The wider differential diagnoses should always be considered when children present with fever and a thorough history and examination is paramount. Alternative diagnoses may have indolent or more chronic symptoms. Our experience has shown that discussion within a multidisciplinary team has helped to ensure alternate diagnoses are not missed.ReferenceHealth Service Journal. National alert as ‘coronavirus-related condition may be emerging in children. April 2020. Available from: https://www.hsj.co.uk/acute-care/exclusive-national-alert-as-coronavirus-related-condition-may-be-emerging-in-children/7027496.article (Last accessed 5th March 2021).

Developing new models of care at speed: learning from healthcare redesign for children with COVID-related multisystem inflammation.

This article describes the rapid, system-wide reconfiguration of local and network services in response to the newly described paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) (also known as multisystem inflammatory syndrome in children). Developing the model of care for this novel disease, whose natural history, characteristics and treatment options were still unclear, presented distinct challenges.We analyse this redesign through the lens of healthcare management science, and outline transferable principles which may be of specific and urgent relevance for paediatricians yet to experience the full impact of the COVID-19 pandemic; and more generally, for those developing a new clinical service or healthcare operating model to manage the sudden emergence of any unanticipated clinical entity. Health service leaders in areas where COVID-19 is, or will soon be, in the ascendancy, and who are anticipating the imminent influx of PIMS-TS, should use these principles and recommendations to plan an agile, responsive and system-wide model of care for these children.

Probable Vertical Transmission of SARS-CoV-2 Infection.

BACKGROUND: To date, although neonatal infections with severe acute respiratory syndrome coronovirus 2 (SARS-CoV-2) have been described, none of these have been proven to be the result of vertical transmission of SARS-CoV-2. METHODS: We describe the probable vertical transmission of SARS-CoV-2 in a neonate born to a mother with coronavirus disease 2019 (COVID-19). RESULTS: Following cesarean section, the neonate was kept in strict isolation. Molecular tests for SARS-CoV-2 on respiratory samples, blood, and meconium were initially negative, but positive on a nasopharyngeal aspirate on the third day of life. On day 5, the neonate developed fever and coryza, which spontaneously resolved. Viral genomic analysis from the mother and neonate showed identical sequences except for 1 nucleotide. CONCLUSION: This report has important implications for infection control and clinical management of pregnant women with COVID-19 and their newborns.