Multisystem inflammatory syndrome in children: Salient echocardiogram findings in the acute phase and longitudinal follow-up

Background Coronary artery (CA) abnormalities and left ventricular (LV) systolic dysfunction have been reported in multisystem inflammatory syndrome in children (MIS-C);however, a thorough review of all findings on transthoracic echocardiogram (TTE) with long term follow-up is lacking. Objectives Comprehensively describe the findings on TTE during the acute phase of MIS-C and how those findings change on serial follow-up 6 months after diagnosis. Methods Pediatric patients meeting CDC criteria for MIS-C were included, with data collected from acute phase (T0), outpatient follow-up at 2 weeks (T1), 6–8 weeks (T2), and 6 months (T3), including TTE findings of descending aorta Doppler profile, CA abnormalities, valvar regurgitation, LV systolic function and pericardial effusion. Results Fifty patients (52% male) were included;45 (90%) were SARS-CoV-2 IgG antibody positive, 13 (26%) PCR positive, and 8 (16%) positive for both. Mean age was 8.3 years (range 9 months - 17 years). Holodiastolic flow reversal in descending aorta was seen in 72% at T0, in 6% at T1, with complete resolution in all by T2. CA abnormalities were seen in 52% at T0, 31% at T1, 13% at T2 and none at T3. Mitral regurgitation was present in 84% at T0, 40% at T1, 36% at T2, and 24% by T3. LV systolic dysfunction (ejection fraction <55%) occurred in 52% at T0, with resolution by discharge in 69%, and complete resolution by T2. Trivial to small pericardial effusion was present in 48% at T0, 13% at T1, 3% at T2 and 4% by T3. Conclusion In addition to CA abnormalities and LV systolic dysfunction, holodiastolic flow reversal in the descending aorta, valvar regurgitation and pericardial effusion are prominent findings in MIS-C. Longitudinal follow-up shows improvement in all.

Multisystem inflammatory syndrome in children and Kawasaki disease: a critical comparison.

Children and adolescents infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are predominantly asymptomatic or have mild symptoms compared with the more severe coronavirus disease 2019 (COVID-19) described in adults. However, SARS-CoV-2 is also associated with a widely reported but poorly understood paediatric systemic vasculitis. This multisystem inflammatory syndrome in children (MIS-C) has features that overlap with myocarditis, toxic-shock syndrome and Kawasaki disease. Current evidence indicates that MIS-C is the result of an exaggerated innate and adaptive immune response, characterized by a cytokine storm, and that it is triggered by prior SARS-CoV-2 exposure. Epidemiological, clinical and immunological differences classify MIS-C as being distinct from Kawasaki disease. Differences include the age range, and the geographical and ethnic distribution of patients. MIS-C is associated with prominent gastrointestinal and cardiovascular system involvement, admission to intensive care unit, neutrophilia, lymphopenia, high levels of IFNγ and low counts of naive CD4+ T cells, with a high proportion of activated memory T cells. Further investigation of MIS-C will continue to enhance our understanding of similar conditions associated with a cytokine storm.

Six Month Follow-up of Patients With Multi-System Inflammatory Syndrome in Children.

BACKGROUND AND OBJECTIVES: Myocardial dysfunction and coronary abnormalities are prominent features of multisystem inflammatory syndrome in children (MIS-C). In this study we aim to evaluate the early and midterm outcomes of MIS-C. METHODS: This is a longitudinal 6-month cohort study of all children admitted and treated for MIS-C from April 17 to June 20, 2020. Patients were followed ∼2 weeks, 8 weeks, and 6 months postadmission, with those with coronary aneurysms evaluated more frequently. RESULTS: Acutely, 31 (62%) patients required intensive care with vasoactive support, 26 (52%) had left ventricular (LV) systolic dysfunction, 16 (32%) had LV diastolic dysfunction, 8 (16%) had coronary aneurysms (z score ≥2.5), and 4 (8%) had coronary dilation (z score <2.5). A total of 48 patients (96%) received immunomodulatory treatment. At 2 weeks, there was persistent mild LV systolic dysfunction in 1 patient, coronary aneurysms in 2, and dilated coronary artery in 1. By 8 weeks through 6 months, all patients returned to functional baseline with normal LV systolic function and resolution of coronary abnormalities. Cardiac MRI performed during recovery in select patients revealed no myocardial edema or fibrosis. Some patients demonstrated persistent diastolic dysfunction at 2 weeks (5, 11%), 8 weeks (4, 9%), and 6 months (1, 4%). CONCLUSIONS: Children with MIS-C treated with immunomodulators have favorable early outcomes with no mortality, normalization of LV systolic function, recovery of coronary abnormalities, and no inflammation or scarring on cardiac MRI. Persistence of diastolic dysfunction is of uncertain significance and indicates need for larger studies to improve understanding of MIS-C. These findings may help guide clinical management, outpatient monitoring, and considerations for sports clearance.

Didactic education in paediatric cardiology during the COVID-19 pandemic: a national fellow survey.

The coronavirus disease 2019 (COVID-19) pandemic has had a profound impact on medical educational curricula. We aimed to examine the impact of these unprecedented changes on the formal education of paediatric cardiology fellows through a nationwide survey. A REDCap™-based voluntary anonymous survey was sent to all current paediatric cardiology fellows in the United States of America in May, 2020. Of 143 respondents, 121 were categorical fellows, representing over one-fourth of all categorical paediatric cardiology fellows in the United States of America. Nearly all (140/143, 97.9%) respondents utilised online learning during the pandemic, with 134 (93.7%) reporting an increase in use compared to pre-pandemic. The percentage of respondents reporting curriculum supplementation with outside lectures increased from 11.9 to 88.8% during the pandemic. Respondents considered online learning to be "equally or more effective" than in-person lectures in convenience (133/142, 93.7%), improving fellow attendance (132/142, 93.0%), improving non-fellow attendance (126/143, 88.1%), and meeting individual learning needs (101/143, 70.6%). The pandemic positively affected the lecture curriculum of 83 respondents (58.0%), with 35 (24.5%) reporting no change and 25 (17.5%) reporting a negative effect. A positive effect was most noted by those whose programmes utilised supplemental outside lectures (62.2 versus 25.0%, p = 0.004) and those whose lecture frequency did not decrease (65.1 versus 5.9%, p < 0.001). Restrictions imposed by the COVID-19 pandemic have greatly increased utilisation of online learning platforms by medical training programmes. This survey reveals that an online lecture curriculum, despite inherent obstacles, offers advantages that may mitigate some negative consequences of the pandemic on fellowship education.

Cardiac Dysfunction and Shock in Pediatric Patients With COVID-19.

Coronavirus disease-2019 (COVID-19) has been reported to cause significant morbidity in adults, with reportedly a lesser impact on children. Cardiac dysfunction has only been described in adults thus far. We describe 3 cases of previously healthy children presenting with shock and COVID-19-related cardiac inflammation. (Level of Difficulty: Intermediate.).