Paediatric multisystem inflammatory syndrome temporally associated with COVID 19: a new virus and a new case presentation

ABSTRACT

We describe the case of an 11-year-old boy who presented with features resembling those described in health alerts on Paediatric Inflammatory Multisystem Syndrome Temporally associated with SARS-COV-2 (PIMS-TS), including persistent pyrexia, haemodynamic instability and abdominal pain. His CXR showed bilateral streaky opacities. Three days prior to presentation he had an altered sense of taste, pyrexia, lethargy. Laboratory tests, including raised inflammatory markers, D-dimer, troponin and a coagulopathy were consistent with PIMS-TS. He required transfer to PICU, where he was monitored for a total of 34 h and was thereafter fit to be discharged to a paediatric ward for continuation of therapy. He was treated with intravenous immunoglobulins, corticosteroids and aspirin, with full resolution of clinical symptoms. His echocardiogram revealed mild left ventricular (LV) impairment but no evidence of coronary ectasia or valvular disfunction Microbiology and pathogenesis Three SARS-CoV-2 PCRs on respiratory samples, taken over the initial 4-day period were negative, as was a SARS-CoV-2 PCR on faeces one month after presentation;titres of IgG were clearly elevated. The negative PCRs in the presence of elevated titres of IgG suggest that the inflammatory syndrome might have developed in a late phase of COVID-19 infection when the virus was no longer detectable in the upper airway. The possibility that PIMS-TS constitutes a post-infectious syndrome cannot however be excluded. PIMS-TS pathogenesis might also be related to delayed type I and III interferon responses that lead to slow viral clearance and cytokine storm, which might fit this presentation. Outcome Following 5 days on the ward the patient was discharged home with low dose aspirin and omeprazole to be taken until otherwise advised by the cardiologist Serial follow-up echocardiograms from one to five months post-discharge were unremarkable and he has now been discharged from cardiology follow up. There have been some psychological sequelae. Learning points • Acute gastrointestinal pain in the context persistent pyrexia during the COVID-19 pandemic should lead to suspicion of PIMS-TS in children. • Cardiac inflammation is a feature of this presentation. • It appears that early treatment with immunoglobulins and intravenous steroids is helpful. • Negative SARS-CoV-2 PCR tests do not exclude COVID-19;SARS-CoV-2 IgG serology ought to be performed. • It is difficult to distinguish between acute Covid-19 and a post-acute syndrome on the basis of nasopharyngeal SARS-CoV 2 PCR alone. • More research is needed into the pathogenesis of this condition. • PCR on faeces should be considered early on, in particular in cases presenting with mainly gastrointestinal symptoms.