Clinical features and treatment of mixed cardiogenic and distributive shock in patients with multisystem inflammatory syndrome in children (MIS-C)

ABSTRACT

Background and Aim: Mixed shock in multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19 is con-sequence of acute heart failure, inflammation-induced vasodilation and potential volume loss. Method(s) Retrospective analysis included 25 patients (7 girls) with MIS-C-related combined shock, treated in period from April 2020 to December 2021. Result(s) Mean age of patients was 12.6 +/- 4.0 years. Admission was 6.1 +/- 1.6 days after symptoms onset. Systemic inflammatory response was manifested with neutrophilia (10.7 +/- 4.2 x109/), lymphopenia (1.1 +/- 0.7 x109/L), elevated CRP (220.9 +/- 86.1 mg/L), ferritin (684.5 +/- 549.5 mug/L) and D-dimer (1528 +/- 1254 ng/mL). One third of patients had acute kidney injury with glomerular filtration rate of 64 +/- 22 mL/min/1.73 m2 and urea level of 16.0 +/- 8.4 mmol/L. All patients had acute heart failure with ejection fraction 47.2% +/- 7.7% and fractional shortening 23.6% +/- 4.9%, 92% of patients had NTproBNP gt;1500 pg/mL and 58% had elevated troponin I (1.34 +/- 1.47 ng/mL). Z-scores for end-diastolic left ventricle, interventricular septum and pos-terior wall diameters were 0.7 +/- 1.1, 1.7 +/- 1.3 and 0.6 +/- 0.7 respectively. All patients had mild/moderate mitral regurgitation, and 60% had mild pericardial effusion. Inotropes, administered during first 3.7 +/- 1.6 days, were divided in three groups 1) dop-amine (n = 14), 2) dobutamine + dopamine (n = 5), 3) milrinone +/- dopamine (n = 6). Additional treatment included diuretics and captopril. Total fluid balance (including insensible loss of 300 mL/m2/day) through days 1-7 was +860 mL/m2, +128 mL/m2,-108 mL/m2,-36 mL/m2,-306 mL/m2,-335 ml/m2,-298 ml/m2 (total-95 ml/m2). Methylprednisolone/intravenous immuno-globulin and low-molecular-weight heparin/acetylsalicylic acid were administered and fever persisted 1.2 days averagely. Oxygen supplementation was needed in 71% of patients. Transitory bradycardia was noticed and there was no difference in heart rate between treatment groups. Profound hypotension was revealed on admission and correction differed regarding treat-ment (p lt;0.05) (Figure 1). All patient survived with clinical improvement (one had mechanical ventilation, and one had stroke). Conclusion(s) Mixed shock is the most severe manifestation of MIS-C, and treatment of heart failure should be combined with cau-tious fluid resuscitation.