Pediatric COVID-19 extracorporeal membrane oxygenation transport during the pandemic.

INTRODUCTION: ExtraCorporeal Membrane Oxygenation (ECMO) in pediatric patients with COVID-19 has a survival rate similar to adults. Occasionally, patients may need to be cannulated by an ECMO team in a referring hospital and transported to an ECMO center. The ECMO transport of a COVID-19 patient has additional risks than normal pediatric ECMO transport for the possible COVID-19 transmissibility to the ECMO team and the reduction of the ECMO team performance due to the need of wearing full personal protective equipment. Since pediatric data on ECMO transport of COVID-19 patients are lacking, we explored the outcomes of the pediatric COVID-19 ECMO transports collected in the EuroECMO COVID_Neo/Ped Survey. METHODS: We reported five European consecutive ECMO transports of COVID-19 pediatric patients collected in the EuroECMO COVID_Neo/Ped Survey including 52 European neonatal and/or pediatric ECMO centers and endorsed by the EuroELSO from March 2020 till September 2021. RESULTS: The ECMO transports were performed for two indications, pediatric ARDS and myocarditis associated to the multisystem inflammatory syndrome related to COVID-19. Cannulation strategies differed among patients according to the age of the patients, transport distance varied between 8 and 390 km with a total transport duration between 5 to 15 h. In all five cases, the ECMO transports were successfully performed without major adverse events. One patient reported a harlequin syndrome and another patient a cannula displacement both without major clinical consequences. Hospital survival was 60% with one patient reporting neurological sequelae. No ECMO team member developed COVID-19 symptoms after the transport. CONCLUSION: Five transports of pediatric patients with COVID-19 supported with ECMO were reported in the EuroECMO COVID_Neo/Ped Survey. All transports were performed by an experienced multidisciplinary ECMO team and were feasible and safe for both the patient and the ECMO team. Further experiences are needed to better characterize these transports and draw insightful conclusions.

Parvovirus B19 myocarditis in children: a diagnostic and therapeutic approach.

Parvovirus B19 is one of the most frequent causes of pediatric myocarditis, associating high mortality rates or need for cardiac transplantation. The aim of this study is to describe the clinical course of Parvovirus B19 myocarditis in children with emphasis on the role of endomyocardial biopsy and cardiac magnetic resonance, and the use of an innovative therapeutic strategy. Eleven patients and 12 episodes of polymerase chain reaction (PCR)-confirmed Parvovirus B19 myocarditis were prospectively collected for 14 years. Diagnosis was confirmed either histopathologically or by magnetic resonance. A life-threatening clinical presentation is described, similar to previous series, but with 83.3% overall survival without transplantation. We also present a case of recurrent myocarditis, which is extraordinarily rare. Electrocardiographic patterns presented chiefly peaked p waves, low QRS voltages, and negative T waves on inferior or lateral leads. Endomyocardial biopsy is the gold standard diagnostic test; alternatively magnetic resonance could be a useful diagnostic tool. A good concordance between myocardial and blood PCRs was observed. Seven patients received treatment with corticosteroids and beta interferon and all underwent a significant cardiac function improvement. CONCLUSION: A severe clinical presentation is reported, similar to previous reports but with better outcomes. Endomyocardial biopsy is the gold standard diagnostic test; alternatively magnetic resonance may be used. Both blood and myocardium PCR can be used in children to establish the microbiological etiology. Steroids with IFNß could be a useful therapeutic option, although further multicenter studies are needed to confirm these results. WHAT IS KNOWN: • Parvovirus B19 is one of the most frequent causes of myocarditis in children. It is associated with a fulminant clinical presentation. • Endomyocardial biopsy is the gold standard diagnostic test but it is an invasive procedure. WHAT IS NEW: • Myocarditis may recur in pediatrics, even it is extraordinarily rare. • IFNß with steroids may be a useful therapeutic option to improve the outcomes.

Differences between genetic dilated cardiomyopathy and myocarditis in children presenting with severe cardiac dysfunction.

Acute myocarditis is an inflammatory disease of the myocardium, and it can present as severe heart failure in children. Differential diagnosis with genetic cardiomyopathy can be difficult. The objective of this study is to identify patterns of clinical presentation and to assess invasive and non-invasive measures to differentiate patients with acute myocarditis from patients with dilated genetic cardiomyopathy. We performed a retrospective descriptive study of all paediatric patients (0-16 years old) that presented with new-onset heart failure with left ventricle ejection fraction < 35% in whom we performed an endomyocardial biopsy (EMB) during the period from April 2007 to December 2020. The patients were classified into two groups: Group 1 included 18 patients with myocarditis. Group 2 included 9 patients with genetic cardiomyopathy. Findings favouring a diagnosis of myocarditis included a fulminant or acute presentation (77.8% vs 33.3%, p = 0.01), higher degree of cardiac enzyme elevation (p = 0.011), lower left ventricular dimension z-score (2.2 vs 5.4, p = 0.03) increase of ventricular wall thickness (88.8% vs 33.3%, p = 0.03) and oedema in the EMB. Seven (77.8%) patients with genetic cardiomyopathy had inflammation in the endomyocardial biopsy fulfilling the diagnostic criteria of inflammatory cardiomyopathy.Conclusion: Differentiating patients with a myocarditis from those with genetic cardiomyopathy can be challenging, even performing an EMB. Some patients with genetic cardiomyopathy fulfil the diagnostic criteria of inflammatory cardiomyopathy. Using invasive and non-invasive measures may be useful to develop a predictive model to differentiate myocarditis from genetic cardiomyopathy. What is Known: • Acute myocarditis could present with cardiogenic shock in paediatric patients. • Parvovirus B19 is the main cause of myocarditis in this population. What is New: • Current diagnostic criteria for myocarditis have limited use in paediatric patients presenting with new-onset heart failure. • Some patients with a genetic cardiomyopathy and a new-onset heart failure fulfill the diagnostic criteria of inflammatory cardiomyopathy.

Influenza-Associated Disseminated Aspergillosis in a 9-Year-Old Girl Requiring ECMO Support.

A previously healthy 9-year-old girl developed fulminant myocarditis due to severe influenza A infection complicated with methicillin-resistant Staphylococcus aureus pneumonia, requiring extracorporeal membrane oxygenation (ECMO) support. Twelve days after admission, Aspergillus fumigatus was isolated in tracheal aspirate, and 12 h later she suddenly developed anisocoria. Computed tomography (CT) of the head showed fungal brain lesions. Urgent decompressive craniectomy with lesion drainage was performed; histopathology found hyphae in surgical samples, culture-positive for Aspergillus fumigatus (susceptible to azoles, echinocandins, and amphotericin B). Extension workup showed disseminated aspergillosis. After multiple surgeries and combined antifungal therapy (isavuconazole plus liposomal amphotericin B), her clinical course was favorable. Isavuconazole therapeutic drug monitoring was performed weekly. Extensive immunological study ruled out primary immunodeficiencies. Fluorine-18 fluorodeoxyglucose positron emission tomography/CT (18F-FDG PET/CT) follow-up showed a gradual decrease in fungal lesions. Influenza-associated pulmonary aspergillosis is well-recognized in critically ill adult patients, but pediatric data are scant. Clinical features described in adults concur with those of our case. Isavuconazole, an off-label drug in children, was chosen because our patient had severe renal failure. To conclude, influenza-associated pulmonary aspergillosis is uncommon in children admitted to intensive care for severe influenza, but pediatricians should be highly aware of this condition to enable prompt diagnosis and treatment.

Transient upper limb ischaemia during veno-arterial extracorporeal membrane oxygenation in a child.

Neck cannulation is the most common cannulation strategy performed to provide veno-arterial extracorporeal membrane oxygenation support in paediatric patients, especially in small children. Upper limb ischaemia is a rare complication of neck cannulation and is likely caused by arterial cannula malposition. We describe a case of right arm ischaemia caused by extrinsic compression of the right subclavian artery by the venous drainage cannula inserted through the right internal jugular vein. Upper limb hypoperfusion was resolved immediately after changing the venous drainage cannula from the right jugular vein to the right femoral vein.

Parvovirus B19 Myocarditis: Looking Beyond the Heart.

Human parvovirus B19 represents the most common etiology of myocarditis in the pediatric population. Although it usually causes a benign exanthematic viral infection, parvovirus B19 may also present as disseminated disease with tropism for the myocardium, causing heart failure with high mortality. We present the case of a 2-year-old patient with fulminating acute myocarditis in whom the histological, immunophenotypic, and microbiological findings in necropsy showed multiorgan involvement caused by parvovirus B19. The autopsy revealed changes due to infection with parvovirus B19 as well as hypoxic-ischemic and secondary autoimmune changes. Medullary aplasia was observed, transmural lymphocyte myocarditis, lymphocytosis in the dermis with endothelial cells positive for parvovirus B19 in immunohistochemistry, cholestatic hepatitis due to ischemia and autoimmune hepatitis, lymphadenitis, and signs of hemophagocytosis. We also found hypoxic-ischemic encephalopathy.

Impact of the implementation of an interdisciplinary infection control program to prevent surgical wound infection in pediatric heart surgery.

UNLABELLED: Surgical site infection (SSI) remains a major source of morbidity, mortality, and increased health care costs in children undergoing heart surgery. The aim of this study was to assess the effectiveness of an intervention program designed to reduce the high incidence of SSI observed at our center in pediatric patients. An interdisciplinary infection control program including pre-, intra-, and postoperative measures was introduced for children undergoing heart surgery with cardiopulmonary bypass. We conducted a quasi-experimental interventional study comparing a pre-intervention cohort (June 2009 to March 2010) and a post-intervention cohort (July 2011 to July 2012). A significant drop in SSI incidence from 10.9 % (95 % CI 4.7-18.8) to 1.92 % (95 % CI 0.4-5.52) was observed. Variables significantly associated with infection risk were median age (14 days in infected vs 2.3 years in non-infected patients; p<0.01), hospitalization unit (10.3 % SSI cumulative incidence in the neonatal intensive care unit vs 0 cases in the pediatric intensive care unit; p<0.01), and median preoperative hospital stay (14 days in infected vs 1 day in non-infected patients; p=0.03). CONCLUSIONS: The implementation of a new intervention program was associated with an 82 % (95 % CI 34-94) reduction in SSI incidence in children undergoing heart surgery at our center. WHAT IS KNOWN: • Surgical site infection (SSI) is associated with significant morbidity and mortality following pediatric cardiac surgery. • Younger patients and longer cardiopulmonary bypass times are associated with higher SSI rates. What is New: • Comprehensive infection control program including preoperative, intraoperative and postoperative nonpharmacologic measures is a key factor for the prevention of SSI. • A significant reduction in SSI rates can be achieve despite a narrower-spectrum antibiotic usage.

Etanercept-induced myelopathy in a pediatric case of blau syndrome.

Blau syndrome is a rare autoinflammatory disorder within the group of pediatric granulomatous diseases. Mutations in nucleotide-binding oligomerization domain 2 (NOD2/CARD15) are responsible for this condition, which has an autosomal dominant pattern of inheritance and variable expressivity. The clinical picture includes arthritis, uveitis, skin rash, and granulomatous inflammation. Central nervous system involvement is seldom reported, although some isolated cases of seizures, neurosensorial hearing loss, and transient cranial nerve palsy have been described. Treatment consists of nonsteroidal anti-inflammatory drugs, corticosteroids, and immunosuppressive agents, among which anti-tumor-necrosis-factor-alpha (TNF-α) biologic agents, such as etanercept, play an important role. Among the major adverse effects of TNF-α inhibitors, demyelinating disease, multiple sclerosis, and acute transverse myelitis have been reported in adults. We describe a case of pediatric Blau syndrome affected by etanercept-induced myelopathy, manifesting as a clinical syndrome of transverse myelitis. The patient experienced rapid recovery after etanercept was discontinued. To our knowledge, this is the first such case reported in the literature and, possibly, the one with the latest onset, following 8 years of treatment. We discuss the etiopathogenic mechanisms of this reaction and possible explanations for the imaging findings.