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Elgohary MA, Mohamed ME, Hamada MM, Fahim JS, El‐Masry TA, Ibrahim AM, Taha AG, Seadawy MG, Alexiou A, Papadakis M, Batiha GE, El‐Bouseary MM. First confirmed case of multisystem inflammatory syndrome in adult in Egypt. Clin Case Rep 2023; 11:e7382. [PMID: 37273670 PMCID: PMC10233214 DOI: 10.1002/ccr3.7382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 04/03/2023] [Accepted: 05/05/2023] [Indexed: 06/06/2023] Open
Abstract
Key Clinical Message Our case report demonstrates extremely uncommon data associated with MIS-A, such as cholestatic jaundice, anemia, and quickly progressing pneumonia. IVIG and pulse steroid medications are the best treatments for improving clinical outcomes. Abstract We report a case of multiple organ dysfunctions due to MIS-A in an adult with a history of suspected COVID-19. Our case demonstrates extremely uncommon data associated with MIS-A, such as cholestatic jaundice, anemia, and quickly progressing pneumonia. IVIG and pulse steroid medications are the best treatments for improving clinical outcomes.
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Affiliation(s)
| | | | | | | | - Thanaa A. El‐Masry
- Department of Pharmacology and Toxicology, Faculty of PharmacyTanta UniversityTantaEgypt
| | | | - Ahmad Gad Taha
- Virology Laboratory DepartmentCentral Military LaboratoriesCairoEgypt
| | | | - Athanasios Alexiou
- Department of Science and EngineeringNovel Global Community Educational FoundationHebershamNew South WalesAustralia
- AFNP MedWienAustria
| | - Marios Papadakis
- Department of Surgery II, University Hospital Witten‐Herdecke, Heusnerstrasse 40University of Witten‐HerdeckeWuppertalGermany
| | - Gaber El‐Saber Batiha
- Department of Pharmacology and Therapeutics, Faculty of Veterinary MedicineDamanhour UniversityDamanhourEgypt
| | - Maisra M. El‐Bouseary
- Department of Pharmaceutical Microbiology, Faculty of PharmacyTanta UniversityTantaEgypt
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La Torre F, Taddio A, Conti C, Cattalini M. Multi-Inflammatory Syndrome in Children (MIS-C) in 2023: Is It Time to Forget about It? CHILDREN (BASEL, SWITZERLAND) 2023; 10:980. [PMID: 37371212 PMCID: PMC10297102 DOI: 10.3390/children10060980] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/31/2023] [Accepted: 05/29/2023] [Indexed: 06/29/2023]
Abstract
Multisystem inflammatory syndrome in children (MIS-C) is defined as a clinically serious condition requiring hospitalization involving fever, multi-system organ dysfunction, and an increase in inflammatory biomarkers. The syndrome was originally described as a post-infectious complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, which usually causes COVID-19. During the COVID-19 pandemic, not only did the virus undergo mutations but vaccines against SARS-CoV-2 were also developed. Both these conditions led to a decrease in the incidence of MIS-C. This narrative review summarizes the recent updates for MIS-C, particularly regarding the change in incidence, the link between the SARS-CoV-2 vaccine and MIS-C, and new updates of MIS-C treatments.
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Affiliation(s)
- Francesco La Torre
- Pediatric Rheumatology Center, Department of Pediatrics, Giovanni XXIII Pediatric Hospital, University of Bari, 70121 Bari, Italy
| | - Andrea Taddio
- Institute of Child and Maternal Health–IRCCS “Burlo Garofolo”, University of Trieste, 34127 Trieste, Italy
| | - Chiara Conti
- Pediatrics Clinic, Department of Experimental and Clinical Sciences, University of Brescia, 25121 Brescia, Italy
| | - Marco Cattalini
- Pediatrics Clinic, Department of Experimental and Clinical Sciences, University of Brescia, 25121 Brescia, Italy
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Ghimire LV, Chou FS, Aljohani OA, Moon-Grady AJ. Impact of congenital heart disease on outcomes among pediatric patients hospitalized for COVID-19 infection. BMC Pediatr 2023; 23:240. [PMID: 37194031 DOI: 10.1186/s12887-023-04058-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 05/04/2023] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND COVID-19 infection is generally regarded as an acute self-limiting illness in children, but it can cause significant morbidity and mortality in both healthy and high-risk children. There are limited data on the outcomes of children with congenital heart disease (CHD) and COVID-19. This study aimed to examine the risks of mortality, in-hospital cardiovascular and non-cardiovascular complications in this patient population. METHODS We analyzed data from hospitalized pediatric patients from 2020 using the nationally representative National Inpatient Sample (NIS). Children hospitalized for COVID-19 were included, and weighted data were used to compare in-hospital mortality and morbidities between children with and without CHD. RESULTS Out of 36,690 children admitted with a diagnosis of COVID-19 infection(ICD-10 code:U07.1 and B97.29) during calendar year 2020, 1240 (3.4%) had CHD. The risk of mortality in children with CHD was not significantly higher than those without CHD(1.2% vs. 0.8%, p = 0.50), with adjusted OR (aOR) of 1.7 (95% CI: 0.6-5.3). Tachyarrhythmias and heart block were more likely in CHD children with an aOR of 4.2 (95% CI: 1.8-9.9) and aOR of 5.0 (95% CI: 2.4-10.8), respectively. Similarly, respiratory failure [aOR = 2.0 (1.5-2.8)], respiratory failure requiring non-invasive mechanical ventilation [aOR = 2.7 (1.4-5.2)] and invasive mechanical ventilation [aOR = 2.6 (1.6-4.0)], and acute kidney injury [aOR = 3.4 (2.2-5.4)] were all significantly higher among patients with CHD. Median length of hospital stay in children with CHD was longer than those without CHD [5 days (IQR: 2-11) vs. 3 days (IQR: 2-5), p = < 0.001]. CONCLUSIONS Children with CHD hospitalized with COVID-19 infection were at increased risk of serious cardiovascular and non-cardiovascular adverse clinical outcomes. They also had increased length of hospital stay and utilization of healthcare resources.
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Affiliation(s)
- Laxmi V Ghimire
- Division of Pediatric Cardiology, Department of Pediatrics, University of California, San Francisco, Fresno, CA, USA
| | - Fu-Sheng Chou
- Department of Neonatal-Perinatal Medicine, Kaiser Permanente Riverside Medical Center, Riverside, CA, USA
| | - Othman A Aljohani
- Division of Pediatric Cardiology, Department of Pediatrics, University of California, San Francisco, 550 16th Street 5th Floor, San Francisco, CA, 94158, USA
| | - Anita J Moon-Grady
- Division of Pediatric Cardiology, Department of Pediatrics, University of California, San Francisco, 550 16th Street 5th Floor, San Francisco, CA, 94158, USA.
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54
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Cannon L, Campbell MJ, Wu EY. Multisystemic Inflammatory Syndrome in Children and Kawasaki Disease: Parallels in Pathogenesis and Treatment. Curr Allergy Asthma Rep 2023:10.1007/s11882-023-01083-0. [PMID: 37171672 PMCID: PMC10176315 DOI: 10.1007/s11882-023-01083-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2023] [Indexed: 05/13/2023]
Abstract
PURPOSE OF REVIEW Since it first appeared, multisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease 2019 (COVID-19) has been compared to Kawasaki disease (KD). Although there were early parallels between MIS-C and KD, key differences emerged over time. Here, we aim to compare the pathogenesis, clinical presentation, treatment, and outcomes of MIS-C and KD. RECENT FINDINGS In this article, we review and compare MIS-C and KD, highlighting differentiating features. We discuss the epidemiological and immunological factors along with clinical and laboratory features which discern MIS-C from KD. We also compare treatment and our understanding of long-term outcomes. Though parallels exist between MIS-C and KD, distinguishing the two is important for clinical management of patients, counseling about natural history, and determining long-term monitoring. While both MIS-C and KD are characterized by profound inflammation and inflammatory vasculopathy, further study is needed to determine whether they are distinct immunopathogenic disorders.
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Affiliation(s)
- Laura Cannon
- Division of Pediatric Rheumatology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - M Jay Campbell
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Eveline Y Wu
- Division of Pediatric Rheumatology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Division of Pediatric Allergy/Immunology, Department of Pediatrics, University of North Carolina at Chapel Hill, 030 MacNider Hall, CB #7231 Chapel Hill, NC, 27599-7231, Chapel Hill, USA.
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55
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Bembea MM, Loftis LL, Thiagarajan RR, Young CC, McCadden TP, Newhams MM, Kucukak S, Mack EH, Fitzgerald JC, Rowan CM, Maddux AB, Kolmar AR, Irby K, Heidemann S, Schwartz SP, Kong M, Crandall H, Havlin KM, Singh AR, Schuster JE, Hall MW, Wellnitz KA, Maamari M, Gaspers MG, Nofziger RA, Lim PPC, Carroll RW, Coronado Munoz A, Bradford TT, Cullimore ML, Halasa NB, McLaughlin GE, Pannaraj PS, Cvijanovich NZ, Zinter MS, Coates BM, Horwitz SM, Hobbs CV, Dapul H, Graciano AL, Butler AD, Patel MM, Zambrano LD, Campbell AP, Randolph AG. Extracorporeal Membrane Oxygenation Characteristics and Outcomes in Children and Adolescents With COVID-19 or Multisystem Inflammatory Syndrome Admitted to U.S. ICUs. Pediatr Crit Care Med 2023; 24:356-371. [PMID: 36995097 PMCID: PMC10153593 DOI: 10.1097/pcc.0000000000003212] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
OBJECTIVES Extracorporeal membrane oxygenation (ECMO) has been used successfully to support adults with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related cardiac or respiratory failure refractory to conventional therapies. Comprehensive reports of children and adolescents with SARS-CoV-2-related ECMO support for conditions, including multisystem inflammatory syndrome in children (MIS-C) and acute COVID-19, are needed. DESIGN Case series of patients from the Overcoming COVID-19 public health surveillance registry. SETTING Sixty-three hospitals in 32 U.S. states reporting to the registry between March 15, 2020, and December 31, 2021. PATIENTS Patients less than 21 years admitted to the ICU meeting Centers for Disease Control criteria for MIS-C or acute COVID-19. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The final cohort included 2,733 patients with MIS-C ( n = 1,530; 37 [2.4%] requiring ECMO) or acute COVID-19 ( n = 1,203; 71 [5.9%] requiring ECMO). ECMO patients in both groups were older than those without ECMO support (MIS-C median 15.4 vs 9.9 yr; acute COVID-19 median 15.3 vs 13.6 yr). The body mass index percentile was similar in the MIS-C ECMO versus no ECMO groups (89.9 vs 85.8; p = 0.22) but higher in the COVID-19 ECMO versus no ECMO groups (98.3 vs 96.5; p = 0.03). Patients on ECMO with MIS-C versus COVID-19 were supported more often with venoarterial ECMO (92% vs 41%) for primary cardiac indications (87% vs 23%), had ECMO initiated earlier (median 1 vs 5 d from hospitalization), shorter ECMO courses (median 3.9 vs 14 d), shorter hospital length of stay (median 20 vs 52 d), lower in-hospital mortality (27% vs 37%), and less major morbidity at discharge in survivors (new tracheostomy, oxygen or mechanical ventilation need or neurologic deficit; 0% vs 11%, 0% vs 20%, and 8% vs 15%, respectively). Most patients with MIS-C requiring ECMO support (87%) were admitted during the pre-Delta (variant B.1.617.2) period, while most patients with acute COVID-19 requiring ECMO support (70%) were admitted during the Delta variant period. CONCLUSIONS ECMO support for SARS-CoV-2-related critical illness was uncommon, but type, initiation, and duration of ECMO use in MIS-C and acute COVID-19 were markedly different. Like pre-pandemic pediatric ECMO cohorts, most patients survived to hospital discharge.
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Affiliation(s)
- Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Laura L Loftis
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Ravi R Thiagarajan
- Division of Cardiac Critical Care, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Cameron C Young
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Timothy P McCadden
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Margaret M Newhams
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Suden Kucukak
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Elizabeth H Mack
- Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston, SC
| | - Julie C Fitzgerald
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Courtney M Rowan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN
| | - Aline B Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Amanda R Kolmar
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Katherine Irby
- Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, AR
| | - Sabrina Heidemann
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Central Michigan University, Detroit, MI
| | - Stephanie P Schwartz
- Department of Pediatrics, University of North Carolina at Chapel Hill Children's Hospital, Chapel Hill, NC
| | - Michele Kong
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Hillary Crandall
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah and Primary Children's Hospital, Salt Lake City, UT
| | - Kevin M Havlin
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Louisville, and Norton Children's Hospital, Louisville, KY
| | - Aalok R Singh
- Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Jennifer E Schuster
- Division of Pediatric Infectious Disease, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Kari A Wellnitz
- Division of Pediatric Critical Care, Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Mia Maamari
- Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Health Medical Center, Dallas, TX
| | - Mary G Gaspers
- Department of Pediatrics and Banner Children's at Diamond Children's Medical Center, University of Arizona, Tucson, AZ
| | - Ryan A Nofziger
- Division of Critical Care Medicine, Department of Pediatrics, Akron Children's Hospital, Akron, OH
| | - Peter Paul C Lim
- Division of Pediatric Critical Care Medicine, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Ryan W Carroll
- Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children, Harvard Medical School, Boston, MA
| | - Alvaro Coronado Munoz
- Pediatric Critical Care Division, Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, TX
| | - Tamara T Bradford
- Division of Cardiology, Department of Pediatrics, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans, LA
| | - Melissa L Cullimore
- Division of Pediatric Critical Care, Department of Pediatrics, Children's Hospital and Medical Center, Omaha, NE
| | - Natasha B Halasa
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Gwenn E McLaughlin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL
| | - Pia S Pannaraj
- Division of Infectious Diseases, Children's Hospital Los Angeles and Departments of Pediatrics and Molecular Microbiology and Immunology, University of Southern California, Los Angeles, CA
| | - Natalie Z Cvijanovich
- Division of Critical Care Medicine, UCSF Benioff Children's Hospital Oakland, Oakland, CA
| | - Matt S Zinter
- Department of Pediatrics, Divisions of Critical Care Medicine and Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, San Francisco, CA
| | - Bria M Coates
- Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Steven M Horwitz
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Charlotte V Hobbs
- Department of Pediatrics, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson, MS
| | - Heda Dapul
- Department of Pediatrics, Division of Infectious Diseases, New York University Grossman School of Medicine and Hassenfeld Children's Hospital, New York, NY
| | - Ana Lia Graciano
- Department of Pediatrics, Division of Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Andrew D Butler
- Division of Pediatric Critical Care, St. Christopher's Hospital for Children, Philadelphia, PA
| | - Manish M Patel
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, GA
| | - Laura D Zambrano
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, GA
| | - Angela P Campbell
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, GA
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
- Departments of Anesthesia and Pediatrics, Harvard Medical School, Boston, MA
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Auger KA, Hall M, Arnold SD, Bhumbra S, Bryan MA, Hartley D, Ivancie R, Katragadda H, Kazmier K, Jacob SA, Jerardi KE, Molloy MJ, Parikh K, Schondelmeyer AC, Shah SS, Brady PW. Identifying and Validating Pediatric Hospitalizations for MIS-C Through Administrative Data. Pediatrics 2023; 151:e2022059872. [PMID: 37102310 PMCID: PMC10158076 DOI: 10.1542/peds.2022-059872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND Individual children's hospitals care for a small number of patients with multisystem inflammatory syndrome in children (MIS-C). Administrative databases offer an opportunity to conduct generalizable research; however, identifying patients with MIS-C is challenging. METHODS We developed and validated algorithms to identify MIS-C hospitalizations in administrative databases. We developed 10 approaches using diagnostic codes and medication billing data and applied them to the Pediatric Health Information System from January 2020 to August 2021. We reviewed medical records at 7 geographically diverse hospitals to compare potential cases of MIS-C identified by algorithms to each participating hospital's list of patients with MIS-C (used for public health reporting). RESULTS The sites had 245 hospitalizations for MIS-C in 2020 and 358 additional MIS-C hospitalizations through August 2021. One algorithm for the identification of cases in 2020 had a sensitivity of 82%, a low false positive rate of 22%, and a positive predictive value (PPV) of 78%. For hospitalizations in 2021, the sensitivity of the MIS-C diagnosis code was 98% with 84% PPV. CONCLUSION We developed high-sensitivity algorithms to use for epidemiologic research and high-PPV algorithms for comparative effectiveness research. Accurate algorithms to identify MIS-C hospitalizations can facilitate important research for understanding this novel entity as it evolves during new waves.
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Affiliation(s)
- Katherine A. Auger
- Division of Hospital Medicine
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Matt Hall
- Children’s Hospital Association, Lenexa, Kansas
| | - Staci D. Arnold
- Department of Pediatrics, Emory University, Aflac Cancer and Blood Disorders Center at Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Samina Bhumbra
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics
| | - Mersine A. Bryan
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children’s Research Institute, Seattle, Washington
| | - David Hartley
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Rebecca Ivancie
- Department of Pediatrics, Stanford School of Medicine, Stanford, California
| | - Harita Katragadda
- Division of Pediatric Hospital Medicine
- Department of Pediatrics, UT Southwestern, Dallas, Texas
| | - Katie Kazmier
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Seethal A. Jacob
- Division of Pediatric Hematology Oncology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Karen E. Jerardi
- Division of Hospital Medicine
- Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | | | - Kavita Parikh
- Division of Hospital Medicine, Children’s National Hospital, Washington, District of Columbia
- George Washington University School of Health Sciences, Washington, District of Columbia
| | - Amanda C. Schondelmeyer
- Division of Hospital Medicine
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Samir S. Shah
- Division of Hospital Medicine
- Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Patrick W. Brady
- Division of Hospital Medicine
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio
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Jain S, He F, Brown K, Burns JC, Tremoulet AH. Multisystem Inflammatory Syndrome therapies in children (MISTIC): A randomized trial. Contemp Clin Trials Commun 2023; 32:101060. [PMID: 36694613 PMCID: PMC9852262 DOI: 10.1016/j.conctc.2023.101060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 11/28/2022] [Accepted: 01/14/2023] [Indexed: 01/22/2023] Open
Abstract
Background Multisystem Inflammatory Syndrome in Children (MIS-C), which occurs 2-6 weeks after initial exposure to SARS-CoV-2, was first identified in early 2020 when patients presented with fever and significant inflammation, often requiring management in the intensive care unit. To date, there has been no clinical trial to determine the most effective treatment. This study compares anti-inflammatory treatments that were selected based on current treatments for Kawasaki disease, a coronary artery vasculitis that shares many clinical features with MIS-C. Methods This randomized, comparative effectiveness trial of children with MIS-C uses the small N Sequential Multiple Assignment Randomized Trial (snSMART) design for rare diseases to compare multiple therapies within an individual. Study participants were treated first with intravenous immunoglobulin (IVIG), and if needed, subjects were then randomized to one of three additional treatments (steroids, anakinra, or infliximab). Participants were re-randomized to remaining treatments if they did not demonstrate clinical improvement. Conclusion This trial continues to enroll eligible participants to determine the most effective therapies in addition to IVIG and best order in which to use them to treat MIS-C. Trial Registration NCT04898231.
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Affiliation(s)
- Sonia Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, University of California at San Diego, USA
| | - Feng He
- Biostatistics Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, University of California at San Diego, USA
| | - Kiana Brown
- Department of Pediatrics, UCSD School of Medicine/Rady Children's Hospital San Diego, 9500 Gilman Dr, Mail Code 0641, La Jolla, CA, 92093-061, USA
| | - Jane C. Burns
- Department of Pediatrics, UCSD School of Medicine/Rady Children's Hospital San Diego, 9500 Gilman Dr, Mail Code 0641, La Jolla, CA, 92093-061, USA
| | - Adriana H. Tremoulet
- Department of Pediatrics, UCSD School of Medicine/Rady Children's Hospital San Diego, 9500 Gilman Dr, Mail Code 0641, La Jolla, CA, 92093-061, USA,Corresponding author. Department of Pediatrics, UCSD School of Medicine, 9500 Gilman Dr, Mail Code 0641, La Jolla, CA, 92093-0641, USA
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58
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Lakshminrusimha S, More K, Shah PS, Wynn JL, Sánchez PJ. Multisystem Inflammatory Syndrome in Neonates (MIS-N) Associated with Perinatal SARS CoV-2 Infection: Does it Exist? Semin Fetal Neonatal Med 2023; 28:101433. [PMID: 37037695 PMCID: PMC10066587 DOI: 10.1016/j.siny.2023.101433] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
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59
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Otten MH, Buysse CMP, Buddingh EP, Terheggen-Lagro SWJ, von Asmuth EGJ, de Sonnaville ESV, Ketharanathan N, Bunker-Wiersma HE, Haverman L, Hogenbirk K, de Hoog M, Humblet M, Joosten KFM, Kneyber MCJ, Krabben G, Lemson J, Maas NM, Maebe S, Roeleveld PP, van Schooneveld M, Timmers-Raaijmaakers B, van Waardenburg D, Walker JC, Wassenberg R, van Woensel JBM, de Wit E, Wolthuis DW, van Zwol A, Oostrom KJ, Knoester H, Dulfer K. Neurocognitive, Psychosocial, and Quality of Life Outcomes After Multisystem Inflammatory Syndrome in Children Admitted to the PICU. Pediatr Crit Care Med 2023; 24:289-300. [PMID: 36688688 PMCID: PMC10072052 DOI: 10.1097/pcc.0000000000003180] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To investigate neurocognitive, psychosocial, and quality of life (QoL) outcomes in children with Multisystem Inflammatory Syndrome in Children (MIS-C) seen 3-6 months after PICU admission. DESIGN National prospective cohort study March 2020 to November 2021. SETTING Seven PICUs in the Netherlands. PATIENTS Children with MIS-C (0-17 yr) admitted to a PICU. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Children and/or parents were seen median (interquartile range [IQR] 4 mo [3-5 mo]) after PICU admission. Testing included assessment of neurocognitive, psychosocial, and QoL outcomes with reference to Dutch pre-COVID-19 general population norms. Effect sizes (Hedges' g ) were used to indicate the strengths and clinical relevance of differences: 0.2 small, 0.5 medium, and 0.8 and above large. Of 69 children with MIS-C, 49 (median age 11.6 yr [IQR 9.3-15.6 yr]) attended follow-up. General intelligence and verbal memory scores were normal compared with population norms. Twenty-nine of the 49 followed-up (59%) underwent extensive testing with worse function in domains such as visual memory, g = 1.0 (95% CI, 0.6-1.4), sustained attention, g = 2.0 (95% CI 1.4-2.4), and planning, g = 0.5 (95% CI, 0.1-0.9). The children also had more emotional and behavioral problems, g = 0.4 (95% CI 0.1-0.7), and had lower QoL scores in domains such as physical functioning g = 1.3 (95% CI 0.9-1.6), school functioning g = 1.1 (95% CI 0.7-1.4), and increased fatigue g = 0.5 (95% CI 0.1-0.9) compared with population norms. Elevated risk for posttraumatic stress disorder (PTSD) was seen in 10 of 30 children (33%) with MIS-C. Last, in the 32 parents, no elevated risk for PTSD was found. CONCLUSIONS Children with MIS-C requiring PICU admission had normal overall intelligence 4 months after PICU discharge. Nevertheless, these children reported more emotional and behavioral problems, more PTSD, and worse QoL compared with general population norms. In a subset undergoing more extensive testing, we also identified irregularities in neurocognitive functions. Whether these impairments are caused by the viral or inflammatory response, the PICU admission, or COVID-19 restrictions remains to be investigated.
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Affiliation(s)
- Marieke H Otten
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Department of Pediatric Intensive Care, Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - Corinne M P Buysse
- Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Department of Pediatric Surgery, Rotterdam, The Netherlands
| | - Emmeline P Buddingh
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Suzanne W J Terheggen-Lagro
- Department of Pediatric Pulmonology, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Erik G J von Asmuth
- Department of Pediatric Stem Cell Transplantation and Laboratory for Pediatric Immunology, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Eleonore S V de Sonnaville
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Department of Pediatrics, Emma Children's Hospital Amsterdam UMC Follow-Me Program & Emma Neuroscience Group, Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - Naomi Ketharanathan
- Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Department of Pediatric Surgery, Rotterdam, The Netherlands
| | - Heleen E Bunker-Wiersma
- Department of Paediatric Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Lotte Haverman
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Department of Child and Adolescent Psychiatry and Psychosocial Care, Amsterdam Reproduction and Development, Amsterdam Public Health, Amsterdam, The Netherlands
| | - Karin Hogenbirk
- Department of Paediatric Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Matthijs de Hoog
- Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Department of Pediatric Surgery, Rotterdam, The Netherlands
| | - Martien Humblet
- Pediatric Intensive Care Unit, Department of Pediatrics, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Koen F M Joosten
- Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Department of Pediatric Surgery, Rotterdam, The Netherlands
| | - Martin C J Kneyber
- Division of Paediatric Intensive Care, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
| | - Geanne Krabben
- Division of Paediatric Intensive Care, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
| | - Joris Lemson
- Department of intensive care medicine, Radboud university medical center, Nijmegen, The Netherlands
| | - Nienke M Maas
- Department of Medical Psychology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sofie Maebe
- Pediatric Intensive Care Unit, Department of Pediatrics, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Peter P Roeleveld
- Department of Paediatric Intensive Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Monique van Schooneveld
- Sector of Neuropsychology, Department of Pediatric Psychology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Brigitte Timmers-Raaijmaakers
- Department of Pediatric Intensive Care, University Medical Center Utrecht, Wilhelmina Children's Hospital, The Netherlands
| | - Dick van Waardenburg
- Pediatric Intensive Care Unit, Department of Pediatrics, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jennifer C Walker
- Department of Pediatric Intensive Care, University Medical Center Utrecht, Wilhelmina Children's Hospital, The Netherlands
| | - Renske Wassenberg
- Department of Medical Psychology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Job B M van Woensel
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Department of Pediatric Intensive Care, Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - Esther de Wit
- Department of Pediatric Intensive Care, University Medical Center Utrecht, Wilhelmina Children's Hospital, The Netherlands
| | - Diana W Wolthuis
- Division of Paediatric Intensive Care, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
| | - Annelies van Zwol
- Department of intensive care medicine, Radboud university medical center, Nijmegen, The Netherlands
| | - Kim J Oostrom
- Department of Child and Adolescent Psychiatry & Psychosocial Care, Amsterdam Reproduction and Development, Emma Children's Hospital, Amsterdam University Medical Centers (Amsterdam UMC), University of Amsterdam, Amsterdam, The Netherlands
| | - Hennie Knoester
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Department of Pediatric Intensive Care, Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - Karolijn Dulfer
- Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Department of Pediatric Surgery, Rotterdam, The Netherlands
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Channon-Wells S, Vito O, McArdle AJ, Seaby EG, Patel H, Shah P, Pazukhina E, Wilson C, Broderick C, D'Souza G, Keren I, Nijman RG, Tremoulet A, Munblit D, Ulloa-Gutierrez R, Carter MJ, Ramnarayan P, De T, Hoggart C, Whittaker E, Herberg JA, Kaforou M, Cunnington AJ, Blyuss O, Levin M. Immunoglobulin, glucocorticoid, or combination therapy for multisystem inflammatory syndrome in children: a propensity-weighted cohort study. THE LANCET. RHEUMATOLOGY 2023; 5:e184-e199. [PMID: 36855438 PMCID: PMC9949883 DOI: 10.1016/s2665-9913(23)00029-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Background Multisystem inflammatory syndrome in children (MIS-C), a hyperinflammatory condition associated with SARS-CoV-2 infection, has emerged as a serious illness in children worldwide. Immunoglobulin or glucocorticoids, or both, are currently recommended treatments. Methods The Best Available Treatment Study evaluated immunomodulatory treatments for MIS-C in an international observational cohort. Analysis of the first 614 patients was previously reported. In this propensity-weighted cohort study, clinical and outcome data from children with suspected or proven MIS-C were collected onto a web-based Research Electronic Data Capture database. After excluding neonates and incomplete or duplicate records, inverse probability weighting was used to compare primary treatments with intravenous immunoglobulin, intravenous immunoglobulin plus glucocorticoids, or glucocorticoids alone, using intravenous immunoglobulin as the reference treatment. Primary outcomes were a composite of inotropic or ventilator support from the second day after treatment initiation, or death, and time to improvement on an ordinal clinical severity scale. Secondary outcomes included treatment escalation, clinical deterioration, fever, and coronary artery aneurysm occurrence and resolution. This study is registered with the ISRCTN registry, ISRCTN69546370. Findings We enrolled 2101 children (aged 0 months to 19 years) with clinically diagnosed MIS-C from 39 countries between June 14, 2020, and April 25, 2022, and, following exclusions, 2009 patients were included for analysis (median age 8·0 years [IQR 4·2-11·4], 1191 [59·3%] male and 818 [40·7%] female, and 825 [41·1%] White). 680 (33·8%) patients received primary treatment with intravenous immunoglobulin, 698 (34·7%) with intravenous immunoglobulin plus glucocorticoids, 487 (24·2%) with glucocorticoids alone; 59 (2·9%) patients received other combinations, including biologicals, and 85 (4·2%) patients received no immunomodulators. There were no significant differences between treatments for primary outcomes for the 1586 patients with complete baseline and outcome data that were considered for primary analysis. Adjusted odds ratios for ventilation, inotropic support, or death were 1·09 (95% CI 0·75-1·58; corrected p value=1·00) for intravenous immunoglobulin plus glucocorticoids and 0·93 (0·58-1·47; corrected p value=1·00) for glucocorticoids alone, versus intravenous immunoglobulin alone. Adjusted average hazard ratios for time to improvement were 1·04 (95% CI 0·91-1·20; corrected p value=1·00) for intravenous immunoglobulin plus glucocorticoids, and 0·84 (0·70-1·00; corrected p value=0·22) for glucocorticoids alone, versus intravenous immunoglobulin alone. Treatment escalation was less frequent for intravenous immunoglobulin plus glucocorticoids (OR 0·15 [95% CI 0·11-0·20]; p<0·0001) and glucocorticoids alone (0·68 [0·50-0·93]; p=0·014) versus intravenous immunoglobulin alone. Persistent fever (from day 2 onward) was less common with intravenous immunoglobulin plus glucocorticoids compared with either intravenous immunoglobulin alone (OR 0·50 [95% CI 0·38-0·67]; p<0·0001) or glucocorticoids alone (0·63 [0·45-0·88]; p=0·0058). Coronary artery aneurysm occurrence and resolution did not differ significantly between treatment groups. Interpretation Recovery rates, including occurrence and resolution of coronary artery aneurysms, were similar for primary treatment with intravenous immunoglobulin when compared to glucocorticoids or intravenous immunoglobulin plus glucocorticoids. Initial treatment with glucocorticoids appears to be a safe alternative to immunoglobulin or combined therapy, and might be advantageous in view of the cost and limited availability of intravenous immunoglobulin in many countries. Funding Imperial College London, the European Union's Horizon 2020, Wellcome Trust, the Medical Research Foundation, UK National Institute for Health and Care Research, and National Institutes of Health.
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Affiliation(s)
- Samuel Channon-Wells
- Centre for Paediatrics and Child Health, Faculty of Medicine, Imperial College London, London, UK
- Department of Infectious Disease, Section of Paediatric Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Ortensia Vito
- Centre for Paediatrics and Child Health, Faculty of Medicine, Imperial College London, London, UK
- Department of Infectious Disease, Section of Paediatric Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Andrew J McArdle
- Centre for Paediatrics and Child Health, Faculty of Medicine, Imperial College London, London, UK
- Department of Infectious Disease, Section of Paediatric Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Eleanor G Seaby
- Department of Infectious Disease, Section of Paediatric Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
- Genomic Informatics Group, University of Southampton, Southampton, UK
- Translational Genomics Group, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Harsita Patel
- Centre for Paediatrics and Child Health, Faculty of Medicine, Imperial College London, London, UK
- Department of Infectious Disease, Section of Paediatric Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Priyen Shah
- Centre for Paediatrics and Child Health, Faculty of Medicine, Imperial College London, London, UK
- Department of Infectious Disease, Section of Paediatric Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | | | - Clare Wilson
- Centre for Paediatrics and Child Health, Faculty of Medicine, Imperial College London, London, UK
- Department of Infectious Disease, Section of Paediatric Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Claire Broderick
- Centre for Paediatrics and Child Health, Faculty of Medicine, Imperial College London, London, UK
- Department of Infectious Disease, Section of Paediatric Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Giselle D'Souza
- Centre for Paediatrics and Child Health, Faculty of Medicine, Imperial College London, London, UK
- Department of Infectious Disease, Section of Paediatric Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Ilana Keren
- Department of Infectious Disease, Section of Paediatric Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Ruud G Nijman
- Centre for Paediatrics and Child Health, Faculty of Medicine, Imperial College London, London, UK
- Department of Infectious Disease, Section of Paediatric Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
- Department of Paediatric Emergency Medicine, Division of Medicine, St Mary's hospital-Imperial College NHS Healthcare Trust, London, London, UK
| | - Adriana Tremoulet
- Department of Paediatrics, University of California San Diego-Rady Children's Hospital San Diego, San Diego, CA, USA
| | - Daniel Munblit
- Inflammation, Repair, and Development Section, National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
- Department of Paediatrics and Paediatric Infectious Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Rolando Ulloa-Gutierrez
- Servicio de Infectologia Pediatrica, Hospital Nacional de Niños "Dr. Carlos Sáenz Herrera", Centro de Ciencias Médicas, Caja Costarricense de Seguro Social (CCSS), San José, Costa Rica
- Instituto de Investigación en Ciencias Médicas UCIMED (IICIMED), San José, Costa Rica
- Cátedra de Pediatría, Facultad de Medicina, Universidad de Ciencias Médicas (UCIMED), San José, Costa Rica
| | - Michael J Carter
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, St Thomas' Hospital, London, UK
| | - Padmanabhan Ramnarayan
- Anaesthetics, Pain Medicine, and Intensive Care (APMIC) Division, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Tisham De
- Department of Infectious Disease, Section of Paediatric Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Clive Hoggart
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Elizabeth Whittaker
- Centre for Paediatrics and Child Health, Faculty of Medicine, Imperial College London, London, UK
- Department of Infectious Disease, Section of Paediatric Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
- Department of Paediatrics, Imperial College Healthcare NHS Trust, London, UK
| | - Jethro A Herberg
- Centre for Paediatrics and Child Health, Faculty of Medicine, Imperial College London, London, UK
- Department of Infectious Disease, Section of Paediatric Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
- Department of Paediatrics, Imperial College Healthcare NHS Trust, London, UK
| | - Myrsini Kaforou
- Centre for Paediatrics and Child Health, Faculty of Medicine, Imperial College London, London, UK
- Department of Infectious Disease, Section of Paediatric Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Aubrey J Cunnington
- Centre for Paediatrics and Child Health, Faculty of Medicine, Imperial College London, London, UK
- Department of Infectious Disease, Section of Paediatric Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
- Department of Paediatrics, Imperial College Healthcare NHS Trust, London, UK
| | - Oleg Blyuss
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Michael Levin
- Centre for Paediatrics and Child Health, Faculty of Medicine, Imperial College London, London, UK
- Department of Infectious Disease, Section of Paediatric Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
- Department of Paediatrics, Imperial College Healthcare NHS Trust, London, UK
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Abstract
PURPOSE OF REVIEW Three years into the coronavirus disease 2019 (COVID-19) pandemic, data on pediatric COVID-19 from African settings is limited. Understanding the impact of the pandemic in this setting with a high burden of communicable and noncommunicable diseases is critical to implementing effective interventions in public health programs. RECENT FINDINGS More severe COVID-19 has been reported in African settings, with especially infants and children with underlying comorbidities at highest risk for more severe disease. Data on the role of tuberculosis and HIV remain sparse. Compared to better resourced settings more children with multisystem inflammatory disease (MISC) are younger than 5 years and there is higher morbidity in all settings and increased mortality in some settings. Several reports suggest decreasing prevalence and severity of MIS-C disease with subsequent severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) variant waves. Whether this decrease continues remains to be determined. Thus far, data on long-COVID in African settings is lacking and urgently needed considering the severity of the disease seen in the African population. SUMMARY Considering the differences seen in the severity of disease and short-term outcomes, there is an urgent need to establish long-term outcomes in children with COVID-19 and MIS-C in African children, including lung health assessment.
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Affiliation(s)
- Marieke M. van der Zalm
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Daniele Dona’
- Division of Paediatric Infectious Diseases, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Helena Rabie
- Paediatric Infectious Diseases, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
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Welzel T, Atkinson A, Schöbi N, Andre MC, Bailey DGN, Blanchard-Rohner G, Buettcher M, Grazioli S, Koehler H, Perez MH, Trück J, Vanoni F, Zimmermann P, Sanchez C, Bielicki JA, Schlapbach LJ. Methylprednisolone versus intravenous immunoglobulins in children with paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS): an open-label, multicentre, randomised trial. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:238-248. [PMID: 36746174 PMCID: PMC9897729 DOI: 10.1016/s2352-4642(23)00020-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/03/2023] [Accepted: 01/13/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND The emergence of paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) led to the widespread use of anti-inflammatory treatments in the absence of evidence from randomised controlled trials (RCTs). We aimed to assess the effectiveness of intravenous methylprednisolone compared with intravenous immunoglobulins. METHODS This is an open-label, multicentre, two-arm RCT done at ten hospitals in Switzerland in children younger than 18 years hospitalised with PIMS-TS (defined as age <18 years; fever and biochemical evidence of inflammation, and single or multiorgan dysfunction; microbiologically proven or putative contact with SARS-CoV-2; and exclusion of any other probable disease). Patients were randomly assigned 1:1 to intravenous methylprednisolone (10 mg/kg per day for 3 days) or intravenous immunoglobulins (2 g/kg as a single dose). The primary outcome was length of hospital stay censored at day 28, death, or discharge. Secondary outcomes included proportion and duration of organ support. Analyses were done by intention-to-treat. The study was registered with Swiss National Clinical Trials Portal (SNCTP000004720) and ClinicalTrials.gov (NCT04826588). FINDINGS Between May 21, 2021, and April 15, 2022, 75 patients with a median age of 9·1 years (IQR 6·2-12·2) were included in the intention-to-treat population (37 in the methylprednisolone group and 38 in the intravenous immunoglobulins group). The median length of hospital stay was 6·0 days (IQR 4·0-8·0) in the methylprednisolone group and 6·0 days (IQR 5·0-8·8) in the intravenous immunoglobulins group (estimated effect size -0·037 of the log10 transformed times, 95% CI -0·13 to 0·065, p=0·42). Fewer patients in the methylprednisolone group (ten [27%] of 37) required respiratory support compared with the intravenous immunoglobulin group (21 [55%] of 38, p=0·025). Need and duration of inotropes, admission to intensive care units, cardiac events after baseline, and major bleeding and thrombotic events were not significantly different between the study groups. INTERPRETATION In this RCT, treatment with methylprednisolone in children with PIMS-TS did not significantly affect the length of hospital stay compared with intravenous immunoglobulins. Intravenous methylprednisolone could be an acceptable first-line treatment in children with PIMS-TS. FUNDING NOMIS Foundation, Vontobel Foundation, and Gaydoul Foundation.
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Affiliation(s)
- Tatjana Welzel
- Paediatric Research Center, University Children's Hospital Basel, University of Basel, Basel, Switzerland; Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland; Pediatric Rheumatology, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - Andrew Atkinson
- Paediatric Research Center, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - Nina Schöbi
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Maya C Andre
- Division of Respiratory and Critical Care Medicine, University Children's Hospital Basel, University of Basel, Basel, Switzerland; Department of Pediatric Hematology and Oncology, University Children's Hospital, Eberhard Karls University, Tuebingen, Germany
| | - Douggl G N Bailey
- Pediatric and Neonatal Intensive Care Unit, Children's Hospital of Eastern Switzerland, St Gallen, Switzerland
| | - Geraldine Blanchard-Rohner
- Pediatric Immunology and Vaccinology Unit, Division of General Pediatrics, Department of Child, Woman and Adolescent Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Michael Buettcher
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland; Paediatric Infectious Diseases Unit, Department of Pediatrics, Cantonal Hospital Lucerne, Lucerne, Switzerland; Faculty of Health Sciences and Medicine, University Lucerne, Lucerne, Switzerland
| | - Serge Grazioli
- Division of Neonatal and Pediatric Intensive Care, Department of Child, Woman and Adolescent Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Henrik Koehler
- Department of Pediatrics, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Marie-Helene Perez
- Pediatric Intensive Care Unit, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | - Johannes Trück
- Division of Immunology, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland; Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Federica Vanoni
- Institute of Pediatrics of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Petra Zimmermann
- Department of Community Health, Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland; Department of Paediatrics, Fribourg Hospital, Fribourg, Switzerland; Infectious Diseases Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Carlos Sanchez
- Paediatric Research Center, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - Julia A Bielicki
- Paediatric Research Center, University Children's Hospital Basel, University of Basel, Basel, Switzerland; Centre for Neonatal and Paediatric Infection, St George's University, London, UK
| | - Luregn J Schlapbach
- Department of Intensive Care and Neonatology, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland; Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland; Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia.
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Ptak K, Szymońska I, Olchawa-Czech A, Kukla K, Cisowska M, Kwinta P. Comparison of the course of multisystem inflammatory syndrome in children during different pandemic waves. Eur J Pediatr 2023; 182:1647-1656. [PMID: 36719477 PMCID: PMC9887239 DOI: 10.1007/s00431-022-04790-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 12/19/2022] [Accepted: 12/27/2022] [Indexed: 02/01/2023]
Abstract
The purpose of this study is to assess the rate, clinical picture, and management of multisystem inflammatory syndrome in children (MIS-C) during the different COVID-19 variants of concern (VOC) domination periods. This was a retrospective analysis of prospectively collected data. The incidence and clinical picture of MIS-C during the original/Alpha (group 1) and Delta/Omicron (Group 2) variant domination periods were compared. Among 108 eligible patients, 74 (68.5%) were hospitalized during the group 1 domination period, and 34 (31.5%) were hospitalized during the group 2 domination period. The median (Me) patient ages were 76 months (interquartile range [IQR] 35-130) and 73 months (IQR 45-118), and 61% and 65% of patients were male, respectively. There was no significant difference in the presence of positive SARS-CoV 2 antibody test results (IgM or IgG) between the groups (84 vs. 90%; p = 0.54).No differences between groups were observed in fever duration prior to admission (Me [IQR]: 5 days [3-6] vs. 5 days [4-6]; p = 0.26) or the presence of mucocutaneous (95 vs. 100%; p = 0.41), circulatory (70.3 vs. 61.8%; p = 0.86), neurological (6.8 vs. 2.9%; p = 0.662), or gastrointestinal symptoms (84 vs. 79%; p = 0.59). Respiratory symptoms were more common in group 2 (70 vs. 91%; p = 0.015). The need for intensive care unit admission was similar in both groups (16.2 vs. 17.6%, p = 1.0). No deaths occurred in the entire cohort. The studied children were characterized by high C-reactive protein and procalcitonin levels, concentrations of ferritin within normal limits, lymphopenia, moderate hypoalbuminemia, and high B-type natriuretic peptide/brain natriuretic peptide (NT-proBNP) concentrations; however, there were no differences between the groups. Intravenous immunoglobulins were administered as a first-line treatment for almost all patients. There was no significant difference in corticosteroid administration between the groups (87% vs. 74%; p = 0.11); however, the summary dose of methylprednisolone was higher in group 2 (Me [IQR]″ 12.6 mg/kg [10.5-17.8] vs. 16.4 mg/kg [13.3-19.5]; p = 0.03). The median length of stay was 11 days [IQR]: [9-14] and 10 days [8-12], respectively (p = 0.065). CONCLUSION The clinical course of MIS-C is similar in subsequent pandemic waves; however, the incidence of MIS-C seems to be decreasing. WHAT IS KNOWN • The clinical picture of COVID-19 is evolving. Multisystem inflammatory syndrome in children (MIS-C) is a relatively new serious disease connected with SARS-CoV-2 infection, and in subsequent waves of the pandemic, new cases of the disease have been recorded. WHAT IS NEW • The clinical picture of MIS-C is not specific, but the course is still severe. • The incidence of MIS-C during the different pandemic waves is decreasing and the diagnosis in the period of lower prevalance is challenging.
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Affiliation(s)
- Katarzyna Ptak
- Department of Pediatrics, Jagiellonian University Medical College, ul. Wielicka 265, 30-663, Cracow, Poland.
| | - Izabela Szymońska
- Department of Pediatrics, Jagiellonian University Medical College, ul. Wielicka 265, 30-663, Cracow, Poland
| | - Anna Olchawa-Czech
- Department of Pediatrics, Jagiellonian University Medical College, ul. Wielicka 265, 30-663, Cracow, Poland
| | - Kornelia Kukla
- Department of Pediatrics, University Children's Hospital, Cracow, Poland
| | - Marta Cisowska
- Department of Pediatrics, University Children's Hospital, Cracow, Poland
| | - Przemko Kwinta
- Department of Pediatrics, Jagiellonian University Medical College, ul. Wielicka 265, 30-663, Cracow, Poland
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Chew C, Ramanan AV. Immunoglobulin, glucocorticoid, or combined therapy for multisystem inflammatory syndrome in children. THE LANCET. RHEUMATOLOGY 2023; 5:e168-e169. [PMID: 36817950 PMCID: PMC9928483 DOI: 10.1016/s2665-9913(23)00035-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Affiliation(s)
- Christine Chew
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol BS2 8BJ, UK
| | - Athimalaipet V Ramanan
- School of Translational Health Sciences, University of Bristol, Bristol, UK
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol BS2 8BJ, UK
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Short to midterm follow-up of multi-system inflammatory syndrome in children with special reference to cardiac involvement. Cardiol Young 2023; 33:371-379. [PMID: 35321771 DOI: 10.1017/s1047951122000828] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES We aim to describe the early and upto 16 months follow-up of post-coronavirus disease (COVID), multi-system inflammatory syndrome in children (MIS-C), with special reference to cardiac involvement. STUDY DESIGN This cohort non-interventional descriptive study included patients <18 years admitted between May, 2020 and April, 2021. Based on underlying similarities, children were classified as post-COVID MIS-C with overlapping Kawasaki Disease, MIS-C with no overlapping Kawasaki Disease, and MIS-C with shock. Post-discharge, patients were followed at 1, 3, 6, 12, and 16 months. RESULTS Forty-one patients predominantly males (73%), at median age of 7 years (range 0.2-16 years) fulfilled the World Health Organisation criteria for MIS-C. Cardiac involvement was seen in 15 (36.5%); impaired left ventricle (LV) function in 5 (12.2%), coronary artery involvement in 10 (24.4%), pericardial effusion in 6 (14.6%) patients, and no arrhythmias. There were two hospital deaths (4.9%), both in MIS-C shock subgroup (2/10, 20%). At 1 month, there was persistent LV dysfunction in 2/5, coronary artery abnormalities in 7/10, and pericardial effusion resolved completely in all patients. By 6 months, LV function returned to normal in all but coronary abnormalities persisted in two patients. At last follow-up (median 9.8 months, interquartile range 2-16 months), in 36/38 (94.7%) patients, coronary artery dilatation was persistent in 2 (20%) patients. CONCLUSIONS Children with MIS-C have a good early outcome, though MIS-C with shock can be life-threatening subgroup in a resource-constrained country setting. On midterm follow-up, there is normalisation of LV function in all and recovery of coronary abnormalities in 80% of patients.
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Kadiyani L, Ramakrishnan S. COVID-19 and heart disease in children: What have we learned? Ann Pediatr Cardiol 2023; 16:81-86. [PMID: 37767179 PMCID: PMC10522153 DOI: 10.4103/apc.apc_104_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 07/31/2023] [Accepted: 08/02/2023] [Indexed: 09/29/2023] Open
Affiliation(s)
- Lamk Kadiyani
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
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Abdulla ZA, Al-Bashir SM, Alzoubi H, Al-Salih NS, Aldamen AA, Abdulazeez AZ. The Role of Immunity in the Pathogenesis of SARS-CoV-2 Infection and in the Protection Generated by COVID-19 Vaccines in Different Age Groups. Pathogens 2023; 12:329. [PMID: 36839601 PMCID: PMC9967364 DOI: 10.3390/pathogens12020329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/09/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023] Open
Abstract
This study aims to review the available data regarding the central role of immunity in combating SARS-CoV-2 infection and in the generation of protection by vaccination against COVID-19 in different age groups. Physiologically, the immune response and the components involved in it are variable, both functionally and quantitatively, in neonates, infants, children, adolescents, and adults. These immunological differences are mirrored during COVID-19 infection and in the post-vaccination period. The outcome of SARS-CoV-2 infection is greatly dependent on the reaction orchestrated by the immune system. This is clearly obvious in relation to the clinical status of COVID-19 infection, which can be symptomless, mild, moderate, or severe. Even the complications of the disease show a proportional pattern in relation to the immune response. On the contrary, the commonly used anti-COVID-19 vaccines generate protective humoral and cellular immunity. The magnitude of this immunity and the components involved in it are discussed in detail. Furthermore, many of the adverse effects of these vaccines can be explained on the basis of immune reactions against the different components of the vaccines. Regarding the appropriate choice of vaccine for different age groups, many factors have to be considered. This is a cornerstone, particularly in the following age groups: 1 day to 5 years, 6 to 11 years, and 12 to 17 years. Many factors are involved in deciding the route, doses, and schedule of vaccination for children. Another important issue in this dilemma is the hesitancy of families in making the decision about whether to vaccinate their children. Added to these difficulties is the choice by health authorities and governments concerning whether to make children's vaccination compulsory. In this respect, although rare and limited, adverse effects of vaccines in children have been detected, some of which, unfortunately, have been serious or even fatal. However, to achieve comprehensive control over COVID-19 in communities, both children and adults have to be vaccinated, as the former group represents a reservoir for viral transmission. The understanding of the various immunological mechanisms involved in SARS-CoV-2 infection and in the preparation and application of its vaccines has given the sciences a great opportunity to further deepen and expand immunological knowledge. This will hopefully be reflected positively on other diseases through gaining an immunological background that may aid in diagnosis and therapy. Humanity is still in continuous conflict with SARS-CoV-2 infection and will be for a while, but the future is expected to be in favor of the prevention and control of this disease.
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Affiliation(s)
| | - Sharaf M. Al-Bashir
- Department of Clinical Sciences, Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan
| | - Hiba Alzoubi
- Department of Basic Medical Sciences, Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan
| | - Noor S. Al-Salih
- Department of Basic Medical Sciences, Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan
| | - Ala A. Aldamen
- Department of Basic Medical Sciences, Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan
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68
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COVID-19 Positive Versus Negative Complete Kawasaki Disease: A Study from the International Kawasaki Disease Registry. Pediatr Cardiol 2023:10.1007/s00246-023-03109-w. [PMID: 36786810 PMCID: PMC9926414 DOI: 10.1007/s00246-023-03109-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 01/19/2023] [Indexed: 02/15/2023]
Abstract
To determine clinical differences for children with complete Kawasaki disease (KD) with and without evidence of preceding SARS-CoV-2 infection. From January 2020, contemporaneous patients with complete KD criteria were classified as either SARS-CoV-2 positive (KDCOVID+; confirmed household exposure, positive PCR and/or serology) or SARS-CoV-2 negative (KDCOVID-; negative testing and no exposure) and compared. Of 744 patients in the International Kawasaki Disease Registry, 52 were KDCOVID- and 61 were KDCOVID+. KDCOVID+ patients were older (median 5.5 vs. 3.7 years; p < 0.001), and all additionally met diagnostic criteria for multisystem inflammatory syndrome in children (MIS-C). They were more likely to have abdominal pain (60% vs. 35%; p = 0.008) and headache (38% vs. 10%; p < 0.001) and had significantly higher CRP, troponin, and BUN/creatinine, and lower hemoglobin, platelets, and lymphocytes. KDCOVID+ patients were more likely to have shock (41% vs. 6%; p < 0.001), ICU admission (62% vs. 10%; p < 0.001), lower left ventricular ejection fraction (mean lowest LVEF 53% vs. 60%; p < 0.001), and to have received inotropic support (60% vs. 10%; p < 0.001). Both groups received IVIG (2 doses in 22% vs. 18%; p = 0.63), but KDCOVID+ were more likely to have received steroids (85% vs. 35%; p < 0.001) and anakinra (60% vs. 10%; p = 0.002). KDCOVID- patients were more likely to have medium/large coronary artery aneurysms (CAA, 12% vs. 0%; p = 0.01). KDCOVID+ patients differ from KDCOVID-, have more severe disease, and greater evidence of myocardial involvement and cardiovascular dysfunction rather than CAA. These patients may be a distinct KD phenotype in the presence of a prevalent specific trigger.
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69
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LaRotta J, Escobar O, Ávila-Aguero ML, Torres JP, Sini de Almeida R, Morales GDC, Srivastava A. COVID-19 in Latin America: A Snapshot in Time and the Road Ahead. Infect Dis Ther 2023; 12:389-410. [PMID: 36633818 PMCID: PMC9835740 DOI: 10.1007/s40121-022-00748-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 12/14/2022] [Indexed: 01/13/2023] Open
Abstract
Since its initial detection in Brazil in February 2020, SARS-CoV-2 and the associated COVID-19 pandemic have continued to devastate Latin America. Specific comorbidities, as well as sociodemographic and lifestyle factors that may be more prevalent in underserved areas, have been identified as risk factors for COVID-19 infection or associated adverse outcomes. Dynamics of infections and deaths in Latin America have varied by country and temporally, as has SARS-CoV-2 variant prevalence; however, more recently, the Delta and subsequent Omicron variants have become ubiquitous. Successful pandemic responses have involved robust infection mitigation measures, testing, and smart deployment of healthcare resourcing. While in some Latin American countries up to 90% of the population is fully vaccinated (i.e., 2 doses) against COVID-19, other countries have failed to reach the World Health Organization's 70% target. Continued focus on comprehensive surveillance, strategies to maximize vaccine availability and uptake, and mitigation of collateral damage on other aspects of public health and social services are critical for managing the COVID-19 pandemic. This review summarizes the COVID-19 experience in Latin America, including epidemiology and vaccination. Key learnings and future considerations for the ongoing pandemic response are also discussed.
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Affiliation(s)
- Jorge LaRotta
- Vaccines Medical and Scientific Affairs, Pfizer SAS, AV Suba 95-66, Bogotá, Colombia.
| | - Omar Escobar
- Vaccines Medical and Scientific Affairs, Pfizer SAS, AV Suba 95-66, Bogotá, Colombia
| | - María L Ávila-Aguero
- Pediatric Infectious Diseases, Hospital Nacional de Niños, San José, Costa Rica
- Center for Infectious Disease Modeling and Analysis, Yale University, New Haven, CT, USA
| | - Juan Pablo Torres
- Departamento de Pediatría y Cirugía Infantil Oriente, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | | | | | - Amit Srivastava
- Vaccines, Medical Development, Scientific and Clinical Affairs, Pfizer Inc, Cambridge, MA, USA
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70
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Zhang HP, Sun YL, Wang YF, Yazici D, Azkur D, Ogulur I, Azkur AK, Yang ZW, Chen XX, Zhang AZ, Hu JQ, Liu GH, Akdis M, Akdis CA, Gao YD. Recent developments in the immunopathology of COVID-19. Allergy 2023; 78:369-388. [PMID: 36420736 PMCID: PMC10108124 DOI: 10.1111/all.15593] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 11/01/2022] [Accepted: 11/22/2022] [Indexed: 11/25/2022]
Abstract
There has been an important change in the clinical characteristics and immune profile of Coronavirus disease 2019 (COVID-19) patients during the pandemic thanks to the extensive vaccination programs. Here, we highlight recent studies on COVID-19, from the clinical and immunological characteristics to the protective and risk factors for severity and mortality of COVID-19. The efficacy of the COVID-19 vaccines and potential allergic reactions after administration are also discussed. The occurrence of new variants of concerns such as Omicron BA.2, BA.4, and BA.5 and the global administration of COVID-19 vaccines have changed the clinical scenario of COVID-19. Multisystem inflammatory syndrome in children (MIS-C) may cause severe and heterogeneous disease but with a lower mortality rate. Perturbations in immunity of T cells, B cells, and mast cells, as well as autoantibodies and metabolic reprogramming may contribute to the long-term symptoms of COVID-19. There is conflicting evidence about whether atopic diseases, such as allergic asthma and rhinitis, are associated with a lower susceptibility and better outcomes of COVID-19. At the beginning of pandemic, the European Academy of Allergy and Clinical Immunology (EAACI) developed guidelines that provided timely information for the management of allergic diseases and preventive measures to reduce transmission in the allergic clinics. The global distribution of COVID-19 vaccines and emerging severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants with reduced pathogenic potential dramatically decreased the morbidity, severity, and mortality of COVID-19. Nevertheless, breakthrough infection remains a challenge for disease control. Hypersensitivity reactions (HSR) to COVID-19 vaccines are low compared to other vaccines, and these were addressed in EAACI statements that provided indications for the management of allergic reactions, including anaphylaxis to COVID-19 vaccines. We have gained a depth knowledge and experience in the over 2 years since the start of the pandemic, and yet a full eradication of SARS-CoV-2 is not on the horizon. Novel strategies are warranted to prevent severe disease in high-risk groups, the development of MIS-C and long COVID-19.
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Affiliation(s)
- Huan-Ping Zhang
- Department of Allergology, Shanxi Bethune Hospital, Shanxi Academy of Medical Science, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
| | - Yuan-Li Sun
- Department of Allergology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Yan-Fen Wang
- Department of Pediatrics, Shanxi Bethune Hospital, Shanxi Academy of Medical Science, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
| | - Duygu Yazici
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland
| | - Dilek Azkur
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, University of Kirikkale, Kirikkale, Turkey
| | - Ismail Ogulur
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland
| | - Ahmet Kursat Azkur
- Department of Virology, Faculty of Veterinary Medicine, University of Kirikkale, Kirikkale, Turkey
| | - Zhao-Wei Yang
- Department of Allergy and Clinical Immunology, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xiao-Xue Chen
- Department of Allergology, Shanxi Bethune Hospital, Shanxi Academy of Medical Science, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
| | - Ai-Zhi Zhang
- Intensive Care Unit, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Jia-Qian Hu
- Department of Allergology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Guang-Hui Liu
- Department of Allergology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Mübeccel Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland
| | - Cezmi A Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland
| | - Ya-Dong Gao
- Department of Allergology, Zhongnan Hospital of Wuhan University, Wuhan, China
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COVID-19 Vaccination in Pediatrics: Was It Valuable and Successful? Vaccines (Basel) 2023; 11:vaccines11020214. [PMID: 36851090 PMCID: PMC9964251 DOI: 10.3390/vaccines11020214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/12/2023] [Accepted: 01/13/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The mass vaccination of children against coronavirus 2019 disease (COVID-19) has been frequently debated. The risk-benefit assessment of COVID-19 vaccination versus infection in children has also been debated. AIM This systematic review looked for answers to the question "was the vaccination of our children valuable and successful?". METHODS The search strategy of different articles in the literature was based on medical subject headings. Screening and selection were based on inclusion/exclusion criteria. RESULTS AND DISCUSSION The search results revealed that the majority of the reported adverse events after COVID-19 vaccination in pediatrics were mild to moderate, with few being severe. Injection site discomfort, fever, headache, cough, lethargy, and muscular aches and pains were the most prevalent side effects. Few clinical studies recorded significant side effects, although the majority of these adverse events had nothing to do with vaccination. In terms of efficacy, COVID-19 disease protection was achieved in 90-95% of cases for mRNA vaccines, in 50-80% of cases for inactivated vaccines, and in 58-92% of cases for adenoviral-based vaccines in children and adolescents. CONCLUSIONS Based on available data, COVID-19 immunizations appear to be safe for children and adolescents. Furthermore, multiple studies have proven that different types of vaccines can provide excellent protection against COVID-19 in pediatric populations. The efficacy of vaccines against new SARS-CoV-2 variants and the reduction in vaccine-related long-term adverse events are crucial for risk-benefit and cost-effectiveness assessments; therefore, additional safety studies are required to confirm the long-term safety and effectiveness of vaccinations in children.
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Haslak F, Gunalp A, Kasapcopur O. A cursed goodbye kiss from severe acute respiratory syndrome-coronavirus-2 to its pediatric hosts: multisystem inflammatory syndrome in children. Curr Opin Rheumatol 2023; 35:6-16. [PMID: 36094472 DOI: 10.1097/bor.0000000000000910] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW We aimed to summarize a novel disease called multisystem inflammatory syndrome in children (MIS-C), which develops several weeks after a severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) illness. RECENT FINDINGS Given the rarity of the disease, the question of why a minority of children develop MIS-C is not known. Certain intrinsic susceptibility factors in the host have been described. In addition to hyperinflammation induced by the innate and acquired immune cells, evidence of molecular mimicry was presented for the disease pathogenesis. As there is an increasing number of infected individuals and mass vaccination schedules, concerns regarding the usefulness of the existing diagnostic criteria sets raised. SUMMARY Although children are likely to have a milder COVID-19 course compared with adults, MIS-C as a postinfectious and life-threatening complication was reported in the pediatric age. After 2 years of the disease definition, optimal treatment regimes, effective preventive measures, and long-term outcomes are still debated.
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Affiliation(s)
- Fatih Haslak
- Department of Pediatric Rheumatology, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
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Muacevic A, Adler JR, Patel AM, Palange A, Adapa S. Post-COVID Multisystem Inflammatory Syndrome-Adult Leading to Cardiomyopathy and Autoimmune Thyroiditis: A Case Report. Cureus 2023; 15:e33754. [PMID: 36793837 PMCID: PMC9922567 DOI: 10.7759/cureus.33754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2023] [Indexed: 01/15/2023] Open
Abstract
The Coronavirus disease pandemic is an evolving disease with myriad presentations and sequelae. Multisystem inflammatory syndrome in adults (MIS-A) can affect various organ systems, including cardiovascular, gastrointestinal, and neurologic systems, with fever and abnormally increased inflammatory markers without significant respiratory affection. This is a well-known complication in children (MIS-C). Validated clinical criteria are used to diagnose this condition. Long-term sequelae of MIS-A are unclear and underreported. Here, we describe a case of Post-COVID-19 MIS-A who presented with cardiac dysfunction, hepatitis, and acute kidney injury and recovered well with steroids. He was left with persistent cardiomyopathy and thyroiditis with hypothyroidism which to date has not fully recovered. This case emphasizes that the sequelae of COVID-19 and its pathophysiology are not fully understood, and more research is needed to predict and prevent the same.
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74
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Lozano-Espinosa DA, Camacho-Moreno G, López-Cubillos JF, Díaz-Maldonado AS, León-Guerra OJ, Galvis-Trujillo DM, Sanguino-Lobo R, Arévalo-Leal OG, del Castillo AMED, Reina-Ávila MF, Cárdenas-Hernández VC, Ivankovich-Escoto G, Tremoulet AH, Ulloa-Gutiérrez R. Multisystem Inflammatory Syndrome in Children (MIS-C) temporally related to COVID-19: the experience at a pediatric reference hospital in Colombia. REVISTA PAULISTA DE PEDIATRIA 2023; 41:e2021267. [DOI: 10.1590/1984-0462/2023/41/2021267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 04/14/2022] [Indexed: 11/16/2022]
Abstract
Abstract Objective: This study aimed to describe the clinical characteristics and the different phenotypes of children with multisystem inflammatory syndrome in children (MIS-C) temporally related to COVID-19 and to evaluate the risk conditions that favored a greater severity of the disease during a 12-month period at a pediatric reference hospital in Colombia. Methods: A 12-month retrospective observational study of children under the age of 18 years who met criteria for MIS-C. Results: A total of 28 children presented MIS-C criteria. The median age was 7 years. Other than fever (100%) (onset 4 days prior to admission), the most frequent clinical features were gastrointestinal (86%) and mucocutaneous (61%). Notably, 14 (50%) children had Kawasaki-like symptoms. The most frequent echocardiographic abnormalities were pericardial effusion (64%), valvular involvement (68%), ventricular dysfunction (39%), and coronary artery abnormalities (29%). In addition, 75% had lymphopenia. All had at least one abnormal coagulation test. Most received intravenous immunoglobulin (89%), glucocorticoids (82%), vasopressors (54%), and antibiotics (64%). Notably, 61% had a more severe form of the disease and were admitted to an intensive care unit (median 4 days, mean 6 days); the severity predictors were patients with the inflammatory/MIS-C phenotype (OR 26.5; 95%CI 1.40–503.7; p=0.029) and rash (OR 14.7; 95%CI 1.2–178.7; p=0.034). Two patients had macrophage activation syndrome. Conclusions: Coronary artery abnormalities, ventricular dysfunction, and intensive care unit admission were frequent, which needs to highlight the importance of early clinical suspicion.
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Affiliation(s)
| | - Germán Camacho-Moreno
- Fundación Hospital Pediátrico La Misericordia, Colombia; Universidad Nacional de Colombia, Colombia
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Tagarro A, Domínguez-Rodríguez S, Mesa JM, Epalza C, Grasa C, Iglesias-Bouzas MI, Fernández-Cooke E, Calvo C, Villaverde S, Torres-Fernández D, Méndez-Echevarria A, Leoz I, Fernández-Pascual M, Saavedra-Lozano J, Soto B, Aguilera-Alonso D, Rivière JG, Fumadó V, Martínez-Campos L, Vivanco A, Pilar-Orive FJ, Alcalá P, Ruiz B, López-Machín A, Oltra M, Moraleda C. Treatments for multi-system inflammatory syndrome in children - discharge, fever, and second-line therapies. Eur J Pediatr 2023; 182:461-466. [PMID: 36282324 PMCID: PMC9595092 DOI: 10.1007/s00431-022-04649-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 09/28/2022] [Accepted: 10/05/2022] [Indexed: 01/21/2023]
Abstract
Scarce evidence exists about the best treatment for multi-system inflammatory syndrome (MIS-C). We analyzed the effects of steroids, intravenous immunoglobulin (IVIG), and their combination on the probability of discharge over time, the probability of switching to second-line treatment over time, and the persistence of fever 2 days after treatment. We did a retrospective study to investigate the effect of different treatments on children with MIS-C from 1 March 2020 to 1 June 2021. We estimated the time-to-event probability using a Cox model weighted by propensity score to balance the baseline characteristics. Thirty of 132 (22.7%) patients were initially treated with steroids alone, 29/132 (21.9%) with IVIG alone, and 73/132 (55%) with IVIG plus steroids. The probability of early discharge was higher with IVIG than with IVIG plus steroids (hazard ratio [HR] 1.65, 95% CI 1.11-2.45, p = 0.013), but with a higher probability of needing second-line therapy compared to IVIG plus steroids (HR 3.05, 95% CI 1.12-8.25, p = 0.028). Patients on IVIG had a higher likelihood of persistent fever than patients on steroids (odds ratio [OR] 4.23, 95% CI 1.43-13.5, p = 0.011) or on IVIG plus steroids (OR 4.4, 95% CI 2.05-9.82, p < 0.001). No differences were found for this endpoint between steroids or steroids plus IVIG. Conclusions: The benefits of each approach may vary depending on the outcome assessed. IVIG seemed to increase the probability of earlier discharge over time but also of needing second-line treatment over time. Steroids seemed to reduce persistent fever, and combination therapy reduced the need for escalating treatment. What is Known: • Steroids plus intravenous immunoglobulin, compared with intravenous immunoglobulin alone for multi-system inflammatory syndrome (MIS-C) might reduce the need for hemodynamic support and the duration of fever, but the certainty of the evidence is low. What is New: • Intravenous immunoglobulin, steroids, and their combination for MIS-C may have different outcomes. • In this study, intravenous immunoglobulin increased the probability of discharge over time, steroids reduced persistent fever, while combination therapy reduced the need for second-line treatments.
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Affiliation(s)
- Alfredo Tagarro
- Fundación de Investigación Biomédica Hospital 12 de Octubre, Instituto de Investigación 12 de Octubre (imas12), Madrid, Spain.
- RITIP (Translational Research Network On Paediatric Infectious Diseases), Madrid, Spain.
- Paediatrics Department, Hospital Universitario Infanta Sofía, Madrid, Spain.
| | - Sara Domínguez-Rodríguez
- Fundación de Investigación Biomédica Hospital 12 de Octubre, Instituto de Investigación 12 de Octubre (imas12), Madrid, Spain
| | - Juan Miguel Mesa
- Paediatrics Department, Hospital Universitario Infanta Sofía, Madrid, Spain
- Paediatrics Research Group, Universidad Europea de Madrid, Madrid, Spain
| | - Cristina Epalza
- Paediatric Infectious Diseases Unit, Department of Paediatrics, Hospital Universitario, Unidad Pediátrica de Investigación y Ensayos Clínicos (UPIC), Instituto de Investigación Hospital 12 Octubre, Madrid, Spain
- Universidad Complutense de Madrid, Madrid, Spain
| | - Carlos Grasa
- Paediatrics, Infectious and Tropical Diseases Department, Hospital Universitario La Paz, Instituto Investigación Hospital La Paz (IDIPaz), Madrid, Spain
- CIBER en Enfermedades Infecciosas (CIBERINFEC), RITIP (Translational Research Network On Paediatric Infectious Diseases), Instituto de Salud Carlos III, Madrid, Spain
| | | | - Elisa Fernández-Cooke
- Paediatric Infectious Diseases Unit, Department of Paediatrics, Hospital Universitario, Unidad Pediátrica de Investigación y Ensayos Clínicos (UPIC), Instituto de Investigación Hospital 12 Octubre, Madrid, Spain
| | - Cristina Calvo
- Paediatrics, Infectious and Tropical Diseases Department, Hospital Universitario La Paz, Instituto Investigación Hospital La Paz (IDIPaz), Madrid, Spain
- CIBER en Enfermedades Infecciosas (CIBERINFEC), RITIP (Translational Research Network On Paediatric Infectious Diseases), Instituto de Salud Carlos III, Madrid, Spain
| | - Serena Villaverde
- Fundación de Investigación Biomédica Hospital 12 de Octubre, Instituto de Investigación 12 de Octubre (imas12), Madrid, Spain
| | - David Torres-Fernández
- Paediatric Infectious Diseases Unit, Department of Paediatrics, Hospital Universitario, Unidad Pediátrica de Investigación y Ensayos Clínicos (UPIC), Instituto de Investigación Hospital 12 Octubre, Madrid, Spain
| | - Ana Méndez-Echevarria
- Paediatrics, Infectious and Tropical Diseases Department, Hospital Universitario La Paz, Instituto Investigación Hospital La Paz (IDIPaz), Madrid, Spain
| | - Inés Leoz
- Paediatrics Intensive Care Unit, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | | | - Jesús Saavedra-Lozano
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Unidad de Investigación Materno-Infantil Fundación Familia Alonso (UDIMIFFA), Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
- CIBER en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Beatriz Soto
- Paediatrics Department, Hospital Universitario de Getafe, Getafe, Madrid, Spain
| | - David Aguilera-Alonso
- Fundación de Investigación Biomédica Hospital 12 de Octubre, Instituto de Investigación 12 de Octubre (imas12), Madrid, Spain
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Unidad de Investigación Materno-Infantil Fundación Familia Alonso (UDIMIFFA), Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
- CIBER en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Jacques G Rivière
- Infectious Diseases and Paediatric Immunology Unit, Department of Paediatrics, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Victoria Fumadó
- Paediatric Infectious Diseases Unit, Department of Paediatrics, Hospital Universitario Sant Joan de Deu, Barcelona, Spain
| | - Leticia Martínez-Campos
- Paediatric Infectious Diseases Unit, Department of Paediatrics, Hospital Universitario Torrecárdenas, Almeria, Spain
| | - Ana Vivanco
- Paediatrics Intensive Care Unit, Hospital Central de Asturias, Asturias, Spain
| | | | - Pedro Alcalá
- Paediatrics Department, Hospital General de Alicante, Alicante, Spain
| | - Beatriz Ruiz
- Paediatrics Department, Hospital Reina Sofía, Córdoba, Spain
| | | | - Manuel Oltra
- Paediatrics Department, Hospital La Fe, Valencia, Spain
| | - Cinta Moraleda
- Fundación de Investigación Biomédica Hospital 12 de Octubre, Instituto de Investigación 12 de Octubre (imas12), Madrid, Spain
- Paediatric Infectious Diseases Unit, Department of Paediatrics, Hospital Universitario, Unidad Pediátrica de Investigación y Ensayos Clínicos (UPIC), Instituto de Investigación Hospital 12 Octubre, Madrid, Spain
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You SD, Kim JH, You J. Clinical characteristics and short-term outcomes of multisystem inflammatory syndrome in a country with a high prevalence of KD. Front Pediatr 2023; 11:1088529. [PMID: 36865687 PMCID: PMC9971980 DOI: 10.3389/fped.2023.1088529] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 01/10/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic has spread continuously. Multisystem inflammatory syndrome in children (MIS-C), like Kawasaki disease (KD), is a potentially severe illness in children that appears to be a delayed, post-infectious complication of COVID-19. However, based on the relatively low MIS-C prevalence and high KD prevalence in Asian children, the clinical features of MIS-C are not fully recognized, especially after the spread of the Omicron variant. Here, we aimed to identify the clinical characteristics of MIS-C in a country with high KD prevalence. METHODS We retrospectively analyzed 98 children diagnosed with KD and MIS-C admitted to Jeonbuk National University Hospital between January 1, 2021, and October 15, 2022. Twenty-two patients were diagnosed with MIS-C, following CDC diagnostic criteria for MIS-C. We reviewed medical records for clinical features, laboratory findings, and echocardiography. RESULTS Age, height, and weight were higher for patients with MIS-C than for those with KD. Lymphocytes percentage was lower, and the segmented neutrophil percentage was higher in the MIS-C group. The inflammation marker C-reactive protein was higher in the MIS-C group. Prothrombin time was prolonged in the MIS-C group. Albumin level was lower in the MIS-C group. The MIS-C group had lower potassium, phosphorus, chloride, and total calcium. Twenty-five percent of patients diagnosed with MIS-C had positive RT-PCR, and all the patients were N-type SARS-CoV-2 antibody-positive. Albumin ≤3.85 g/dl effectively predicted MIS-C. Regarding echocardiography, the right coronary artery z-score, the absolute value of apical 4-chamber left ventricle longitudinal strain, and the ejection fraction (EF) was significantly lower in the MIS-C group. A month after diagnosis using echocardiographic data, all coronary artery z-scores had reduced significantly. EF and fractional shortening (FS) also improved one month after diagnosis. CONCLUSION Albumin values can differentiate MIS-C and KD. In addition, a decrease in the absolute LV longitudinal strain value, EF, and FS was observed in the MIS-C group using echocardiography. Coronary artery dilatation was not evident at the initial diagnosis; however, a change in coronary artery size, EF, and FS was observed on follow-up echocardiography a month after diagnosis.
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Affiliation(s)
- Sung Doo You
- Department of Pediatrics, Jeonbuk National University Children's Hospital, Jeonju, Korea
| | - Jin Ho Kim
- Department of Pediatrics, Jeonbuk National University Children's Hospital, Jeonju, Korea
| | - Jihye You
- Department of Pediatrics, Jeonbuk National University Children's Hospital, Jeonju, Korea.,Research Institute of Clinical Medicine of Jeonbuk National University, Jeonju, Korea
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Feleszko W, Okarska-Napierała M, Buddingh EP, Bloomfield M, Sediva A, Bautista-Rodriguez C, Brough HA, Eigenmann PA, Eiwegger T, Eljaszewicz A, Eyerich S, Gomez-Casado C, Fraisse A, Janda J, Jiménez-Saiz R, Kallinich T, Krohn IK, Mortz CG, Riggioni C, Sastre J, Sokolowska M, Strzelczyk Z, Untersmayr E, Tramper-Stranders G. Pathogenesis, immunology, and immune-targeted management of the multisystem inflammatory syndrome in children (MIS-C) or pediatric inflammatory multisystem syndrome (PIMS): EAACI Position Paper. Pediatr Allergy Immunol 2023; 34:e13900. [PMID: 36705045 DOI: 10.1111/pai.13900] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 12/05/2022] [Indexed: 01/06/2023]
Abstract
Multisystem inflammatory syndrome in children (MIS-C) is a rare, but severe complication of coronavirus disease 2019 (COVID-19). It develops approximately 4 weeks after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and involves hyperinflammation with multisystem injury, commonly progressing to shock. The exact pathomechanism of MIS-C is not known, but immunological dysregulation leading to cytokine storm plays a central role. In response to the emergence of MIS-C, the European Academy of Allergy and Clinical Immunology (EAACI) established a task force (TF) within the Immunology Section in May 2021. With the use of an online Delphi process, TF formulated clinical statements regarding immunological background of MIS-C, diagnosis, treatment, follow-up, and the role of COVID-19 vaccinations. MIS-C case definition is broad, and diagnosis is made based on clinical presentation. The immunological mechanism leading to MIS-C is unclear and depends on activating multiple pathways leading to hyperinflammation. Current management of MIS-C relies on supportive care in combination with immunosuppressive and/or immunomodulatory agents. The most frequently used agents are systemic steroids and intravenous immunoglobulin. Despite good overall short-term outcome, MIS-C patients should be followed-up at regular intervals after discharge, focusing on cardiac disease, organ damage, and inflammatory activity. COVID-19 vaccination is a safe and effective measure to prevent MIS-C. In anticipation of further research, we propose a convenient and clinically practical algorithm for managing MIS-C developed by the Immunology Section of the EAACI.
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Affiliation(s)
- Wojciech Feleszko
- Department of Pediatric Pneumology and Allergy, The Medical University of Warsaw, Warsaw, Poland
| | | | - Emilie Pauline Buddingh
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, The Netherlands
| | - Marketa Bloomfield
- Department of Immunology, 2nd Faculty of Medicine, Motol University Hospital, Charles University, Prague, Czech Republic.,Department of Pediatrics, 1st Faculty of Medicine, Thomayer University Hospital, Charles University, Prague, Czech Republic
| | - Anna Sediva
- Department of Immunology, 2nd Faculty of Medicine, Motol University Hospital, Charles University, Prague, Czech Republic
| | - Carles Bautista-Rodriguez
- Pediatric Cardiology Services, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Helen A Brough
- Paediatric Allergy Group, Department of Women and Children's Health, School of Life Course Sciences, St. Thomas' Hospital, King's College London, London, UK.,Children's Allergy Service, Evelina Children's Hospital, Guy's and St.Thomas' Hospital NHS Foundation Trust, London, UK.,Paediatric Allergy Group, Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, Guys' Hospital, King's College London, London, UK
| | - Philippe A Eigenmann
- Department of Women-Children-Teenagers, University Hospital of Geneva, Geneva, Switzerland
| | - Thomas Eiwegger
- Karl Landsteiner University of Health Sciences, Krems, Austria.,Translational Medicine Program, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Immunology, University of Toronto, Toronto, Ontario, Canada.,Department of Pediatric and Adolescent Medicine, University Hospital St. Pölten, St. Pölten, Austria
| | - Andrzej Eljaszewicz
- Department of Regenerative Medicine and Immune Regulation, Medical University of Bialystok, Bialystok, Poland
| | - Stefanie Eyerich
- Center for Allergy and Environment (ZAUM), Technical University and Helmholtz Center Munich, Munich, Germany
| | - Cristina Gomez-Casado
- Department of Dermatology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Alain Fraisse
- Pediatric Cardiology Services, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Jozef Janda
- Faculty of Science, Charles University, Prague, Czech Republic
| | - Rodrigo Jiménez-Saiz
- Department of Immunology, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa (IIS-Princesa), Madrid, Spain.,Department of Immunology and Oncology, Centro Nacional de Biotecnología (CNB-CSIC), Madrid, Spain.,Faculty of Experimental Sciences, Universidad Francisco de Vitoria (UFV), Madrid, Spain.,Department of Medicine, McMaster Immunology Research Centre, McMaster University, Hamilton, Ontario, Canada
| | - Tilmann Kallinich
- Pediatric Pneumology, Immunology and Critical Care Medicine, Charité - Universitätsmedizin Berlin and Deutsches Rheuma-Forschungszentrum (DRFZ), an Institute of the Leibniz Association, Berlin, Germany
| | - Inge Kortekaas Krohn
- SKIN Research Group, Vrije Univeristeit Brussel (VUB), Brussels, Belgium.,Department of Dermatology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Charlotte G Mortz
- Department of Dermatology and Allergy Center, Odense Research Center for Anaphylaxis (ORCA), Odense University Hospital, Odense, Denmark
| | - Carmen Riggioni
- Allergy, Immunology and Rheumatology Division, Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Joaquin Sastre
- Fundacion Jimenez Diaz and CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Milena Sokolowska
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Davos, Switzerland.,Christine Kühne - Center for Allergy Research and Education (CK-CARE), Davos, Switzerland
| | - Ziemowit Strzelczyk
- Department of Pediatric Pneumology and Allergy, The Medical University of Warsaw, Warsaw, Poland
| | - Eva Untersmayr
- Institute of Pathophysiology and Allergy Research, Center of Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | - Gerdien Tramper-Stranders
- Department of Paediatric Medicine, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands.,Department of Neonatology, Erasmus MC-Sophia, Rotterdam, The Netherlands
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78
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Vainstein E, Baleani S, Urrutia L, Affranchino N, Ackerman J, Cazalas M, Goldsman A, Sardella A, Tolin AL, Goldaracena P, Fabi M, Cosentino M, Magliola R, Roggiero G, Manso P, Triguy J, Ballester C, Cervetto V, Vaccarello M, De Carli DN, De Carli ME, Ciotti AL, Sicurello MI, Rios Leiva C, Villalba C, Hortas M, Peña S, González G, Zold CL, Murer MG, Vázquez H, Morós C, Di Santo M, Villa A, Lazota P, Foti M, Napoli N, Katsikas MM, Tonello L, Peña J, Etcheverry M, Iglesias D, Alcalde AL, Bruera MJ, Bruzzo V, Giordano P, Acero FP, Pelandi GN, Pastaro D, Bleiz J, Rodríguez MF, Laghezza L, Molina MB, Patynok N, Chatelain, Aguilar MJ, Gamboa J, Cervan M, Ruggeri A, Marinelli I, Checcacci E, Meregalli C, Damksy Barbosa J, Fernie L, Fernández MJ, Saenz Tejeira MM, Cereigido C, Nunell A, Villar D, Mansilla AD, Darduin MD. Multicentre observational study on multisystem inflammatory syndrome related to COVID-19 in Argentina. Pediatr Int 2023; 65:e15431. [PMID: 36464947 PMCID: PMC9878215 DOI: 10.1111/ped.15431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 10/07/2022] [Accepted: 11/21/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND The impact of the pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) in low- and middle-income countries remains poorly understood. Our aim was to understand the characteristics and outcomes of PIMS-TS in Argentina. METHODS This observational, prospective, and retrospective multicenter study enrolled patients younger than 18 years-old manifesting PIMS-TS, Kawasaki disease (KD) or Kawasaki shock syndrome (KSS) between March 2020 and May 2021. Patients were followed-up until hospital discharge or death (one case). The primary outcome was pediatric intensive care unit (PICU) admission. Multiple logistic regression was used to identify variables predicting PICU admission. RESULTS Eighty-one percent, 82%, and 14% of the 176 enrolled patients fulfilled the suspect case criteria for PIMS-TS, KD, and KSS, respectively. Temporal association with SARS-CoV-2 was confirmed in 85% of the patients and 38% were admitted to the PICU. The more common clinical manifestations were fever, abdominal pain, rash, and conjunctival injection. Lymphopenia was more common among PICU-admitted patients (87% vs. 51%, p < 0.0001), who also showed a lower platelet count and higher plasmatic levels of inflammatory and cardiac markers. Mitral valve insufficiency, left ventricular wall motion alterations, pericardial effusion, and coronary artery alterations were observed in 30%, 30%, 19.8%, and 18.6% of the patients, respectively. Days to initiation of treatment, rash, lymphopenia, and low platelet count were significant independent contributions to PICU admission. CONCLUSION Rates of severe outcomes of PIMS-TS in the present study agreed with those observed in high-income countries. Together with other published studies, this work helps clinicians to better understand this novel clinical entity.
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Affiliation(s)
- Eduardo Vainstein
- Clínica Pediátrica, Hospital de Niños Dr. Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Silvia Baleani
- Clínica Pediátrica, Hospital de Niños Dr. Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Luis Urrutia
- Clínica Pediátrica, Hospital Nacional de Pediatría Juan P Garrahan, Buenos Aires, Argentina
| | - Nicolás Affranchino
- Clínica Pediátrica, Hospital Nacional de Pediatría Juan P Garrahan, Buenos Aires, Argentina
| | - Judith Ackerman
- Unidad de Cardiología, Hospital General de Niños Pedro de Elizalde, Buenos Aires, Argentina
| | - Mariana Cazalas
- División de Cardiología, Hospital de Niños Dr. Ricardo Gutiérrez y Sanatorio Sagrado Corazón, Buenos Aires, Argentina
| | - Alejandro Goldsman
- División de Cardiología, Hospital de Niños Dr. Ricardo Gutiérrez y Sanatorio Sagrado Corazón, Buenos Aires, Argentina
| | - Angela Sardella
- División de Cardiología, Hospital de Niños Dr. Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Ana Laura Tolin
- Servicio de Inmunología, Hospital H. Notti, Provincia de Mendoza, Argentina
| | - Pablo Goldaracena
- Clínica Médica, Hospital Sor María Ludovica de La Plata, Provincia de Buenos Aires, Argentina
| | - Mariana Fabi
- Servicio de Reumatología, Hospital Sor María Ludovica de La Plata, Provincia de Buenos Aires, Argentina
| | | | - Ricardo Magliola
- Clínica Pediátrica, Unidad Terapia Intensiva, Hospital Británico, Buenos Aires, Argentina
| | - Gustavo Roggiero
- Servicio de Cardiología, Hospital El Cruce Néstor Carlos Kirchner y Clínica del Niño de Quilmes, Provincia de Buenos Aires, Argentina
| | - Paula Manso
- Servicio de Cardiología, Hospital El Cruce Néstor Carlos Kirchner, Provincia de Buenos Aires, Argentina
| | - Jésica Triguy
- Servicio de Inmunología, Hospital H. Notti, Provincia de Mendoza, Argentina
| | - Celeste Ballester
- Servicio de Inmunología, Hospital H. Notti, Provincia de Mendoza, Argentina
| | - Vanesa Cervetto
- Reumatología, Hospital General de Niños Pedro de Elizalde y Hospital Británico, Buenos Aires, Argentina
| | - María Vaccarello
- Clínica Pediátrica, Sanatorio la Trinidad, Quilmes, Provincia de Buenos Aires, Argentina
| | | | - Maria Estela De Carli
- Clínica Pediátrica, Clínica del Niño de Quilmes, Provincia de Buenos Aires, Argentina
| | - Ana Laura Ciotti
- Servicio de Cardiología, Hospital A. Posadas, Provincia de Buenos Aires, Argentina
| | - María Irene Sicurello
- División de Cardiología, Hospital de Niños Dr. Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Cecilia Rios Leiva
- Servicio de Cardiología, Hospital Eva Perón de San Martín, Provincia de Buenos Aires, Argentina
| | - Claudia Villalba
- Servicio de Cardiología, Hospital Británico y Hospital Nacional de Pediatría Juan P Garrahan, Buenos Aires, Argentina
| | - María Hortas
- Servicio de Reumatología, Sanatorio la Trinidad, Quilmes, Provincia de Buenos Aires, Argentina
| | - Sonia Peña
- Servicio de Inmunología, Hospital H. Notti, Provincia de Mendoza, Argentina
| | - Gabriela González
- Servicio de Cardiología, Hospital H. Notti, Provincia de Mendoza, Argentina
| | - Camila Lidia Zold
- Universidad de Buenos Aires, CONICET, Instituto de Fisiología y Biofísica (IFIBIO) Bernardo Houssay, Buenos Aires, Argentina
| | - Mario Gustavo Murer
- Universidad de Buenos Aires, CONICET, Instituto de Fisiología y Biofísica (IFIBIO) Bernardo Houssay, Buenos Aires, Argentina
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79
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Bakhtiari Koohsorkhi M, Wu J, Ziaee V. Editorial: Case Reports in Pediatric Rheumatology 2022. Front Pediatr 2023; 11:1137843. [PMID: 36814592 PMCID: PMC9939888 DOI: 10.3389/fped.2023.1137843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 01/20/2023] [Indexed: 02/08/2023] Open
Affiliation(s)
| | - Junfeng Wu
- Department of Rheumatology and Immunology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Vahid Ziaee
- Children's Medical Center, Pediatrics Center of Excellence, Tehran, Iran.,Department of Pediatrics, Tehran University of Medical Sciences, Tehran, Iran.,Pediatric Rheumatology Research Group, Rheumatology Research Center, Tehran University of Medical Science, Tehran, Iran.,Pediatric Rheumatology Society of Iran, Tehran, Iran
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80
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Sadeghi P, Gorji M, Assari R, Tahghighi F, Raeeskarami SR, Ziaee V. Methylprednisolone pulses as an initial treatment in hyperinflammatory syndrome after COVID-19 in children: evaluation of laboratory data, serial echocardiography and outcome: a case series. Intensive Care Med Exp 2022; 10:56. [PMID: 36585531 PMCID: PMC9803403 DOI: 10.1186/s40635-022-00484-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 12/17/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Hyper-inflammatory syndrome in children and young adult occur 2-6 weeks after COVID-19 infection or closed contact with COVID-19 persons. In this study, the laboratory data and echocardiography and abdominal ultrasonography assessments were evaluated before and after Methylprednisolone pulse as an initial treatment of hyper-inflammatory syndrome. Therefore, the aim of this study is to assessment the clinical manifestations and laboratory data and outcome after methylprednisolone pulse as an initial treatment. METHOD In this retrospective study, the demographic status, clinical features, laboratory data, echocardiography, abdominal ultrasound, treatment and outcome of 31 pediatric patients under 16 years old, with inflammatory process after COVID-19 were evaluated. The clinical assessments, laboratory data, sonography and echocardiography were evaluated before and after methylprednisolone pulse. The patients were divided in two age group < and ≥ 7 years old and the clinical manifestations were compared with each other. The Mann-Whitney U test was used to assess the difference in quantitative variables between two groups. To compare pre- and post- treatment values, Wilcoxol test was used. To assess the correlation between qualitative variables chi-square test was used. The level of significant was considered 0.05. These patients with fever and hyper-inflammation features admitted to the referral pediatric rheumatology ward in Children Medical Center of Tehran University of medical sciences, from April 2020 to May 2021 were assessed. RESULT The mean age ± SD were (5.94 ± 3) and 51.6% (16) patients were male and 48.4% (15) patients were female. The most documented of previous COVID infection were antibody positive in about 27 (87%) patients. Moreover, 1 (3.8%) was PCR positive, 2 (7.7%) were positive in both PCR and serology and 3(11.5%) had closed contact with COVID-19 patients. About 9(29%) of patients were admitted in Intensive Care Unit (ICU). There were significant correlation between days of delay in starting treatment and ICU admission (P-value = 0.02). The mortality rate was negative in patients and no re-hospitalization was documented. There were significant differences (P-value < 0.05) between lymphocytes, platelet, Erythrocyte Sedimentation rate, C-reactive protein, Aspartate transaminase, Alanine transaminase and ferritin before and after treatment. Skin rashes and cardiac involvement totally as carditis (myocarditis, vulvulitis and pericarditis) (33.3%) and coronary involvements (53.3%) were the most prominent initial presentation in patients. There were near significant correlation (P-value = 0.066) between ferritin level and carditis before treatment. Cervical lymphadenopathy was seen significantly more in ≥ 7 years old (P-value = 0.01). CONCLUSION Multisystem inflammatory system in children as a hyperinflammatory syndrome could be treated with first step methylprednisolone pulse with decreasing inflammation in laboratory data and cardiac involvements and good outcome. Furthermore, the ferritin level may be one of the predictor of severe hyper-inflammatory syndrome leading to aggressive and urgent treatment with methylprednisolone pulse.
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Affiliation(s)
- Payman Sadeghi
- grid.411705.60000 0001 0166 0922Department of Pediatric Rheumatology, Pediatric Center of Excellence, Children’s Medical Center of Tehran University of Medical Science, No 63, Gharib Ave., Keshavarz Blv., Tehran, Iran
| | - Mojtaba Gorji
- grid.411705.60000 0001 0166 0922Department of Pediatric Cardiology, Pediatric Center of Excellence, Children’s Medical Center of Tehran University of Medical Science, Tehran, Iran
| | - Raheleh Assari
- grid.411705.60000 0001 0166 0922Department of Pediatric Rheumatology, Pediatric Center of Excellence, Children’s Medical Center of Tehran University of Medical Science, No 63, Gharib Ave., Keshavarz Blv., Tehran, Iran
| | - Fatemeh Tahghighi
- grid.411705.60000 0001 0166 0922Department of Pediatric Rheumatology, Pediatric Center of Excellence, Children’s Medical Center of Tehran University of Medical Science, No 63, Gharib Ave., Keshavarz Blv., Tehran, Iran
| | - Seyed Reza Raeeskarami
- grid.411705.60000 0001 0166 0922Department of Pediatric Rheumatology, Imam Khomeini Hospital Complex, Tehran University of Medical Science, Tehran, Iran
| | - Vahid Ziaee
- grid.411705.60000 0001 0166 0922Department of Pediatric Rheumatology, Pediatric Center of Excellence, Children’s Medical Center of Tehran University of Medical Science, No 63, Gharib Ave., Keshavarz Blv., Tehran, Iran
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81
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Melgar M, Lee EH, Miller AD, Lim S, Brown CM, Yousaf AR, Zambrano LD, Belay ED, Godfred-Cato S, Abrams JY, Oster ME, Campbell AP. Council of State and Territorial Epidemiologists/CDC Surveillance Case Definition for Multisystem Inflammatory Syndrome in Children Associated with SARS-CoV-2 Infection - United States. MMWR Recomm Rep 2022; 71:1-14. [PMID: 36520808 PMCID: PMC9762894 DOI: 10.15585/mmwr.rr7104a1] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Since May 14, 2020, CDC has conducted national surveillance for multisystem inflammatory syndrome in children (MIS-C) associated with infection with SARS-CoV-2, the virus that causes COVID-19, among persons aged <21 years using a CDC case definition based on public health need and data from early reports of patients with this condition. Recent analyses of accumulated data indicated that certain criteria from the 2020 CDC MIS-C case definition performed better than others in distinguishing MIS-C from other illnesses and that certain other criteria likely contributed to misclassification. To incorporate lessons learned from MIS-C surveillance and public health investigations and to improve feasibility of implementation by surveillance staff at state, local, territorial, and tribal health departments, the Council of State and Territorial Epidemiologists (CSTE) and CDC developed a CSTE/CDC position statement (approved by CSTE in 2022) that includes an MIS-C surveillance case definition for voluntary reporting to CDC (effective January 1, 2023) This report summarizes the evidence and rationale supporting the components of the CSTE/CDC MIS-C surveillance case definition and describes the methods used to develop the definition. These methods included convening MIS-C clinical experts (i.e., consultants) regarding identification of MIS-C and its distinction from other pediatric conditions, a review of available literature comparing MIS-C phenotype with that of pediatric COVID-19 and other hyperinflammatory syndromes, and retrospective application of different criteria to data from MIS-C cases previously reported to CDC. The CSTE/CDC surveillance case definition for MIS-C includes four important changes, in comparison with the 2020 CDC MIS-C case definition. These changes are 1) no required duration of subjective or measured fever; 2) requirement of C-reactive protein ≥3.0 mg/dL to indicate systemic inflammation; 3) adjustments to criteria of organ system involvement to include addition of shock as a separate category and elimination of respiratory, neurologic, and renal criteria; and 4) new requirements on timing of positive SARS-CoV-2 laboratory testing relative to the MIS-C illness. Although MIS-C is not a nationally notifiable condition and reporting is voluntary, CSTE and CDC recommend that all states and territories report all cases meeting confirmed, probable, or suspect criteria of the CSTE/CDC MIS-C surveillance case definition beginning January 1, 2023, for cases with MIS-C illness onset on or after that date
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82
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Bagri NK, Khan M, Pandey RM, Lodha R, Kabra SK, Angurana SK, Awasthi S, Bamnawat H, Bhat JI, Bhutia TD, Charoo BA, Choudhary A, Choudhary B, Das RR, Dwibedi B, Ghosh S, Girish M, Gulla KM, Goyal JP, Gupta P, I S, Jindal A, John J, Joshi P, Kaur R, Khera D, Kumar A, Kumar P, Kumar P, Lalitha AV, Maheshwari M, Malik S, Mondal R, Muralidharan J, Pawar G, Prasad A, Rao SK, Ratageri VH, Sarkar M, Satpathy AK, Sankar J, Sharma S, Singh A, Singh K, Singhal T, Sood M, Sudeepthi SV, Tiwari L, Verma N, Yonzon R. Initial Immunomodulation and Outcome of Children with Multisystem Inflammatory Syndrome Related to COVID-19: A Multisite Study from India. Indian J Pediatr 2022; 89:1236-1242. [PMID: 35699843 PMCID: PMC9192925 DOI: 10.1007/s12098-022-04254-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 04/11/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine the outcomes in children with MIS-C receiving different immunomodulatory treatment. METHODS In this multicentric, retrospective cohort study, data regarding treatment and outcomes of children meeting the WHO case definition for MIS-C, were collected. The primary composite outcome was the requirement of vasoactive/inotropic support on day 2 or beyond or need of mechanical ventilation on day 2 or beyond after initiation of immunomodulatory treatment or death during hospitalization in the treatment groups. Logistic regression and propensity score matching analyses were used to compare the outcomes in different treatment arms based on the initial immunomodulation, i.e., IVIG alone, IVIG plus steroids, and steroids alone. RESULTS The data of 368 children (diagnosed between April 2020 and June 2021) meeting the WHO case definition for MIS-C, were analyzed. Of the 368 subjects, 28 received IVIG alone, 82 received steroids alone, 237 received IVIG and steroids, and 21 did not receive any immunomodulation. One hundred fifty-six (42.39%) children had the primary outcome. On logistic regression analysis, the treatment group was not associated with the primary outcome; only the children with shock at diagnosis had higher odds for the occurrence of the outcome [OR (95% CI): 11.4 (5.19-25.0), p < 0.001]. On propensity score matching analysis, the primary outcome was comparable in steroid (n = 45), and IVIG plus steroid (n = 84) groups (p = 0.515). CONCLUSION While no significant difference was observed in the frequency of occurrence of the primary outcome in different treatment groups, data from adequately powered RCTs are required for definitive recommendations.
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Affiliation(s)
- Narendra Kumar Bagri
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - M Khan
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - R M Pandey
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Lodha
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India.
| | - S K Kabra
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | | | - Suresh Kumar Angurana
- Department of Pediatrics, Advanced Pediatric Center, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Shally Awasthi
- Department of Pediatrics, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Harshita Bamnawat
- Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Javeed Iqbal Bhat
- Department of Pediatrics, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu & Kashmir, India
| | - Tsultem D Bhutia
- Department of Pediatrics, New STNMMS Hospital, Gangtok, Sikkim, India
| | - Bashir Ahmad Charoo
- Department of Pediatrics, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu & Kashmir, India
| | - Abhijit Choudhary
- Department of Pediatrics, All India Institute of Medical Sciences, Nagpur, Maharashtra, India
| | - Bharat Choudhary
- Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Rashmi Ranjan Das
- Department of Pediatrics, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Bhagirathi Dwibedi
- Department of Pediatrics, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Sanajit Ghosh
- Department of Pediatrics, Medical College Kolkata, Kolkata, West Bengal, India
| | - Meenakshi Girish
- Department of Pediatrics, All India Institute of Medical Sciences, Nagpur, Maharashtra, India
| | - Krishna Mohan Gulla
- Department of Pediatrics, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Jagdish Prasad Goyal
- Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Prakriti Gupta
- Department of Pediatrics, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Shivanand I
- Department of Pediatrics, KIMS, Hubbali, Karnataka, India
| | - Atul Jindal
- Department of Pediatrics, All India Institute of Medical Sciences, Raipur, India
| | - Joseph John
- Department of Pediatrics, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Preetha Joshi
- Department of Pediatrics, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, India
| | - Ravleen Kaur
- Department of Pediatrics, Dr Rajendra Prasad Government Medical College Kangra at Tanda, Himachal Pradesh, India
| | - Daisy Khera
- Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Amit Kumar
- Department of Pediatrics, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Pradeep Kumar
- Department of Pediatrics, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Prawin Kumar
- Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - A V Lalitha
- Department of Pediatric Intensive Care, St. John's Medical College and Hospital, Bangalore, Karanataka, India
| | - Mahesh Maheshwari
- Department of Pediatrics, All India Institute of Medical Sciences, Bhopal, India
| | - Shikha Malik
- Department of Pediatrics, All India Institute of Medical Sciences, Bhopal, India
| | - Rakesh Mondal
- Department of Pediatrics, Medical College Kolkata, Kolkata, West Bengal, India
| | - Jayashree Muralidharan
- Department of Pediatrics, Advanced Pediatric Center, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Gayatri Pawar
- Department of Pediatrics, KIMS, Hubbali, Karnataka, India
| | - Arun Prasad
- Department of Pediatrics, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Sunil Kumar Rao
- Department of Pediatrics, Institute of Medical Sciences, BHU, Varanasi, Uttar Pradesh, India
| | | | - Mihir Sarkar
- Department of Pediatrics, Medical College Kolkata, Kolkata, West Bengal, India
| | - Amit Kumar Satpathy
- Department of Pediatrics, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Jhuma Sankar
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Seema Sharma
- Department of Pediatrics, Dr Rajendra Prasad Government Medical College Kangra at Tanda, Himachal Pradesh, India
| | - Ankur Singh
- Department of Pediatrics, Institute of Medical Sciences, BHU, Varanasi, Uttar Pradesh, India
| | - Kuldeep Singh
- Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Tanu Singhal
- Department of Pediatrics, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, India
| | - Mangla Sood
- Department of Pediatrics, IGMC, Shimla, Himachal Pradesh, India
| | | | - Lokesh Tiwari
- Department of Pediatrics, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Nishant Verma
- Department of Pediatrics, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Ruth Yonzon
- Department of Pediatrics, New STNMMS Hospital, Gangtok, Sikkim, India
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83
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Freitas J, Sanpera J, Dessouki T, Rainsley V, Nyirenda M, Canet Tarrés A, Thomas J. Fifteen-minute consultation: An approach to the management of PIMS-TS in a district general hospital. Arch Dis Child Educ Pract Ed 2022; 107:408-414. [PMID: 34697035 DOI: 10.1136/archdischild-2021-321921] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 10/11/2021] [Indexed: 11/04/2022]
Abstract
The COVID-19 pandemic has caused significant disease across the globe but children seem to be much less affected than adults. Coincidentally with the first wave of the pandemic, a cluster of children with fever, hyperinflammation and shock were identified, and this was first described as paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) by the Royal College of Paediatrics and Child Health. Patients with this novel condition were transferred to tertiary centres for management, increasing the pressure in these hospitals that were already extremely busy. There are multiple challenges related to the identification of patients presenting with PIMS-TS given that they mimic multiple other well-known paediatric conditions, like Kawasaki disease and toxic shock syndrome. Investigations and admission criteria to a district general hospital (DGH) need to be well established, and clear guidance should be available for easy decision making in a busy paediatric emergency department. Furthermore, these children can deteriorate suddenly and rapidly; close monitoring is vital, and any deterioration must be taken seriously and addressed immediately. All children who present severely ill, with shock and multiorgan failure, should be retrieved to a paediatric intensive care unit. As our knowledge of the condition has developed, more patients are now managed in a DGH, with virtual multidisciplinary team involvement. This paper outlines a structured approach to management of children presenting with suspected PIMS-TS in a DGH.
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Affiliation(s)
- Joana Freitas
- General Paediatrics, Queen Elizabeth Hospital, London, UK
| | - Julia Sanpera
- General Paediatrics, Queen Elizabeth Hospital, London, UK
| | - Tareq Dessouki
- General Paediatrics, Queen Elizabeth Hospital, London, UK
| | - Victoria Rainsley
- Paediatric Emergency Department, The Royal London Hospital, London, UK
| | - Maggie Nyirenda
- General Paediatrics and Paediatric Infectious Diseases, University Hospital Lewisham, London, UK
| | - Anna Canet Tarrés
- Paediatric Intensive Care Unit, Evelina London Children's Hospital, London, UK
| | - Jessica Thomas
- General Paediatrics, Queen Elizabeth Hospital, London, UK
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Multisystem Inflammatory Syndrome in Children in Western Countries? Decreasing Incidence as the Pandemic Progresses?: An Observational Multicenter International Cross-sectional Study. Pediatr Infect Dis J 2022; 41:989-993. [PMID: 36102705 PMCID: PMC9645445 DOI: 10.1097/inf.0000000000003713] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND SARS-CoV-2 variations as well as immune protection after previous infections and/or vaccination may have altered the incidence of multisystemic inflammatory syndrome in children (MIS-C). We aimed to report an international time-series analysis of the incidence of MIS-C to determine if there was a shift in the regions or countries included into the study. METHODS This is a multicenter, international, cross-sectional study. We collected the MIS-C incidence from the participant regions and countries for the period July 2020 to November 2021. We assessed the ratio between MIS-C cases and COVID-19 pediatric cases in children <18 years diagnosed 4 weeks earlier (average time for the temporal association observed in this disease) for the study period. We performed a binomial regression analysis for 8 participating sites [Bogotá (Colombia), Chile, Costa Rica, Lazio (Italy), Mexico DF, Panama, The Netherlands and Catalonia (Spain)]. RESULTS We included 904 cases of MIS-C, among a reference population of 17,906,432 children. We estimated a global significant decrease trend ratio in MIS-C cases/COVID-19 diagnosed cases in the previous month ( P < 0.001). When analyzing separately each of the sites, Chile and The Netherlands maintained a significant decrease trend ( P < 0.001), but this ratio was not statistically significant for the rest of sites. CONCLUSIONS To our knowledge, this is the first international study describing a global reduction in the trend of the MIS-C incidence during the pandemic. COVID-19 vaccination and other factors possibly linked to the virus itself and/or community transmission may have played a role in preventing new MIS-C cases.
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85
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Management of Multisystem Inflammatory Syndrome in Children: Decision-Making Regarding a New Condition in the Absence of Clinical Trial Data. Can J Cardiol 2022:S0828-282X(22)01048-0. [PMID: 36455760 PMCID: PMC9705008 DOI: 10.1016/j.cjca.2022.11.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/22/2022] [Accepted: 11/24/2022] [Indexed: 11/30/2022] Open
Abstract
Multisystem inflammatory syndrome in children (MIS-C) is a new illness that evolved during the COVID-19 pandemic with initial reports of severe disease including use of extracorporeal membrane oxygenation and death. Institutions rapidly assembled task forces to develop treatment algorithms. At the national/international levels, collaboratives and associations assembled consensus writing groups to draft guidelines. These guidelines and algorithms were initially on the basis of expert opinion and small case series. Some groups used the Delphi approach, and the resultant guidelines often mimicked those for other conditions that resembled MIS-C, like Kawasaki disease (KD). For instance, intravenous immunoglobulin (IVIG), a known effective treatment for KD, was recommended for MIS-C. Early in the pandemic many favoured IVIG over steroids as first-line therapy. As evidence evolved so did some guidelines, which now endorse the dual use of IVIG with steroids as first-line therapy. In contrast, withholding immunotherapy became an option for some MIS-C patients with mild symptoms. Herein, we review guidelines and discuss the evidence informing early recommendations, how this has evolved, the role and limitations of expert opinion and observational data, and the importance of leveraging existing research infrastructures, such as the intensive care unit collaborative (Overcoming COVID-19 surveillance registry), and the International Kawasaki Disease Registry. Finally, we discuss strategies to rapidly develop, deploy, and adapt clinical trials evaluating the treatment of such rare conditions in children, which might include alternatives to conventional clinical trial design. The emergence of MIS-C during the COVID-19 pandemic has highlighted unmet needs regarding research of a new condition.
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86
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Longitudinal Cardiac Outcomes of Multisystem Inflammatory Syndrome in Children: A Systematic Review and Meta-Analysis. Pediatr Cardiol 2022; 44:892-907. [PMID: 36416893 PMCID: PMC9684941 DOI: 10.1007/s00246-022-03052-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 11/14/2022] [Indexed: 11/24/2022]
Abstract
There is a paucity of longitudinal data on cardiac outcomes in multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19. We aimed to investigate the longitudinal cardiovascular outcomes in MIS-C. PubMed and EMBASE were searched through May 2022. Observational studies were included, reporting mid-term (≥ 3 months) outcomes in children (aged < 21) with MIS-C. Data were extracted by two researchers. Longitudinal outcomes were synthesized by a one-group meta-analysis using a random-effects model. Eleven studies with a follow-up period (3 months to 1 year) were identified, including 547 MIS-C patients. The mortality was 2.5% (95% CI 1.3-4.9). The majority of left ventricular (LV) systolic dysfunction present in 46.8% (95% CI 32.7-61.3) in the acute phase resolved by 3 months, and the prevalence of LV systolic dysfunction was 1.7% (95% CI 0.5-5.7) and 2.1% (95% CI 0.8-5.4) at 3 month and 6 month follow-up, respectively. Additionally, the persistent LV systolic dysfunction in the small population was mild. However, coronary abnormalities such as coronary artery dilatation or aneurysms, seen in 23.7% (95% CI 17.7-31.1) at baseline, persisted in 4.7% (95% CI 1.5-14.3) at 3 months and 5.2% (95% CI 3.0-8.9) at 6 months. Mitral regurgitation (MR), which was observed in 56.6% (95% CI 27.7-81.6) at baseline, also persisted in 7.5% at 6 months. In conclusion, our study demonstrated largely favorable cardiac outcomes, suggesting resolution of LV systolic dysfunction in the majority of cases. However, coronary abnormalities and MR persisted in a subset of patients at mid-term follow-up.
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87
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Sinkovits G, Schnur J, Hurler L, Kiszel P, Prohászka ZZ, Sík P, Kajdácsi E, Cervenak L, Maráczi V, Dávid M, Zsigmond B, Rimanóczy É, Bereczki C, Willems L, Toonen EJM, Prohászka Z. Evidence, detailed characterization and clinical context of complement activation in acute multisystem inflammatory syndrome in children. Sci Rep 2022; 12:19759. [PMID: 36396679 PMCID: PMC9670087 DOI: 10.1038/s41598-022-23806-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 11/06/2022] [Indexed: 11/18/2022] Open
Abstract
Multisystem inflammatory syndrome in children (MIS-C) is a rare, life-threatening complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. MIS-C develops with high fever, marked inflammation and shock-like picture several weeks after exposure to, or mild infection with SARS-CoV-2. Deep immune profiling identified activated macrophages, neutrophils, B-plasmablasts and CD8 + T cells as key determinants of pathogenesis together with multiple inflammatory markers. The disease rapidly responds to intravenous immunoglobulin (IVIG) treatment with clear changes of immune features. Here we present the results of a comprehensive analysis of the complement system in the context of MIS-C activity and describe characteristic changes during IVIG treatment. We show that activation markers of the classical, alternative and terminal pathways are highly elevated, that the activation is largely independent of anti-SARS-CoV-2 humoral immune response, but is strongly associated with markers of macrophage activation. Decrease of complement activation is closely associated with rapid improvement of MIS-C after IVIG treatment.
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Affiliation(s)
- György Sinkovits
- grid.11804.3c0000 0001 0942 9821Department of Internal Medicine and Hematology, Semmelweis University, Budapest, 1085 Hungary
| | - János Schnur
- grid.413987.00000 0004 0573 5145Heim Pál National Pediatric Institute, Budapest, 1089 Hungary
| | - Lisa Hurler
- grid.11804.3c0000 0001 0942 9821Department of Internal Medicine and Hematology, Semmelweis University, Budapest, 1085 Hungary
| | - Petra Kiszel
- grid.11804.3c0000 0001 0942 9821Research Group for Immunology and Hematology, Semmelweis University-Eötvös Loránd Research Network (Office for Supported Research Groups), Budapest, 1085 Hungary
| | - Zita Z. Prohászka
- grid.11804.3c0000 0001 0942 9821Department of Internal Medicine and Hematology, Semmelweis University, Budapest, 1085 Hungary
| | - Pál Sík
- grid.11804.3c0000 0001 0942 9821Department of Internal Medicine and Hematology, Semmelweis University, Budapest, 1085 Hungary
| | - Erika Kajdácsi
- grid.11804.3c0000 0001 0942 9821Department of Internal Medicine and Hematology, Semmelweis University, Budapest, 1085 Hungary
| | - László Cervenak
- grid.11804.3c0000 0001 0942 9821Department of Internal Medicine and Hematology, Semmelweis University, Budapest, 1085 Hungary
| | - Veronika Maráczi
- grid.413987.00000 0004 0573 5145Heim Pál National Pediatric Institute, Budapest, 1089 Hungary
| | - Máté Dávid
- grid.413987.00000 0004 0573 5145Heim Pál National Pediatric Institute, Budapest, 1089 Hungary
| | - Borbála Zsigmond
- grid.413987.00000 0004 0573 5145Heim Pál National Pediatric Institute, Budapest, 1089 Hungary
| | - Éva Rimanóczy
- grid.413987.00000 0004 0573 5145Heim Pál National Pediatric Institute, Budapest, 1089 Hungary
| | - Csaba Bereczki
- grid.9008.10000 0001 1016 9625Department of Pediatrics, University of Szeged, Szeged, 6720 Hungary
| | - Loek Willems
- grid.435189.2R&D Department, Hycult Biotech, 5405 PB Uden, The Netherlands
| | - Erik J. M. Toonen
- grid.435189.2R&D Department, Hycult Biotech, 5405 PB Uden, The Netherlands
| | - Zoltán Prohászka
- grid.11804.3c0000 0001 0942 9821Department of Internal Medicine and Hematology, Semmelweis University, Budapest, 1085 Hungary ,grid.11804.3c0000 0001 0942 9821Research Group for Immunology and Hematology, Semmelweis University-Eötvös Loránd Research Network (Office for Supported Research Groups), Budapest, 1085 Hungary
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88
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Abstract
OBJECTIVES To characterize the prevalence of pediatric critical illness from multisystem inflammatory syndrome in children (MIS-C) and to assess the influence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) strain on outcomes. DESIGN Retrospective cohort study. SETTING Database evaluation using the Virtual Pediatric Systems Database. PATIENTS All children with MIS-C admitted to the PICU in 115 contributing hospitals between January 1, 2020, and June 30, 2021. MEASUREMENTS AND MAIN RESULTS Of the 145,580 children admitted to the PICU during the study period, 1,338 children (0.9%) were admitted with MIS-C with the largest numbers of children admitted in quarter 1 (Q1) of 2021 ( n = 626). The original SARS-CoV-2 viral strain and the D614G Strain were the predominant strains through 2020, with Alpha B.1.1.7 predominating in Q1 and quarter 2 (Q2) of 2021. Overall, the median PICU length of stay (LOS) was 2.7 days (25-75% interquartile range [IQR], 1.6-4.7 d) with a median hospital LOS of 6.6 days (25-75% IQR, 4.7-9.3 d); 15.2% received mechanical ventilation with a median duration of mechanical ventilation of 3.1 days (25-75% IQR, 1.9-5.8 d), and there were 11 hospital deaths. During the study period, there was a significant decrease in the median PICU and hospital LOS and a decrease in the frequency of mechanical ventilation, with the most significant decrease occurring between quarter 3 and quarter 4 (Q4) of 2020. Children admitted to a PICU from the general care floor or from another ICU/step-down unit had longer PICU LOS than those admitted directly from an emergency department. CONCLUSIONS Overall mortality from MIS-C was low, but the disease burden was high. There was a peak in MIS-C cases during Q1 of 2021, following a shift in viral strains in Q1 of 2021. However, an improvement in MIS-C outcomes starting in Q4 of 2020 suggests that viral strain was not the driving factor for outcomes in this population.
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Cardiovascular injury and clinical features of multisystem inflammatory syndrome in children (MIS-C) related to Covid-19 in Vietnam. Pediatr Neonatol 2022; 63:569-574. [PMID: 35871994 PMCID: PMC9262642 DOI: 10.1016/j.pedneo.2022.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/04/2022] [Accepted: 05/10/2022] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND This study aimed to describe the cardiovascular injury and clinical features of multisystem inflammatory syndrome in children (MIS-C) related to coronavirus disease 2019 (COVID-19) in Ho Chi Minh City, Vietnam. METHODS This was a retrospective cohort study of children with MIS-C (from September 1, 2021 to February 28, 2022) in Children's Hospital 1, Ho Chi Minh City. Demographics, clinical history, significant underlying conditions, clinical manifestations, laboratory investigations, and medical management were analyzed. RESULTS A total of 76 patients were included (median age, 5.9 years old, 2 months-16 years). The male/female ratio was 1.6/1. Most patients (75/76) had no previous medical conditions. The mean time from acute severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection to symptom onset was 39 days. During an acute SARS-CoV-2 infection, these patients are either asymptomatic or mildly symptomatic. In addition to fever, gastrointestinal symptoms were also prominent, as observed in our study, with 75%, 73.7%, and 72.3% of patients presenting with abdominal pain, vomiting, and loose stools, respectively. The levels of inflammatory markers increased upon admission and returned to normal levels after treatment. Echocardiography revealed decreased myocardial contractility and coronary injury in 16 (21.1%) and 32 (42.1%) patients, respectively. Most cases (72/76) had no fever within 3 days of intravenous immunoglobulin (IVIG) and methylprednisolone treatment. No deaths occurred in this study. The mean duration of hospitalization was 7.2 days. CONCLUSION Cardiovascular involvement was observed in approximately 53.9% of the patients. Anti-inflammatory treatment with IVIG and methylprednisolone had a favorable short-term outcome. However, long-term follow-up studies on post-discharge MIS-C cases are needed to make appropriate treatment recommendations in the acute phase.
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90
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Son MBF, Berbert L, Young C, Dallas J, Newhams M, Chen S, Ardoin SP, Basiaga ML, Canny SP, Crandall H, Dhakal S, Dhanrajani A, Sagcal-Gironella ACP, Hobbs CV, Huie L, James K, Jones M, Kim S, Lionetti G, Mannion ML, Muscal E, Prahalad S, Schulert GS, Tejtel KS, Villacis-Nunez DS, Wu EY, Zambrano LD, Campbell AP, Patel MM, Randolph AG. Postdischarge Glucocorticoid Use and Clinical Outcomes of Multisystem Inflammatory Syndrome in Children. JAMA Netw Open 2022; 5:e2241622. [PMID: 36367723 PMCID: PMC9652757 DOI: 10.1001/jamanetworkopen.2022.41622] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
IMPORTANCE Minimal data are available regarding the postdischarge treatment of multisystem inflammatory syndrome in children (MIS-C). OBJECTIVES To evaluate clinical characteristics associated with duration of postdischarge glucocorticoid use and assess postdischarge clinical course, laboratory test result trajectories, and adverse events in a multicenter cohort with MIS-C. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included patients with MIS-C hospitalized with severe illness and followed up for 3 months in an ambulatory setting. Patients younger than 21 years who were admitted between May 15, 2020, and May 31, 2021, at 13 US hospitals were included. Inclusion criteria were inpatient treatment comprising intravenous immunoglobulin, diagnosis of cardiovascular dysfunction (vasopressor requirement or left ventricular ejection fraction ≤55%), and availability of complete outpatient data for 3 months. EXPOSURES Glucocorticoid treatment. MAIN OUTCOMES AND MEASURES Main outcomes were patient characteristics associated with postdischarge glucocorticoid treatment, laboratory test result trajectories, and adverse events. Multivariable regression was used to evaluate factors associated with postdischarge weight gain (≥2 kg in 3 months) and hyperglycemia during illness. RESULTS Among 186 patients, the median age was 10.4 years (IQR, 6.7-14.2 years); most were male (107 [57.5%]), Black non-Hispanic (60 [32.3%]), and Hispanic or Latino (59 [31.7%]). Most children were critically ill (intensive care unit admission, 163 [87.6%]; vasopressor receipt, 134 [72.0%]) and received inpatient glucocorticoid treatment (178 [95.7%]). Most were discharged with continued glucocorticoid treatment (173 [93.0%]); median discharge dose was 42 mg/d (IQR, 30-60 mg/d) or 1.1 mg/kg/d (IQR, 0.7-1.7 mg/kg/d). Inpatient severity of illness was not associated with duration of postdischarge glucocorticoid treatment. Outpatient treatment duration varied (median, 23 days; IQR, 15-32 days). Time to normalization of C-reactive protein and ferritin levels was similar for glucocorticoid duration of less than 3 weeks vs 3 or more weeks. Readmission occurred in 7 patients (3.8%); none was for cardiovascular dysfunction. Hyperglycemia developed in 14 patients (8.1%). Seventy-five patients (43%) gained 2 kg or more after discharge (median 4.1 kg; IQR, 3.0-6.0 kg). Inpatient high-dose intravenous and oral glucocorticoid therapy was associated with postdischarge weight gain (adjusted odds ratio, 6.91; 95% CI, 1.92-24.91). CONCLUSIONS AND RELEVANCE In this multicenter cohort of patients with MIS-C and cardiovascular dysfunction, postdischarge glucocorticoid treatment was often prolonged, but clinical outcomes were similar in patients prescribed shorter courses. Outpatient weight gain was common. Readmission was infrequent, with none for cardiovascular dysfunction. These findings suggest that strategies are needed to optimize postdischarge glucocorticoid courses for patients with MIS-C.
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Affiliation(s)
- Mary Beth F. Son
- Division of Immunology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Laura Berbert
- Institute Centers for Clinical and Translational Research, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Cameron Young
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Johnathan Dallas
- Division of Immunology, Boston Children’s Hospital, Boston, Massachusetts
- Western Atlantic University School of Medicine, Freeport, Grand Bahama, Bahamas
| | - Margaret Newhams
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Sabrina Chen
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Stacy P. Ardoin
- Rheumatology, Nationwide Children’s Hospital, Department of Pediatrics, Ohio State College of Medicine, Columbus
| | - Matthew L. Basiaga
- Division of Pediatric Rheumatology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Susan P. Canny
- Division of Pediatric Rheumatology, Seattle Children’s Hospital, Department of Pediatrics, University of Washington, Seattle
| | - Hillary Crandall
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Primary Children’s Hospital, Salt Lake City
| | - Sanjeev Dhakal
- Division of Rheumatology, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Anita Dhanrajani
- Pediatric Rheumatology, Department of Pediatrics, University of Mississippi Medical Center, Jackson
| | - Anna Carmela P. Sagcal-Gironella
- Department of Pediatrics, Hackensack Meridian School of Medicine, Hackensack, New Jersey
- Division of Rheumatology, Joseph M. Sanzari Children’s Hospital, Hackensack, New Jersey
| | - Charlotte V. Hobbs
- Division of Pediatric Infectious Disease, Department of Pediatrics, University of Mississippi Medical Center, Jackson
| | - Livie Huie
- Division of Pediatric Rheumatology, University of Alabama at Birmingham
| | - Karen James
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Utah, Primary Children’s Hospital, Salt Lake City
| | - Madelyn Jones
- Rheumatology, Nationwide Children’s Hospital, Department of Pediatrics, Ohio State College of Medicine, Columbus
| | - Susan Kim
- Pediatric Rheumatology, UCSF Benioff Children’s Hospital, Department of Pediatrics, University of California at San Francisco School of Medicine
| | - Geraldina Lionetti
- Pediatric Rheumatology, UCSF Benioff Children’s Hospital, Department of Pediatrics, University of California at San Francisco School of Medicine
| | | | - Eyal Muscal
- Division of Rheumatology, Texas Children’s Hospital, Department of Pediatrics, Baylor School of Medicine, Houston
| | - Sampath Prahalad
- Children’s Healthcare of Atlanta, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Grant S. Schulert
- Division of Rheumatology, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Kristen Sexson Tejtel
- Division of Cardiology, Texas Children’s Hospital, Department of Pediatrics, Baylor School of Medicine, Houston
| | - D. Sofia Villacis-Nunez
- Children’s Healthcare of Atlanta, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Eveline Y. Wu
- Division of Pediatric Rheumatology, UNC Children’s Hospital, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill
| | - Laura D. Zambrano
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Angela P. Campbell
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Manish M. Patel
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
- Public Health Service Commissioned Corps, Rockville, Maryland
| | - Adrienne G. Randolph
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Departments of Pediatrics and Anesthesiology, Harvard Medical School, Boston, Massachusetts
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91
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Abstract
UNLABELLED Multisystem Inflammatory Syndrome in Children is a rare form of COVID-19 that affects various organ systems and carries the risk of morbidity and mortality. Cardiac involvement is commonly observed in Multisystem Inflammatory Syndrome in Children cases; hence, this study was conducted to evaluate the cardiac findings of the Multisystem Inflammatory Syndrome in Children cases that were diagnosed and followed up in our hospital. MATERIALS AND METHODS The medical histories, laboratory results, cardiac findings, and treatments of the cases that were diagnosed with Multisystem Inflammatory Syndrome in Children between December 2020 and August 2021 were evaluated retrospectively. RESULTS Our study group consisted of 14 males and 12 females whose median age was 3.67 years. Of the 26 patients, 24 had echocardiographic findings and 12 cases had cardiac pathologies that were mostly mild. Among these, mitral valve insufficiency, coronary artery pathology, and pericardial effusion were the most common. Perivascular brightness, aortic and tricuspid insufficiency, systolic dysfunction, and tricuspid thrombosis were less common. The cardiac pathologies of all patients resolved in less than a month following treatment. CONCLUSION Although the cardiac pathologies of Multisystem Inflammatory Syndrome in Children cases disappear fairly rapidly, the long-term cardiac effects of this disease are not known clearly. To improve our current understanding of Multisystem Inflammatory Syndrome in Children, more multi-centred studies with long-term follow-up periods should be conducted, and treatment protocols for cases of different severities should be developed to maximise the treatments' efficacy.
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92
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Estrada-Luna D, Carreón-Torres E, González-Reyes S, Martínez-Salazar MF, Ortiz-Rodríguez MA, Ramírez-Moreno E, Arias-Rico J, Jiménez-Osorio AS. Nutraceuticals for Complementary Treatment of Multisystem Inflammatory Syndrome in Children: A Perspective from Their Use in COVID-19. Life (Basel) 2022; 12:life12101652. [PMID: 36295088 PMCID: PMC9605437 DOI: 10.3390/life12101652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 11/24/2022] Open
Abstract
Multisystem inflammatory syndrome in children (MIS-C) has been widely reported in some children diagnosed with SARS-CoV-2. Clinical signs of MIS-C are manifested at 2 to 4 weeks after SARS-CoV-2 infection, where elevated biomarkers of inflammation and cardiac dysfunction are the hallmark of this syndrome when infection or exposure to SARS-CoV-2 has been confirmed. However, after two years of acknowledgment, MIS-C treatment is still under research to reach safety and effectiveness in the acute phase in children. Therefore, in this review, we discuss the potential use of natural compounds with antioxidant and anti-inflammatory effects to reduce collateral damage caused by hyperinflammation in MIS-C pathology for new research in treatment and interventions.
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Affiliation(s)
- Diego Estrada-Luna
- Área Académica de Enfermería, Instituto de Ciencias de la Salud, Universidad Autónoma del Estado Hidalgo, Circuito Ex Hacienda La Concepción S/N, Carretera Pachuca-Actopan, San Agustín Tlaxiaca 42160, Mexico
| | - Elizabeth Carreón-Torres
- Department of Molecular Biology, Instituto Nacional de Cardiología Ignacio Chávez, Juan Badiano 1, Sección XVI, Tlalpan, Mexico City 14080, Mexico
| | - Susana González-Reyes
- Facultad de Medicina y Psicología, Universidad Autónoma de Baja California, Tijuana 22390, Mexico
| | - María Fernanda Martínez-Salazar
- Facultad de Ciencias del Deporte, Universidad Autónoma del Estado de Morelos, Av. Universidad No. 1001 Col. Chamilpa, Cuernavaca 62209, Mexico
| | - María Araceli Ortiz-Rodríguez
- Facultad de Nutrición, Universidad Autónoma del Estado de Morelos, Iztaccíhuatl 100 Col. Los Volcanes, Cuernavaca 62350, Mexico
| | - Esther Ramírez-Moreno
- Área Académica de Nutrición, Instituto de Ciencias de la Salud, Universidad Autónoma del Estado Hidalgo, Circuito Ex Hacienda La Concepción S/N, Carretera Pachuca-Actopan, San Agustín Tlaxiaca 42160, Mexico
| | - José Arias-Rico
- Área Académica de Enfermería, Instituto de Ciencias de la Salud, Universidad Autónoma del Estado Hidalgo, Circuito Ex Hacienda La Concepción S/N, Carretera Pachuca-Actopan, San Agustín Tlaxiaca 42160, Mexico
| | - Angélica Saraí Jiménez-Osorio
- Área Académica de Enfermería, Instituto de Ciencias de la Salud, Universidad Autónoma del Estado Hidalgo, Circuito Ex Hacienda La Concepción S/N, Carretera Pachuca-Actopan, San Agustín Tlaxiaca 42160, Mexico
- Correspondence: ; Tel.: +52-771-717-2000 (ext. 4323)
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93
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Rodriguez-Gonzalez M, Castellano-Martinez A. Age-adjusted NT-proBNP could help in the early identification and follow-up of children at risk for severe multisystem inflammatory syndrome associated with COVID-19 (MIS-C). World J Clin Cases 2022; 10:10435-10450. [PMID: 36312492 PMCID: PMC9602208 DOI: 10.12998/wjcc.v10.i29.10435] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 06/17/2022] [Accepted: 08/31/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Multisystem inflammatory syndrome in children (MIS-C) has emerged as a new disease associated with COVID-19 that presents in acute critically ill children with acute cardiovascular dysfunction.
AIM To determine whether the age-adjusted N-terminal pro-brain natriuretic peptide (NT-proBNP) value (Z-log-NT-proBNP) is associated with severe MIS-C and myocardial dysfunction.
METHODS A retrospective study was conducted which included children with MIS-C managed at our institution between April 1, 2020, and February 28, 2022. We divided the population into groups depending on severity based on pediatric intensive care unit (PICU) admission. We compared Z-log-NT-proBNP values across these groups and analyzed Z-log-NT-proBNP dynamics during the one-month follow-up.
RESULTS We included 17 participants [median age 3 (2-9) years] and seven (41%) required PICU admission. All (100%) of these cases presented very high (Z-log > 4) levels of NT-proBNP at the time of admission compared to only 5 (50%) patients with non-severe MIS-C (P = 0.025). NT-proBNP was significantly correlated with high-sensitive Troponin I levels (P = 0.045), Ross modified score (P = 0.003) and left ventricle ejection fraction (P = 0.021).
CONCLUSION Raised NT-proBNP, specifically very high values (Z-log-NT-proBNP > 4) could help in the early identification of MIS-C patients with myocardial dysfunction requiring inotropic support and PICU admission.
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94
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Remuzzi G, Schiaffino S, Santoro MG, FitzGerald GA, Melino G, Patrono C. Drugs for the prevention and treatment of COVID-19 and its complications: An update on what we learned in the past 2 years. Front Pharmacol 2022; 13:987816. [PMID: 36304162 PMCID: PMC9595217 DOI: 10.3389/fphar.2022.987816] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 09/12/2022] [Indexed: 12/15/2022] Open
Abstract
The COVID-19 Committee of the Lincei Academy has reviewed the scientific evidence supporting the efficacy and safety of existing and new drugs/biologics for the preventing and treating of COVID-19 and its complications. This position paper reports what we have learned in the field in the past 2 years. The focus was on, but not limited to, drugs and neutralizing monoclonal antibodies, anti-SARS-CoV-2 agents, anti-inflammatory and immunomodulatory drugs, complement inhibitors and anticoagulant agents. We also discuss the risks/benefit of using cell therapies on COVID-19 patients. The report summarizes the available evidence, which supports recommendations from health authorities and panels of experts regarding some drugs and biologics, and highlights drugs that are not recommended, or drugs for which there is insufficient evidence to recommend for or against their use. We also address the issue of the safety of drugs used to treat underlying concomitant conditions in COVID-19 patients. The investigators did an enormous amount of work very quickly to understand better the nature and pathophysiology of COVID-19. This expedited the development and repurposing of safe and effective therapeutic interventions, saving an impressive number of lives in the community as well as in hospitals.
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Affiliation(s)
- Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
- *Correspondence: Giuseppe Remuzzi,
| | | | - Maria Gabriella Santoro
- Department of Biology, University of Rome Tor Vergata, Rome, Italy
- Institute of Translational Pharmacology, CNR, Rome, Italy
| | - Garret A. FitzGerald
- Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Philadelphia, Philadelphia, PA, United States
| | - Gennaro Melino
- Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Carlo Patrono
- Department of Pharmacology, Catholic University of the Sacred Heart, Rome, Italy
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95
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Gelzo M, Castaldo A, Giannattasio A, Scalia G, Raia M, Esposito MV, Maglione M, Muzzica S, D’Anna C, Grieco M, Tipo V, La Cava A, Castaldo G. MIS-C: A COVID-19-as sociated condition between hypoimmunity and hyperimmunity. Front Immunol 2022; 13:985433. [PMID: 36263058 PMCID: PMC9574022 DOI: 10.3389/fimmu.2022.985433] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 09/15/2022] [Indexed: 11/13/2022] Open
Abstract
Multisystem inflammatory syndrome in children (MIS-C) is a rare, severe complication of COVID-19. A better knowledge of immunological, cellular, and genetic characteristics of MIS-C could help better understand the pathogenesis of the disease and contribute to identifying specific diagnostic biomarkers and develop targeted therapies. We studied 37 MIS-C children at hospital admission and 24 healthy controls analyzing serum cytokines (IFN-α, IFN-β, IFN-γ, IL-6, IL-10, IL-17A, IL-12p70 and TNF), lymphocyte populations by flow cytometry and 386 genes related to autoimmune diseases, autoinflammation and primary immunodeficiencies by NGS. MIS-C patients showed a significant increase of serum IFNγ (despite a significant reduction of activated Th1) and ILs, even if with a great heterogeneity among patients, revealing different pathways involved in MIS-C pathogenesis and suggesting that serum cytokines at admission may help to select the inflammatory pathways to target in each patient. Flow cytometry demonstrated a relevant reduction of T populations while the percentage of B cell was increased in agreement with an autoimmune pathogenesis of MIS-C. Genetic analysis identified variants in 34 genes and 83.3% of patients had at least one gene variant. Among these, 9 were mutated in more patients. Most genes are related to autoimmune diseases like ATM, NCF1, MCM4, FCN3, and DOCK8 or to autoinflammatory diseases associated to the release of IFNγ like PRF1, NOD2, and MEF. Thus, an incomplete clearance of the Sars-CoV2 during the acute phase may induce tissue damage and self-antigen exposure and genetic variants can predispose to hyper-reactive immune dysregulation events of MIS-C-syndrome. Type II IFN activation and cytokine responses (mainly IL-6 and IL-10) may cause a cytokine storm in some patients with a more severe acute phase of the disease, lymphopenia and multisystemic organ involvement. The timely identification of such patients with an immunocytometric panel might be critical for targeted therapeutic management.
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Affiliation(s)
- Monica Gelzo
- CEINGE-Biotecnologie Avanzate, Scarl, Naples, Italy
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università di Napoli Federico II, Naples, Italy
| | - Alice Castaldo
- Dipartimento di Scienze Mediche Traslazionali, Sezione di Pediatria, Università di Napoli Federico II, Naples, Italy
| | - Antonietta Giannattasio
- Pediatric Emergency and Short Stay Unit, Santobono-Pausilipon Children’s Hospital, Naples, Italy
| | | | | | | | - Marco Maglione
- Pediatric Emergency and Short Stay Unit, Santobono-Pausilipon Children’s Hospital, Naples, Italy
| | - Stefania Muzzica
- Pediatric Emergency and Short Stay Unit, Santobono-Pausilipon Children’s Hospital, Naples, Italy
| | - Carolina D’Anna
- Pediatric Emergency and Short Stay Unit, Santobono-Pausilipon Children’s Hospital, Naples, Italy
| | - Michela Grieco
- Pediatric Emergency and Short Stay Unit, Santobono-Pausilipon Children’s Hospital, Naples, Italy
| | - Vincenzo Tipo
- Pediatric Emergency and Short Stay Unit, Santobono-Pausilipon Children’s Hospital, Naples, Italy
| | - Antonio La Cava
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università di Napoli Federico II, Naples, Italy
- Department of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Giuseppe Castaldo
- CEINGE-Biotecnologie Avanzate, Scarl, Naples, Italy
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università di Napoli Federico II, Naples, Italy
- *Correspondence: Giuseppe Castaldo,
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96
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Lam JY, Shimizu C, Tremoulet AH, Bainto E, Roberts SC, Sivilay N, Gardiner MA, Kanegaye JT, Hogan AH, Salazar JC, Mohandas S, Szmuszkovicz JR, Mahanta S, Dionne A, Newburger JW, Ansusinha E, DeBiasi RL, Hao S, Ling XB, Cohen HJ, Nemati S, Burns JC. A machine-learning algorithm for diagnosis of multisystem inflammatory syndrome in children and Kawasaki disease in the USA: a retrospective model development and validation study. Lancet Digit Health 2022; 4:e717-e726. [PMID: 36150781 PMCID: PMC9507344 DOI: 10.1016/s2589-7500(22)00149-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 06/27/2022] [Accepted: 07/13/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Multisystem inflammatory syndrome in children (MIS-C) is a novel disease that was identified during the COVID-19 pandemic and is characterised by systemic inflammation following SARS-CoV-2 infection. Early detection of MIS-C is a challenge given its clinical similarities to Kawasaki disease and other acute febrile childhood illnesses. We aimed to develop and validate an artificial intelligence algorithm that can distinguish among MIS-C, Kawasaki disease, and other similar febrile illnesses and aid in the diagnosis of patients in the emergency department and acute care setting. METHODS In this retrospective model development and validation study, we developed a deep-learning algorithm called KIDMATCH (Kawasaki Disease vs Multisystem Inflammatory Syndrome in Children) using patient age, the five classic clinical Kawasaki disease signs, and 17 laboratory measurements. All features were prospectively collected at the time of initial evaluation from patients diagnosed with Kawasaki disease or other febrile illness between Jan 1, 2009, and Dec 31, 2019, at Rady Children's Hospital in San Diego (CA, USA). For patients with MIS-C, the same data were collected from patients between May 7, 2020, and July 20, 2021, at Rady Children's Hospital, Connecticut Children's Medical Center in Hartford (CT, USA), and Children's Hospital Los Angeles (CA, USA). We trained a two-stage model consisting of feedforward neural networks to distinguish between patients with MIS-C and those without and then those with Kawasaki disease and other febrile illnesses. After internally validating the algorithm using stratified tenfold cross-validation, we incorporated a conformal prediction framework to tag patients with erroneous data or distribution shifts. We finally externally validated KIDMATCH on patients with MIS-C enrolled between April 22, 2020, and July 21, 2021, from Boston Children's Hospital (MA, USA), Children's National Hospital (Washington, DC, USA), and the CHARMS Study Group consortium of 14 US hospitals. FINDINGS 1517 patients diagnosed at Rady Children's Hospital between Jan 1, 2009, and June 7, 2021, with MIS-C (n=69), Kawasaki disease (n=775), or other febrile illnesses (n=673) were identified for internal validation, with an additional 16 patients with MIS-C included from Connecticut Children's Medical Center and 50 from Children's Hospital Los Angeles between May 7, 2020, and July 20, 2021. KIDMATCH achieved a median area under the receiver operating characteristic curve during internal validation of 98·8% (IQR 98·0-99·3) in the first stage and 96·0% (95·6-97·2) in the second stage. We externally validated KIDMATCH on 175 patients with MIS-C from Boston Children's Hospital (n=50), Children's National Hospital (n=42), and the CHARMS Study Group consortium of 14 US hospitals (n=83). External validation of KIDMATCH on patients with MIS-C correctly classified 76 of 81 patients (94% accuracy, two rejected by conformal prediction) from 14 hospitals in the CHARMS Study Group consortium, 47 of 49 patients (96% accuracy, one rejected by conformal prediction) from Boston Children's Hospital, and 36 of 40 patients (90% accuracy, two rejected by conformal prediction) from Children's National Hospital. INTERPRETATION KIDMATCH has the potential to aid front-line clinicians to distinguish between MIS-C, Kawasaki disease, and other similar febrile illnesses to allow prompt treatment and prevent severe complications. FUNDING US Eunice Kennedy Shriver National Institute of Child Health and Human Development, US National Heart, Lung, and Blood Institute, US Patient-Centered Outcomes Research Institute, US National Library of Medicine, the McCance Foundation, and the Gordon and Marilyn Macklin Foundation.
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Affiliation(s)
- Jonathan Y Lam
- Department of Biomedical Informatics, University of California San Diego, La Jolla, CA, USA.
| | - Chisato Shimizu
- Department of Pediatrics, Rady Children's Hospital and University of California San Diego, San Diego, CA, USA
| | - Adriana H Tremoulet
- Department of Pediatrics, Rady Children's Hospital and University of California San Diego, San Diego, CA, USA
| | - Emelia Bainto
- Department of Pediatrics, Rady Children's Hospital and University of California San Diego, San Diego, CA, USA
| | - Samantha C Roberts
- Department of Pediatrics, Rady Children's Hospital and University of California San Diego, San Diego, CA, USA
| | - Nipha Sivilay
- Department of Pediatrics, Rady Children's Hospital and University of California San Diego, San Diego, CA, USA
| | - Michael A Gardiner
- Department of Pediatrics, Rady Children's Hospital and University of California San Diego, San Diego, CA, USA
| | - John T Kanegaye
- Department of Pediatrics, Rady Children's Hospital and University of California San Diego, San Diego, CA, USA
| | - Alexander H Hogan
- Department of Pediatrics, Connecticut Children's Medical Center, Hartford, CT, USA; Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Juan C Salazar
- Department of Pediatrics, Connecticut Children's Medical Center, Hartford, CT, USA; Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Sindhu Mohandas
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | | | - Simran Mahanta
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Audrey Dionne
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Emily Ansusinha
- Division of Pediatric Infectious Diseases, Children's National Hospital, Washington, DC, USA
| | - Roberta L DeBiasi
- Division of Pediatric Infectious Diseases, Children's National Hospital, Washington, DC, USA
| | - Shiying Hao
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Xuefeng B Ling
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Harvey J Cohen
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Shamim Nemati
- Department of Biomedical Informatics, University of California San Diego, La Jolla, CA, USA
| | - Jane C Burns
- Department of Pediatrics, Rady Children's Hospital and University of California San Diego, San Diego, CA, USA
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Munblit D, Greenhawt M, Brough HA, Pushkareva A, Karimova D, Demidova A, Warner JO, Kalayci O, Sediva A, Untersmayr E, Rodriguez Del Rio P, Vazquez-Ortiz M, Arasi S, Alvaro-Lozano M, Tsabouri S, Galli E, Beken B, Eigenmann PA. Allergic diseases and immunodeficiencies in children, lessons learnt from COVID-19 pandemic by 2022: A statement from the EAACI-section on pediatrics. Pediatr Allergy Immunol 2022; 33:e13851. [PMID: 36282136 PMCID: PMC9538373 DOI: 10.1111/pai.13851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/23/2022] [Accepted: 08/31/2022] [Indexed: 11/28/2022]
Abstract
By the April 12, 2022, the COVID-19 pandemic had resulted in over half a billion people being infected worldwide. There have been 6.1 million deaths directly due to the infection, but the pandemic has had many more short- and long-term pervasive effects on the physical and mental health of the population. Allergic diseases are among the most prevalent noncommunicable chronic diseases in the pediatric population, and health-care professionals and researchers were seeking answers since the beginning of pandemic. Children are at lower risk of developing severe COVID-19 or dying from infection. Allergic diseases are not associated with a higher COVID-19 severity and mortality, apart from severe/poorly controlled asthma. The pandemic disrupted routine health care, but many mitigation strategies, including but not limited to telemedicine, were successfully implemented to continue delivery of high-standard care. Although children faced a multitude of pandemic-related issues, allergic conditions were effectively treated remotely while reduction in air pollution and lack of contact with outdoor allergens resulted in improvement, particularly respiratory allergies. There is no evidence to recommend substantial changes to usual management modalities of allergic conditions in children, including allergen immunotherapy and use of biologicals. Allergic children are not at greater risk of multisystem inflammatory syndrome development, but some associations with Long COVID were reported, although the data are limited, and further research is needed. This statement of the EAACI Section on Pediatrics provides recommendations based on the lessons learnt from the pandemic, as available evidence.
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Affiliation(s)
- Daniel Munblit
- Inflammation, Repair and Development Section, Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, UK
| | - Matthew Greenhawt
- Section of Allergy and Clinical Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Helen A Brough
- Children's Allergy Service, Evelina Children's Hospital, Guy's and St. Thomas' Hospital, London, UK.,Paediatric Allergy Group, Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Anna Pushkareva
- European Academy of Allergy and Clinical Immunology (EAACI), Zurich, Switzerland
| | - Diana Karimova
- European Academy of Allergy and Clinical Immunology (EAACI), Zurich, Switzerland
| | - Anastasia Demidova
- European Academy of Allergy and Clinical Immunology (EAACI), Zurich, Switzerland
| | - John O Warner
- Inflammation, Repair and Development Section, Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, UK
| | - Omer Kalayci
- Pediatric Allergy and Asthma, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Anna Sediva
- Department of Immunology, 2nd Medical Faculty, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Eva Untersmayr
- Institute of Pathophysiology and Allergy Research, Center of Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | | | - Marta Vazquez-Ortiz
- Inflammation, Repair and Development Section, Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, UK
| | - Stefania Arasi
- Translational Research in Pediatric Specialities Area, Division of Allergy, IRCCS, Bambino Gesù Children's Hospital, Rome, Italy
| | - Montserrat Alvaro-Lozano
- Allergology and Clinical Immunology Department, Institut de Recerca Sant Joan de Déu, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - Sophia Tsabouri
- Child Health Department, University of Ioannina School of Medicine, Ioannina, Greece
| | - Elena Galli
- Pediatric Allergology Unit, Department of Pediatric Medicine, S.Pietro Hospital Fatebenefratelli, Rome, Italy
| | - Burcin Beken
- Department of Pediatric Allergy and Immunology, Acibadem University School of Medicine, Istanbul, Turkey
| | - Philippe A Eigenmann
- Pediatric Allergy Unit, Department of Woman, Child and Adolescent, University Hospitals of Geneva, Geneva, Switzerland
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98
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Sugunan S, Bindusha S, Niyas HR, Geetha S, Chinchilu RV. Factors Associated with Pulse Methylprednisolone Treatment Failure in COVID-19-Related Multisystem Inflammatory Syndrome in Children (MIS-C). J PEDIAT INF DIS-GER 2022. [DOI: 10.1055/s-0042-1755210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Abstract
Objective This article determines the occurrence and variables associated with pulse methylprednisolone treatment failure in children with coronavirus disease 2019 (COVID-19)-related multisystem inflammatory syndrome in children (MIS-C).
Methods This prospective observational study was undertaken at a tertiary care teaching hospital in Kerala, India. Children admitted with COVID-19-related MIS-C who were treated with pulse methylprednisolone as first-line therapy were included in the study. Depending on the response to the treatment, they were divided into two groups. The clinical, laboratory parameters, and follow-up findings at 3 months were compared between the two groups
Results Seventy-six patients were admitted with MIS-C during the study period. Sixty received pulse methylprednisolone as the first-line therapy. Of the 60 patients who received pulse methylprednisolone, 50 responded to treatment, while 10 required repeat immunomodulation. Need for noninvasive or invasive ventilation (relative risk [RR]: 13.14, 95% confidence interval [CI]: 3.147–54.88), six or more organ involvement (RR: 4.667, 95% CI: 1.349–16.149), thrombocytopenia (RR: 6.43, 95% CI: 0.87–47.6, p 0.003), and abnormal chest X-ray findings at admission (RR: 4.5, 95% CI: 1.46–13.8), were found to be associated with increased risk of treatment failure with pulse methylprednisolone therapy. Note that 88% of patients with coronary artery involvement showed resolution at 3-month follow-up.
Conclusion More than 80% of children with MIS-C can be treated successfully with corticosteroids. The need for ventilator support, abnormal chest X-ray findings, and thrombocytopenia at admission were found to be factors associated with pulse methylprednisolone treatment failure.
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Affiliation(s)
- Sheeja Sugunan
- Department of Paediatrics, Government Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
| | - S. Bindusha
- SAT Hospital, Government Medical College, Thiruvananthapuram, Kerala, India
| | - H. R. Niyas
- SAT Hospital, Government Medical College, Thiruvananthapuram, Kerala, India
| | - S. Geetha
- SAT Hospital, Government Medical College, Thiruvananthapuram, Kerala, India
| | - R V Chinchilu
- SAT Hospital, Government Medical College, Thiruvananthapuram, Kerala, India
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99
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Hoste L, Soriano-Arandes A, Buddingh EP, Whittaker E, Belot A, Ulloa-Gutierrez R, Olbrich P, Haerynck F. Severe Acute Respiratory Syndrome Coronavirus 2 Vaccination in Children with a History of Multisystem Inflammatory Syndrome in Children: An International Survey. J Pediatr 2022; 248:114-118. [PMID: 35598642 PMCID: PMC9119291 DOI: 10.1016/j.jpeds.2022.05.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 04/25/2022] [Accepted: 05/16/2022] [Indexed: 12/16/2022]
Abstract
The optimal severe acute respiratory syndrome coronavirus 2 vaccine strategy for patients with a history of multisystem inflammatory syndrome in children (MIS-C) is unclear. We performed an international survey (32 countries) and found substantial variations in vaccine policies. Respondents did not report relapses of MIS-C or other severe inflammatory side effects after severe acute respiratory syndrome coronavirus 2 vaccination in 273 patients with a history of MIS-C.
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Affiliation(s)
- Levi Hoste
- Primary Immune Deficiency Research Laboratory, Department of Internal Diseases and Pediatrics, Centre for Primary Immunodeficiency Ghent, Jeffrey Modell Diagnosis and Research Centre, Ghent University Hospital, Ghent, Belgium,Department of Internal Medicine and Pediatrics, Division of Pediatric Pulmonology, Infectious Diseases and Inborn Errors of Immunity, Ghent University Hospital, Ghent, Belgium
| | | | - Antoni Soriano-Arandes
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron (HUVH), Barcelona, Spain
| | | | - Elizabeth Whittaker
- Paediatric Infectious Diseases, Imperial College Healthcare NHS Trust, London, United Kingdom,Section of Paediatric Infectious Diseases, Imperial College, London, United Kingdom
| | - Alexandre Belot
- Pediatric Nephrology Rheumatology and Dermatology, CHU Lyon, Lyon, France
| | - Rolando Ulloa-Gutierrez
- Servicio de Infectología Pediátrica, Hospital Nacional de Niños “Dr Carlos Sáenz Herrera”, Centro de Ciencias Médicas, Caja Costarricense de Seguro Social (C.C.S.S.), San José, Costa Rica
| | - Peter Olbrich
- Pediatric Infectious Diseases, Rheumatology and Immunology Unit, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla, IBiS/Universidad de Sevilla/CSIC, Red de Investigación Traslacional en Infectología Pediátrica RITIP, Sevilla, Spain,Departamento de Farmacología, Pediatría y Radiología, Facultad de Medicina, Universidad de Sevilla, Spain
| | - Filomeen Haerynck
- Primary Immune Deficiency Research Laboratory, Department of Internal Diseases and Pediatrics, Centre for Primary Immunodeficiency Ghent, Jeffrey Modell Diagnosis and Research Centre, Ghent University Hospital, Ghent, Belgium; Department of Internal Medicine and Pediatrics, Division of Pediatric Pulmonology, Infectious Diseases and Inborn Errors of Immunity, Ghent University Hospital, Ghent, Belgium.
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Multisystem inflammatory syndrome in children (MIS-C) and neonates (MIS-N) associated with COVID-19: optimizing definition and management. Pediatr Res 2022; 93:1499-1508. [PMID: 36050390 PMCID: PMC9436161 DOI: 10.1038/s41390-022-02263-w] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 06/07/2022] [Accepted: 07/08/2022] [Indexed: 12/15/2022]
Abstract
During the SARS-CoV-2-associated infection (COVID-19), pandemic initial reports suggested relative sparing of children inversely related to their age. Children and neonates have a decreased incidence of SARS-CoV-2 infection, and if infected they manifested a less severe phenotype, in part due to enhanced innate immune response. However, a multisystem inflammatory syndrome in children (MIS-C) or paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 emerged involving coronary artery aneurysms, cardiac dysfunction, and multiorgan inflammatory manifestations. MIS-C has many similarities to Kawasaki disease and other inflammatory conditions and may fit within a spectrum of inflammatory conditions based on immunological results. More recently neonates born to mothers with SARS-CoV-2 infection during pregnancy demonstrated evidence of a multisystem inflammatory syndrome with raised inflammatory markers and multiorgan, especially cardiac dysfunction that has been described as multisystem inflammatory syndrome in neonates (MIS-N). However, there is a variation in definitions and management algorithms for MIS-C and MIS-N. Further understanding of baseline immunological responses to allow stratification of patient groups and accurate diagnosis will aid prognostication, and inform optimal immunomodulatory therapies. IMPACT: Multisystem inflammatory system in children and neonates (MIS-C and MIS-N) post COVID require an internationally recognized consensus definition and international datasets to improve management and plan future clinical trials. This review incorporates the latest review of pathophysiology, clinical information, and management of MIS-C and MIS-N. Further understanding of the pathophysiology of MIS-C and MIS-N will allow future targeted therapies to prevent and limit clinical sequelae.
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