Cytokine Storm in COVID-19-Immunopathological Mechanisms, Clinical Considerations, and Therapeutic Approaches: The REPROGRAM Consortium Position Paper

Cardiovascular impact of COVID-19 with a focus on children: A systematic review

BACKGROUND

Since the beginning of the pandemic, coronavirus disease-2019 (COVID-19) in children has shown milder cases and a better prognosis than adults. Although the respiratory tract is the primary target for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), cardiovascular involvement is emerging as one of the most significant and life-threatening complications of SARS-CoV-2 infection in adults.

AIM

To summarize the current knowledge about the potential cardiovascular involvement in pediatric COVID-19 in order to give a perspective on how to take care of them during the current pandemic emergency.

METHODS

Multiple searches in MEDLINE, PubMed were performed using the search terms "COVID-19" or "SARS-CoV-2" were used in combination with "myocardial injury" or "arrhythmia" or "cardiovascular involvement" or "heart disease" or "congenital heart disease" or "pulmonary hypertension" or "long QT" or "cardiomyopathies" or "channelopathies" or "Multisystem inflammatory system" or "PMIS" or "MIS-C" or "Pediatric multisystem inflammatory syndrome" or "myocarditis" or "thromboembolism to identify articles published in English language from January 1st, 2020 until July 31st, 2020. The websites of World Health Organization, Centers for Disease control and Prevention, and the Johns Hopkins Coronavirus Resource Center were reviewed to provide up to date numbers and infection control recommendations. Reference lists from the articles were reviewed to identify additional pertinent articles. Retrieved manuscripts concerning the subject were reviewed by the authors, and the data were extracted using a standardized collection tool. Data were subsequently analyzed with descriptive statistics. For Pediatric multisystemic inflammatory syndrome temporally associated with COVID-19 (PMIS), multiple meta-analyses were conducted to summarize the pooled mean proportion of different cardiovascular variables in this population in pseudo-cohorts of observed patients.

RESULTS

A total of 193 articles were included. Most publications used in this review were single case reports, small case series, and observational small-sized studies or literature reviews. The meta-analysis of 16 studies with size > 10 patients and with complete data about cardiovascular involvement in children with PMIS showed that PMIS affects mostly previously healthy school-aged children and adolescents presenting with Kawasaki disease-like features and multiple organ failure with a focus on the heart, accounting for most cases of pediatric COVID-19 mortality. They frequently presented cardiogenic shock (53%), ECG alterations (27%), myocardial dysfunction (52%), and coronary artery dilation (15%). Most cases required PICU admission (75%) and inotropic support (57%), with the rare need for extracorporeal membrane oxygenation (4%). Almost all of these children wholly recovered in a few days, although rare deaths have been reported (2%). Out of PMIS cases we identified 10 articles reporting sporadic cases of myocarditis, pulmonary hypertension and cardiac arrythmias in previously healthy children. We also found another 10 studies reporting patients with pre-existing heart diseases. Most cases consisted in children with severe COVID-19 infection with full recovery after intensive care support, but cases of death were also identified. The management of different cardiac conditions are provided based on current guidelines and expert panel recommendations.

CONCLUSION

There is still scarce data about the role of cardiovascular involvement in COVID-19 in children. Based on our review, children (previously healthy or with pre-existing heart disease) with acute COVID-19 requiring hospital admission should undergo a cardiac workup and close cardiovascular monitoring to identify and treat timely life-threatening cardiac complications.

SARS-CoV-2 Aiming for the Heart: A Multicenter Italian Perspective About Cardiovascular Issues in COVID-19

The rapid spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the high fatality rate of coronavirus disease 2019 (COVID-19) have been putting a strain on the world since December 2019. Infected individuals exhibit unpredictable symptoms that tend to worsen if age is advanced, a state of malnutrition persists, or if cardiovascular comorbidities are present. Once transmitted, the virus affects the lungs and in predisposed individuals can elicit a sequela of fatal cardiovascular consequences. We aim to present the pathophysiology of COVID-19, emphasizing the major cellular and clinical manifestations from a cardiological perspective. As a roaming viral particle or more likely via the Trojan horse route, SARS-CoV-2 can access different parts of the body. Cardiovascular features of COVID-19 can count myocardial injuries, vasculitis-like syndromes, and atherothrombotic manifestations. Deviations in the normal electrocardiogram pattern could hide pericardial effusion or cardiac inflammation, and dispersed microthrombi can cause ischemic damages, stroke, or even medullary reflex dysfunctions. Tailored treatment for reduced ejection fraction, arrhythmias, coronary syndromes, macrothrombosis and microthrombosis, and autonomic dysfunctions is mandatory. Confidently, evidence-based therapies for this multifaceted nevertheless purely cardiological COVID-19 will emerge after the global assessment of different approaches.

Acute Seizures Occurring in Association With SARS-CoV-2

Seizures are an infrequent and serious neurological complication of SARS-CoV-2 infection, with limited data describing the etiology and the clinical context in which these occur or the associated electrographic and imaging findings. This series details four cases of seizures occurring in patients with COVID-19 with distinct time points, underlying pathology, and proposed physiological mechanisms. An enhanced understanding of seizure manifestations in COVID-19 and their clinical course may allow for earlier detection and improved patient management.

Evidence Regarding Vitamin D and Risk of COVID-19 and Its Severity

Vitamin D deficiency co-exists in patients with COVID-19. At this time, dark skin color, increased age, the presence of pre-existing illnesses and vitamin D deficiency are features of severe COVID disease. Of these, only vitamin D deficiency is modifiable. Through its interactions with a multitude of cells, vitamin D may have several ways to reduce the risk of acute respiratory tract infections and COVID-19: reducing the survival and replication of viruses, reducing risk of inflammatory cytokine production, increasing angiotensin-converting enzyme 2 concentrations, and maintaining endothelial integrity. Fourteen observational studies offer evidence that serum 25-hydroxyvitamin D concentrations are inversely correlated with the incidence or severity of COVID-19. The evidence to date generally satisfies Hill's criteria for causality in a biological system, namely, strength of association, consistency, temporality, biological gradient, plausibility (e.g., mechanisms), and coherence, although experimental verification is lacking. Thus, the evidence seems strong enough that people and physicians can use or recommend vitamin D supplements to prevent or treat COVID-19 in light of their safety and wide therapeutic window. In view of public health policy, however, results of large-scale vitamin D randomized controlled trials are required and are currently in progress.

Successful Treatment of a COVID-19 Case with Pneumonia and Renal Injury Using Tocilizumab

A 49-year-old male Japanese patient was admitted to our hospital under the diagnosis of COVID-19 pneumonia. For 5 days before admission, he had experienced various symptoms, including high fever, watery diarrhea, dyspnea, and cough, and he tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nucleic acid. The patient is a smoker who was on medication for hypertension. A chest computed tomography scan showed bilateral multiple patchy ground-glass opacities. Despite being treated with several therapeutic agents, he still exhibited dyspnea (oxygen saturation [SpO2] in ambient air: 88%), a high fever (axillary temperature: 39 °C), and high blood pressure (148/98 mmHg). Because laboratory data revealed high levels of C-reactive protein (CRP; 2.10 mg/dL) and urinary β2-microglobulin (B2M; 33,683 µg/mL), the anti-interleukin-6 receptor antibody tocilizumab (TCZ; 400 mg) was administered intravenously. One day after injection, he was afebrile. Four days after the TCZ injection, his CRP level dropped to 0.27 mg/dL, B2M level decreased to 3817 µg/mL, and viral load became low. No adverse drug reaction due to TCZ was observed. The patient was discharged 15 days after admission. The early administration of TCZ in this patient prevented the pneumonia and kidney injury caused by COVID-19 from progressing to hyperinflammation syndrome.

The Association of Cerebrovascular Disease with Adverse Outcomes in COVID-19 Patients: A Meta-Analysis Based on Adjusted Effect Estimates

Objective

The aim of this study was to address the association between cerebrovascular disease and adverse outcomes in coronavirus disease 2019 (COVID-19) patients by using a quantitative meta-analysis based on adjusted effect estimates.

Method

A systematic search was performed in PubMed, Web of Science, and EMBASE up to August 10th, 2020. The adjusted effect estimates were extracted and pooled to evaluate the risk of the unfavorable outcomes in COVID-19 patients with cerebrovascular disease. Subgroup analysis and meta-regression were also carried out.

Results

There were 12 studies with 10,304 patients included in our meta-analysis. A significant trend was observed when evaluating the association between cerebrovascular disease and adverse outcomes (pooled effect = 2.05, 95% confidence interval (CI): 1.34–3.16). In addition, the pooled effects showed that patients with a history of cerebrovascular disease had more likelihood to progress fatal outcomes than patients without a history of cerebrovascular disease (pooled effect = 1.78, 95% CI: 1.04–3.07).

Conclusion

This study for the first time indicated that cerebrovascular disease was an independent risk factor for predicting the adverse outcomes, particularly fatal outcomes, in COVID-19 patients on the basis of adjusted effect estimates. Well-designed studies with larger sample size are needed for further verification.

Coronavirus Disease-2019 Treatment Strategies Targeting Interleukin-6 Signaling and Herbal Medicine

Coronavirus disease-2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is evolving across the world and new treatments are urgently needed as with vaccines to prevent the illness and stem the contagion. The virus affects not only the lungs but also other tissues, thus lending support to the idea that COVID-19 is a systemic disease. The current vaccine and treatment development strategies ought to consider such systems medicine perspectives rather than a narrower focus on the lung infection only. COVID-19 is associated with elevated levels of the inflammatory cytokines such as interleukin-6 (IL-6), IL-10, and interferon-gamma (IFN-γ). Elevated levels of cytokines and the cytokine storm have been linked to fatal disease. This suggests new therapeutic strategies through blocking the cytokine storm. IL-6 is one of the major cytokines associated with the cytokine storm. IL-6 is also known to display pleiotropic/diverse pathophysiological effects. We suggest the blockage of IL-6 signaling and its downstream mediators such as Janus kinases (JAKs), and signal transducer and activators of transcription (STATs) offer potential hope for the treatment of severe cases of COVID-19. Thus, repurposing of already approved IL-6-JAK-STAT signaling inhibitors as well as other anti-inflammatory drugs, including dexamethasone, is under development for severe COVID-19 cases. We conclude this expert review by highlighting the potential role of precision herbal medicines, for example, the Cannabis sativa, provided that omics technologies can be utilized to build a robust scientific evidence base on their clinical safety and efficacy. Precision herbal medicine buttressed by omics systems science would also help identify new molecular targets for drug discovery against COVID-19.

Significant COVID-19 burden in Polish children

Introduction

COVID-19 cases have rarely been reported in children. We sought to analyse the attack rate in paediatric population in Poland, focusing on local variations among the provinces, correlation with the number of tests per capita, and test positivity rate.

Material and methods

This cross-sectional study involved the 38.38 million population and detected 17,921 cases (age known in 17,822). Data were collected from publicly available registries and were analysed by age group and province of the country.

Results

Children constituted 6.68% of cases (n = 1,191). The attack rate reached 15.49/100,000 children, increasing with age (10.79/100,000 in < 4 y.o. to 21.59/100,000 in 15-19 y.o.). Significant variations in the attack rates were observed: a 9.52-fold ratio between the highest and the lowest attack rates in provinces. The provinces from the first and fourth attack rate quartiles differed in the test positivity rate (4.96% vs. 1.98%, p < 0.05), but not in the number of tests per capita. The lowest quartile provinces showed 1.87- to 5.78-fold lower attack rates, compared to the directly neighbouring provinces, without any known population susceptibility differences. The attack rates in children and adults correlated very strongly (rho = 0.81). The attack rate correlated with the test positivity rate (rho = 0.64 in children and rho = 0.71 in adults) but not with the number of tests per capita.

Conclusions

COVID-19 burden in children is significant. The local differences highlight various testing strategies, but the awareness of SARS-CoV-2 in children is essential. The correlation between attack rates in children and adults shows that the outbreak in children is parallel to the one observed in adults.