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Muthiah D, Chan M, Low YW, Ramasamy SN, Amin Z, Chan-Ng PPL, Low JL, Low JM. Multisystem inflammatory syndrome in neonates (MIS-N): an updated systematic review. Front Pediatr 2024; 12:1382133. [PMID: 39026941 PMCID: PMC11256206 DOI: 10.3389/fped.2024.1382133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 06/11/2024] [Indexed: 07/20/2024] Open
Abstract
Introduction The aim of the study was to summarize and update clinical features and outcomes of multisystem inflammatory syndrome in neonates (MIS-N). Methods A systematic literature search was conducted of studies on MIS-N published in PubMed, MEDLINE, EMBASE, CNKI, and WHO COVID-19 databases between 1 December 2019 and 30 June 2023. Reference lists of selected articles, Google Scholar, and pre-print servers were searched for additional studies. The methodological quality of included studies was assessed. Results Of 1,572 records screened after the initial search, 35 studies involving a total of 201 neonates with MIS-N were included. One study was retrieved from a pre-print server. For those with available data, 34/47 (78.7%) mothers were infected in the third trimester. Of the 199 mothers (two with twin pregnancies), 183 (92.0%) were from India. The median age of neonates at presentation was 2.0 days (interquartile range 1.0-9.5). Over two-thirds (144/201, 71.6%) presented with respiratory distress, while 112 (55.7%) had cardiac involvement, such as ventricular dysfunctions, involvement of coronary arteries, and atrioventricular blocks. Arrhythmias and thrombosis were reported in 15/201 (7.5%) and 2/201 (3.0%) neonates, respectively. All neonates, except one, required critical care; 64/160 (40.0%) required inotropic support and 105/187 (56.1%) required respiratory support, of whom 59/105 (56.2%) were specified to require intubation. The mortality rate was 5.0% (10/201). Discussion/Conclusion MIS-N should be considered in ill neonates presenting with involvement of two or more organ systems, especially among those neonates with cardiorespiratory dysfunctions, in the presence of proven or suspected maternal COVID-19 infection during pregnancy. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021278717, PROSPERO, identifier CRD42021278717.
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Affiliation(s)
| | - Ming Chan
- Department of Nursing, Changi General Hospital, Singapore, Singapore
| | - Yue Wey Low
- Ministry of Health Holdings, Singapore, Singapore
| | - Sheena Nishanti Ramasamy
- Department of Paediatrics, Khoo Teck Puat—National University Children’s Medical Institute, National University Hospital, National University Health System, Singapore, Singapore
| | - Zubair Amin
- Department of Paediatrics, Khoo Teck Puat—National University Children’s Medical Institute, National University Hospital, National University Health System, Singapore, Singapore
- Department of Neonatology, Khoo Teck Puat—National University Children’s Medical Institute, National University Hospital, National University Health System, Singapore, Singapore
| | - Pauline Poh Lin Chan-Ng
- Department of Paediatrics, Khoo Teck Puat—National University Children’s Medical Institute, National University Hospital, National University Health System, Singapore, Singapore
| | | | - Jia Ming Low
- Department of Paediatrics, Khoo Teck Puat—National University Children’s Medical Institute, National University Hospital, National University Health System, Singapore, Singapore
- Department of Neonatology, Khoo Teck Puat—National University Children’s Medical Institute, National University Hospital, National University Health System, Singapore, Singapore
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Vijay A, Shenoy S, Sindgikar SP. Neonatal arterial thrombosis: an arcane COVID sequelae. BMJ Case Rep 2024; 17:e256793. [PMID: 38490698 PMCID: PMC10946375 DOI: 10.1136/bcr-2023-256793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2024] Open
Abstract
We describe a case of a term neonate with a swollen right arm and weakened pulses, diagnosed with arterial thromboembolism in the right axillary and brachial arteries. Treatment involved heparin, followed by enoxaparin, resulting in significant improvement. Maternal SARS-CoV-2 infection during pregnancy was considered as a potential factor, supported by the newborn's reactive COVID antibodies. The authors hypothesise a potential correlation between neonatal thrombosis and maternal SARS-CoV-2 infection during pregnancy. It is important to note that this association remains speculative and warrants further investigation for validation. The case underscores the importance of recognising and managing neonatal arterial thrombosis, especially in the context of maternal illness. We discuss the case in detail and review current knowledge on this condition.
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Rao S, Gross RS, Mohandas S, Stein CR, Case A, Dreyer B, Pajor NM, Bunnell HT, Warburton D, Berg E, Overdevest JB, Gorelik M, Milner J, Saxena S, Jhaveri R, Wood JC, Rhee KE, Letts R, Maughan C, Guthe N, Castro-Baucom L, Stockwell MS. Postacute Sequelae of SARS-CoV-2 in Children. Pediatrics 2024; 153:e2023062570. [PMID: 38321938 PMCID: PMC10904902 DOI: 10.1542/peds.2023-062570] [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: 11/01/2023] [Indexed: 02/08/2024] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has caused significant medical, social, and economic impacts globally, both in the short and long term. Although most individuals recover within a few days or weeks from an acute infection, some experience longer lasting effects. Data regarding the postacute sequelae of severe acute respiratory syndrome coronavirus 2 infection (PASC) in children, or long COVID, are only just emerging in the literature. These symptoms and conditions may reflect persistent symptoms from acute infection (eg, cough, headaches, fatigue, and loss of taste and smell), new symptoms like dizziness, or exacerbation of underlying conditions. Children may develop conditions de novo, including postural orthostatic tachycardia syndrome, myalgic encephalomyelitis/chronic fatigue syndrome, autoimmune conditions and multisystem inflammatory syndrome in children. This state-of-the-art narrative review provides a summary of our current knowledge about PASC in children, including prevalence, epidemiology, risk factors, clinical characteristics, underlying mechanisms, and functional outcomes, as well as a conceptual framework for PASC based on the current National Institutes of Health definition. We highlight the pediatric components of the National Institutes of Health-funded Researching COVID to Enhance Recovery Initiative, which seeks to characterize the natural history, mechanisms, and long-term health effects of PASC in children and young adults to inform future treatment and prevention efforts. These initiatives include electronic health record cohorts, which offer rapid assessments at scale with geographical and demographic diversity, as well as longitudinal prospective observational cohorts, to estimate disease burden, illness trajectory, pathobiology, and clinical manifestations and outcomes.
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Affiliation(s)
- Suchitra Rao
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, Colorado
| | - Rachel S. Gross
- Departments of Pediatrics
- Population Health, NYU Grossman School of Medicine, New York, New York
| | - Sindhu Mohandas
- Division of Infectious Diseases
- Department of Pediatrics and Radiology, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Cheryl R. Stein
- Child and Adolescent Psychiatry, New York University Grossman School of Medicine, New York, New York
| | - Abigail Case
- Department of Pediatrics and Rehabilitation Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Benard Dreyer
- Department of Pediatrics and Radiology, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Nathan M. Pajor
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - H. Timothy Bunnell
- Biomedical Research Informatics Center, Nemours Children’s Health, Nemours Children’s Hospital, Delaware, Wilmington, Delaware
| | - David Warburton
- Department of Pediatrics and Radiology, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Elizabeth Berg
- Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Jonathan B. Overdevest
- Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Mark Gorelik
- Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Joshua Milner
- Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Sejal Saxena
- Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Ravi Jhaveri
- Division of Infectious Diseases, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - John C. Wood
- Department of Pediatrics and Radiology, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Kyung E. Rhee
- Department of Pediatrics, University of California, San Diego, School of Medicine, San Diego, California
| | - Rebecca Letts
- Population Health, NYU Grossman School of Medicine, New York, New York
| | - Christine Maughan
- Population Health, NYU Grossman School of Medicine, New York, New York
| | - Nick Guthe
- Population Health, NYU Grossman School of Medicine, New York, New York
| | | | - Melissa S. Stockwell
- Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
- Department of Population and Family Health, Columbia University Mailman School of Public Health, New York, New York
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4
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Monroe JM, Quach HQ, Punia S, Enninga EAL, Fedyshyn Y, Girsch JH, Fedyshyn B, Lemens M, Littlefield D, Behl S, Sintim-Aboagye E, Mejia Plazas MC, Yamaoka S, Ebihara H, Pandey A, Correia C, Ung CY, Li H, Vassallo R, Sun J, Johnson EL, Olson JE, Theel ES, Badley AD, Kennedy RB, Theiler RN, Chakraborty R. Vertical Transmission of SARS-CoV-2-Specific Antibodies and Cytokine Profiles in Pregnancy. J Infect Dis 2024; 229:473-484. [PMID: 37786979 DOI: 10.1093/infdis/jiad399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 09/05/2023] [Accepted: 09/13/2023] [Indexed: 10/04/2023] Open
Abstract
Despite intensive characterization of immune responses after COVID-19 infection and vaccination, research examining protective correlates of vertical transmission in pregnancy are limited. Herein, we profiled humoral and cellular characteristics in pregnant women infected or vaccinated at different trimesters and in their corresponding newborns. We noted a significant correlation between spike S1-specific IgG antibody and its RBD-ACE2 blocking activity (receptor-binding domain-human angiotensin-converting enzyme 2) in maternal and cord plasma (P < .001, R > 0.90). Blocking activity of spike S1-specific IgG was significantly higher in pregnant women infected during the third trimester than the first and second trimesters. Elevated levels of 28 cytokines/chemokines, mainly proinflammatory, were noted in maternal plasma with infection at delivery, while cord plasma with maternal infection 2 weeks before delivery exhibited the emergence of anti-inflammatory cytokines. Our data support vertical transmission of protective SARS-CoV-2-specific antibodies. This vertical antibody transmission and the presence of anti-inflammatory cytokines in cord blood may offset adverse outcomes of inflammation in exposed newborns.
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Affiliation(s)
| | | | - Sohan Punia
- Children Research Center, Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine
| | | | - Yaroslav Fedyshyn
- Children Research Center, Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine
| | - James H Girsch
- Children Research Center, Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine
- Graduate School of Biomedical Sciences
| | | | - Maureen Lemens
- Division of Obstetrics, Department of Obstetrics and Gynecology
| | - Dawn Littlefield
- Children Research Center, Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine
| | - Supriya Behl
- Children Research Center, Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine
| | - Elise Sintim-Aboagye
- Children Research Center, Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine
| | - Maria C Mejia Plazas
- Children Research Center, Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine
| | | | | | - Akhilesh Pandey
- Division of Clinical Biochemistry and Immunology, Department of Laboratory Medicine and Pathology, Center for Individualized Medicine, Mayo Clinic, Rochester, Minnesota
- Center for Molecular Medicine, National Institute of Mental Health and Neurosciences, Bangalore
- Department of Community Medicine, Manipal Academy of Higher Education, Manipal, India
| | - Cristina Correia
- Department of Molecular Pharmacology and Experimental Therapeutics
| | - Choong Yong Ung
- Department of Molecular Pharmacology and Experimental Therapeutics
| | - Hu Li
- Department of Molecular Pharmacology and Experimental Therapeutics
| | - Robert Vassallo
- Thoracic Diseases Research Unit, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Department of Immunology, College of Medicine and Science, Mayo Clinic, Rochester, Minnesota
| | - Jie Sun
- Thoracic Diseases Research Unit, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Department of Immunology, College of Medicine and Science, Mayo Clinic, Rochester, Minnesota
- Carter Immunology Center, School of Medicine, University of Virginia, Charlottesville
| | - Erica L Johnson
- Department of Microbiology, Biochemistry, and Immunology, Morehouse School of Medicine, Atlanta, Georgia
| | | | - Elitza S Theel
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology
| | - Andrew D Badley
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Regan N Theiler
- Division of Obstetrics, Department of Obstetrics and Gynecology
| | - Rana Chakraborty
- Children Research Center, Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine
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Cimolai N. COVID-19 among infants: key clinical features and remaining controversies. Clin Exp Pediatr 2024; 67:1-16. [PMID: 38013408 PMCID: PMC10764668 DOI: 10.3345/cep.2023.00794] [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: 06/07/2023] [Revised: 08/11/2023] [Accepted: 09/19/2023] [Indexed: 11/29/2023] Open
Abstract
Infants aged <1 year represent a seemingly more susceptible pediatric subset for infections. Despite this, coronavirus disease 2019 (COVID-19) infection has not been proven as more serious in this age group (outside the very early neonatal period) than in others. Indeed, a considerable number of asymptomatic infections have been recorded, and the symptoms and morbidity associated with COVID- 19 differ minimally from those of other respiratory viral infections. Whether due to an abundance of caution or truly reduced susceptibility, infections in infants have not raised the same profile as those in other age groups. In addition to direct severe acute respiratory syndrome coronavirus 2 diagnostic tests, laboratory markers that differentiate COVID-19 from other viral infections lack specificity in infants. Gastrointestinal presentations are common, and the neurological complications of infection mirror those of other respiratory viral infections. There have been relatively few reports of infant deaths. Under appropriate precautions, breastfeeding in the context of maternal infections has been associated with tangible but infrequent complications. Vaccination during pregnancy provides protection against infection in infants, at least in the early months of life. Multi-inflammatory syndrome in children and multi-inflammatory syndrome in neonates are commonly cited as variants of COVID-19; however, their clinical definitions remain controversial. Similarly, reliable definitions of long COVID in the infant group are controversial. This narrative review examines the key clinical and laboratory features of COVID-19 in infants and identifies several areas of science awaiting further clarification.
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Affiliation(s)
- Nevio Cimolai
- Faculty of Medicine, The University of British Columbia and Children’s and Women’s Health Centre of British Columbia, Vancouver, Canada
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Hernández-García M, Roldan-Berengue E, Guitart C, Girona-Alarcón M, Argüello G, Pino R, F de Sevilla M, García-García JJ, Jordan I. Multisystem inflammatory syndrome in children (MIS-C) and sepsis differentiation by a clinical and analytical score: MISSEP score. Eur J Pediatr 2023; 182:5109-5118. [PMID: 37676491 PMCID: PMC10640430 DOI: 10.1007/s00431-023-05168-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 08/08/2023] [Accepted: 08/16/2023] [Indexed: 09/08/2023]
Abstract
Differential diagnosis between Multisystem Inflammatory Syndrome in Children (MIS-C) and other causes of systemic inflammatory response such as sepsis is complex. The aims were to evaluate the differences between pediatric patients with MIS-C and sepsis and to develop a score to distinguish both entities. This was a retrospective study that compared demographic, clinical, diagnostic, and therapeutic data of pediatric patients with MIS-C (cohort 2020-2022) and sepsis (cohorts 2010-2014 and 2017-2018) admitted to a Pediatric Intensive Care Unit (PICU) of a tertiary care hospital. A diagnostic score was developed with variables that differentiated the two conditions. Twenty-nine patients with MIS-C were identified, who were matched 1:3 with patients with sepsis (n = 87). Patients with MIS-C were older (10 vs. 4 years old), and the majority were male (69%). Clinical characteristics that demonstrated differences were prolonged fever and signs and symptoms affecting skin-mucosa and gastrointestinal system. Leukocytes, PCT, and ferritin were higher in sepsis, while thrombocytopenia, lymphopenia, and elevated fibrinogen and adrenomedullin (biomarker with a role for the detection of invasive infections) were more frequent in MIS-C. MIS-C patients presented greater myocardial dysfunction (p < 0.001). Five criteria were selected and included in the MISSEP score after fitting them into a multivariate logistic regression model: fever > 48 hours (20 points), thrombocytopenia < 150 × 103/µL (6 points), abdominal pain (15 points), conjunctival erythema (11 points), and Vasoactive Inotropic Score (VIS) > 10 (7 points). The cutoff > 25 points allowed to discriminate MIS-C from sepsis with a sensitivity of 0.89 and specificity of 0.95. Conclusion: MIS-C phenotype overlaps with sepsis. MISSEP score could be useful to distinguish between both entities and direct specific treatment. What is Known: • Differential diagnosis between Multisystem Inflammatory Syndrome in Children (MIS-C) and other causes of systemic inflammatory response such as sepsis is complex. • It is essential to establish an accurate initial diagnosis and early specific treatment in both cases of MIS-C and sepsis to improve the prognosis of these patients. What is New: • Patients with MIS-C are older and have characteristic symptoms of prolonged fever, gastrointestinal symptoms, skin-mucosal involvement, and greater myocardial dysfunction, compared to patients with sepsis. • The use of diagnostic scores, such as the MISSEP score, can be very useful to distinguish between the two entities and help direct specific treatment.
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Affiliation(s)
- María Hernández-García
- Paediatrics Department, Hospital Sant Joan de Déu Barcelona, Barcelona, Spain
- Infectious Diseases and Microbiome, Institut de Recerca Sant Joan de Déu (IRSJD), Barcelona, Spain
| | | | - Carmina Guitart
- Infectious Diseases and Microbiome, Institut de Recerca Sant Joan de Déu (IRSJD), Barcelona, Spain
- Paediatric Intensive Care Unit, Hospital Sant Joan de Déu Barcelona, Barcelona, Spain
| | - Mònica Girona-Alarcón
- Infectious Diseases and Microbiome, Institut de Recerca Sant Joan de Déu (IRSJD), Barcelona, Spain
- Paediatric Intensive Care Unit, Hospital Sant Joan de Déu Barcelona, Barcelona, Spain
| | - Guillermo Argüello
- Faculty of Computer Science, Multimedia and Telecommunications, Universitat Oberta de Catalunya, Barcelona, Spain
- Statistics and Operations Research, Universidad de Oviedo, Oviedo, Asturias, Spain
| | - Rosa Pino
- Paediatrics Department, Hospital Sant Joan de Déu Barcelona, Barcelona, Spain
| | - Mariona F de Sevilla
- Paediatrics Department, Hospital Sant Joan de Déu Barcelona, Barcelona, Spain
- Infectious Diseases and Microbiome, Institut de Recerca Sant Joan de Déu (IRSJD), Barcelona, Spain
- Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBER-ESP), Instituto de Salud Carlos III, Madrid, Spain
| | - Juan José García-García
- Paediatrics Department, Hospital Sant Joan de Déu Barcelona, Barcelona, Spain
- Infectious Diseases and Microbiome, Institut de Recerca Sant Joan de Déu (IRSJD), Barcelona, Spain
- Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBER-ESP), Instituto de Salud Carlos III, Madrid, Spain
| | - Iolanda Jordan
- Infectious Diseases and Microbiome, Institut de Recerca Sant Joan de Déu (IRSJD), Barcelona, Spain.
- Paediatric Intensive Care Unit, Hospital Sant Joan de Déu Barcelona, Barcelona, Spain.
- Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain.
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBER-ESP), Instituto de Salud Carlos III, Madrid, Spain.
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Siramdas D, Anudeep P, Subramanian P, Chitgupikar S. Case Series of Multisystem Inflammatory Syndrome in Neonates (MIS-N) With a Link to Coagulopathy. Cureus 2023; 15:e49681. [PMID: 38161855 PMCID: PMC10756854 DOI: 10.7759/cureus.49681] [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: 11/29/2023] [Indexed: 01/03/2024] Open
Abstract
Introduction Multisystem inflammatory syndrome in neonates (MIS-N) is an emerging clinical entity observed in neonates born to mothers with exposure to the SARS-CoV-2 virus before or during the antenatal period. Methods We report 18 neonates diagnosed with MIS-N from retrospectively collected data. A total of 18 neonates (13 term and five late-preterm; 10 males) admitted to the neonatal intensive care unit (NICU) of a tertiary care medical institute, between June 2021 to November 2022, were diagnosed with MIS-N. Results The median age of presentation of the 18 neonates was 1.5 days of life. All the neonates were positive for SARS-CoV-2 IgG antibodies and had elevated D-dimer levels. Respiratory system involvement was the most common (12 of 18 neonates: 66.67%). Ten out of 18 neonates (55.55%) had coagulopathy. Seven of the ten neonates with coagulopathy had central nervous system (CNS) involvement as seizures and/or intracerebral infarcts/bleeds. Cardiovascular and gastrointestinal system involvement was observed in nine (50%) and seven (38.89%) neonates, respectively. One out of 18 neonates died due to intraventricular and cerebral hemorrhage. The mortality rate was 5.55% (n=1). Ten of 18 neonates with coagulopathy required fresh frozen plasma along with repeated therapeutic doses of injection vitamin K. Eight neonates (44.44%) required human intravenous immunoglobulin (IVIG), and three neonates (16.67%) required steroids and IVIG for recovery along with supportive care. Conclusion Coagulopathy can be one of the salient features of presentation in MIS-N. In the immediate post-pandemic era, it is essential that MIS-N is considered in the differential diagnosis of neonates presenting with intracerebral bleeds/infarcts. IVIG and steroids might play an important role in the treatment of neonates with MIS-N.
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Affiliation(s)
- Deepthi Siramdas
- Pediatrics, MediCiti Institute of Medical Sciences, Hyderabad, IND
| | - Peddi Anudeep
- Pediatrics, MediCiti Institute of Medical Sciences, Hyderabad, IND
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Terciu M, Luca I, Panait E, Leibovitz E, Mitrica M, Popovici B, Ilea A, Falup-Pecurariu OG. Early Outcome of Multisystem Inflammatory Syndrome in Neonates Diagnosed following Prenatal Maternal COVID-19 Infection: A Three-Case Series. Pediatr Rep 2023; 15:591-598. [PMID: 37873800 PMCID: PMC10594475 DOI: 10.3390/pediatric15040054] [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: 07/15/2023] [Revised: 09/25/2023] [Accepted: 09/27/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND The aim of this case series report is to evaluate the characteristics of multisystem inflammatory syndrome (MIS) in neonates following prenatal maternal COVID-19 infection. METHODS We present a case series of three newborns (≤28 days of age) diagnosed with MIS due to the vertical transmission of SARS-CoV2 infection and admitted from 1 January 2021 to 1 June 2023. The inclusion criteria were negative RT-PCR-SARS-CoV-2 test in infants, initial negative IgM-SARS-CoV-2 in infants followed by the emergence of positive IgG-SARS-CoV-2 antibodies in infants and maternal COVID-19 infection in the third trimester of pregnancy. Patients enrolled in this case series were admitted due to acute febrile illnesses. RESULTS All three cases occurred in patients born at a mean gestational age of 39 weeks and who were appropriate for gestational age. The mean age at admission was 18.3 days. Fibrinogen (>400 mg/dL) and ferritin (>120 mg/dL) were elevated above the upper normal limit. Elevated levels of myocardial biomarkers (D-dimers, N-terminal pro b-type natriuretic peptide troponin T and creatine phosphokinase myocardial band) were recorded, with normal heart function evaluated using echocardiography. All three patients were treated with antibiotics; one received intravenous immunoglobulin. A 4-week follow-up was completed in two patients when their myocardial biomarkers and ferritin were still elevated but lower compared with previous examinations. D-dimers levels were normalized in 2/3 patients. CONCLUSIONS Subclinical myocarditis was diagnosed as an early outcome in infants with MIS diagnosed postnatally due to the vertical transmission of SARS-CoV2 infection and may represent a new challenge for pediatricians in the pandemic era.
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Affiliation(s)
- Maria Terciu
- Children’s Clinical Hospital, 500002 Brasov, Romania; (M.T.); (M.M.)
| | - Ioana Luca
- Children’s Clinical Hospital, 500002 Brasov, Romania; (M.T.); (M.M.)
| | - Emilia Panait
- Children’s Clinical Hospital, 500002 Brasov, Romania; (M.T.); (M.M.)
| | - Eugene Leibovitz
- Faculty of Medicine, Transilvania University, 500002 Brasov, Romania
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel
| | - Maria Mitrica
- Children’s Clinical Hospital, 500002 Brasov, Romania; (M.T.); (M.M.)
- Faculty of Medicine, Transilvania University, 500002 Brasov, Romania
| | - Bianca Popovici
- Children’s Clinical Hospital, 500002 Brasov, Romania; (M.T.); (M.M.)
- Faculty of Medicine, Transilvania University, 500002 Brasov, Romania
| | - Anca Ilea
- Children’s Clinical Hospital, 500002 Brasov, Romania; (M.T.); (M.M.)
- Faculty of Medicine, Transilvania University, 500002 Brasov, Romania
| | - Oana Gabriela Falup-Pecurariu
- Children’s Clinical Hospital, 500002 Brasov, Romania; (M.T.); (M.M.)
- Faculty of Medicine, Transilvania University, 500002 Brasov, Romania
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Upadhyay S, Devkota S. Multisystem inflammatory syndrome in a neonate secondary to COVID-19: a case report. Ann Med Surg (Lond) 2023; 85:5191-5195. [PMID: 37811070 PMCID: PMC10553167 DOI: 10.1097/ms9.0000000000001178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 08/08/2023] [Indexed: 10/10/2023] Open
Abstract
Introduction and importance Multisystem inflammatory syndrome in children secondary to coronavirus disease 2019 (COVID-19) (MIS-C) is very common and may present with clinical features similar to Kawasaki disease but is rarely reported in neonates (MIS-N). Any history of maternal upper respiratory tract infection should raise suspicion of MIS-N secondary to COVID-19 in critically ill neonates. Case presentation The authors present a term neonate with gradually progressive respiratory distress requiring mechanical ventilation with marked improvement after starting immunoglobulin and steroids after blood investigations revealed high IgG COVID-19 antibody titers. Clinical findings and investigation Admitted to the Neonatal Intensive Care Unit as he received bag and mask ventilation for 30 s following delivery, he was kept under oxygen via nasal prongs; but he still had nasal flaring, subcostal retraction, and tachypnea. All the blood investigations were within normal limits except for elevated C-reactive protein. Intervention and outcome With no improvement despite oxygen via nasal prongs, he was kept under bubble continuous positive airway pressure with positive end-expiratory pressure of 5 cm of H2O. With no improvement even after 24 h of noninvasive ventilation, he was kept under mechanical ventilation in assisted pressure-controlled mode with a peak inspiratory pressure of 22 cm H2O and respiratory rate of 40 breaths/minute. As the mother gave a history of on-and-off cough for almost a month, samples were sent for COVID-19 antibodies which came out to be positive with very high titers of IgG antibodies. Intravenous steroids, immunoglobulin, and subcutaneous low molecular weight heparin were started and marked improvement was noted. The peak inspiratory pressure and FiO2 were gradually tapered off, and he was extubated on the 10th day of mechanical ventilation. Conclusion Multisystem inflammatory syndrome in neonates is rare but should always be considered in neonates with multisystem involvement and a history of maternal upper respiratory tract infection after excluding all other causes.
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Affiliation(s)
| | - Sagar Devkota
- Department of Anesthesiology and Intensive Care, Kulhudhuffushi Regional Hospital, Kulhudhuffushi, Maldives
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10
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Diwakar K, Sarangi T, Srivastava P, Tanti SK, Swaroop S. Human Adenovirus Infection Causing Hyperinflammatory Syndrome Mimicking Multisystem Inflammatory Syndrome in Children (MIS-C): A Case Report. Cureus 2023; 15:e40239. [PMID: 37440807 PMCID: PMC10333626 DOI: 10.7759/cureus.40239] [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: 06/10/2023] [Indexed: 07/15/2023] Open
Abstract
Transmission of human adenovirus (HAdV) infection and the associated clinical disease can be sporadic or epidemic and manifestations may range from mild infection to severe disease. HAdV has been seen to behave as a proinflammatory virus that can trigger the release of high levels of inflammatory cytokines and chemokines in children. Here, we report an unusual case of an infant with HAdV infection who presented with respiratory illness, with a protracted course, complicated with hyperinflammation and multi-system involvement with clinical characteristics mimicking multisystem inflammatory syndrome in children (MIS-C) and Kawasaki disease. The patient was an 11-month-old male infant with a background of infantile epilepsy, epileptic encephalopathy, hemimegaloencephaly, and global developmental delay, diagnosed as Ohtahara syndrome. He was admitted with a three-day history of cough, cold, fever, and respiratory distress. Management was initiated with a heated humidified high-flow nasal cannula and given ceftriaxone and hypertonic saline nebulization. Additionally, he developed loose motion on the fifth day of admission. The reverse transcriptase polymerase chain reaction (RT-PCR) of the nasopharyngeal swab was positive for HAdV. Due to persistent fever, elevated inflammatory markers, multisystem involvement (diarrhea, coagulopathy), an absence of a clear microbial etiology, and an epidemiologic link to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, MIS-C was diagnosed. The first dose of intravenous immunoglobulins (IVIG) was administered over the course of 48 hours and the baby required a second dose of IVIG as the fever failed to settle after the first dose. Within 24 hours of the second IVIG dose, defervescence occurred. His platelet count started to rise, and the baby developed thrombocytosis in the third week of illness. Echocardiography was suggestive of dilatation of mild left main coronary artery. He was weaned off oxygen support by day 14 and discharged on day 17. To our knowledge, this is the first reported case of HAdV infection with hyperinflammatory syndrome and vasculitis akin to MIS-C and Kawasaki disease.
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Affiliation(s)
- Kumar Diwakar
- Pediatrics, Tata Main Hospital, Jamshedpur, IND
- Pediatrics, Manipal Tata Medical College, Jamshedpur, IND
| | | | - Preeti Srivastava
- Pediatrics, Tata Main Hospital, Jamshedpur, IND
- Pediatrics, Manipal Tata Medical College, Jamshedpur, IND
| | - Sanjay K Tanti
- Pediatrics, Tata Main Hospital, Jamshedpur, IND
- Pediatrics, Manipal Tata Medical College, Jamshedpur, IND
| | - Shikha Swaroop
- Pediatrics, Tata Main Hospital, Jamshedpur, IND
- Pediatrics, Manipal Tata Medical College, Jamshedpur, IND
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11
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Aguilar-Caballero D, Capcha JMC, Caballero V, Young KC, Duara S, Borchetta M, Gonzalez I, Saad AG, Webster KA, Shehadeh LA, Bandstra ES, Schmidt AF. Case report: Fatal lung hyperinflammation in a preterm newborn with SARS-CoV-2 infection. Front Pediatr 2023; 11:1144230. [PMID: 37287630 PMCID: PMC10242137 DOI: 10.3389/fped.2023.1144230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 04/28/2023] [Indexed: 06/09/2023] Open
Abstract
Vertical transmission of SARS-CoV-2 from mother to fetus is widely accepted. Whereas most infected neonates present with mild symptoms or are asymptomatic, respiratory distress syndrome (RDS) and abnormal lung images are significantly more frequent in COVID-19 positive neonates than in non-infected newborns. Fatality is rare and discordant meta-analyses of case reports and series relating perinatal maternal COVID-19 status to neonatal disease severity complicate their extrapolation as prognostic indicators. A larger database of detailed case reports from more extreme cases will be required to establish therapeutic guidelines and allow informed decision making. Here we report an unusual case of a 28 weeks' gestation infant with perinatally acquired SARS-CoV-2, who developed severe protracted respiratory failure. Despite intensive care from birth with first line anti-viral and anti-inflammatory therapy, respiratory failure persisted, and death ensued at 5 months. Lung histopathology showed severe diffuse bronchopneumonia, and heart and lung immunohistochemistry confirmed macrophage infiltration, platelet activation and neutrophil extracellular trap formation consistent with late multisystem inflammation. To our knowledge, this is the first report of SARS CoV-2 pulmonary hyperinflammation in a preterm newborn with fatal outcome.
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Affiliation(s)
- Daniela Aguilar-Caballero
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Holz Children's Hospital/Jackson Memorial Hospital, Miami, FL, USA
| | - Jose M. C. Capcha
- Division of Cardiology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
- Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Veronica Caballero
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Holz Children's Hospital/Jackson Memorial Hospital, Miami, FL, USA
| | - Karen C. Young
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Holz Children's Hospital/Jackson Memorial Hospital, Miami, FL, USA
| | - Shahnaz Duara
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Holz Children's Hospital/Jackson Memorial Hospital, Miami, FL, USA
| | - Michael Borchetta
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ivan Gonzalez
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ali G. Saad
- Division of Anatomic Pathology, Department of Pathology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Keith A. Webster
- Integene International, LLC, Miami, FL, United States
- Baylor College of Medicine, Everglades Biopharma, Cullen Eye Institute, Houston, TX, United States
| | - Lina A. Shehadeh
- Division of Cardiology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
- Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Emmalee S. Bandstra
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Holz Children's Hospital/Jackson Memorial Hospital, Miami, FL, USA
| | - Augusto F. Schmidt
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Holz Children's Hospital/Jackson Memorial Hospital, Miami, FL, USA
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12
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Esposito S, Amirthalingam G, Bassetti M, Blasi F, De Rosa FG, Halasa NB, Hung I, Osterhaus A, Tan T, Torres JP, Vena A, Principi N. Monoclonal antibodies for prophylaxis and therapy of respiratory syncytial virus, SARS-CoV-2, human immunodeficiency virus, rabies and bacterial infections: an update from the World Association of Infectious Diseases and Immunological Disorders and the Italian Society of Antinfective Therapy. Front Immunol 2023; 14:1162342. [PMID: 37256125 PMCID: PMC10226646 DOI: 10.3389/fimmu.2023.1162342] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 04/26/2023] [Indexed: 06/01/2023] Open
Abstract
Monoclonal antibodies (mABs) are safe and effective proteins produced in laboratory that may be used to target a single epitope of a highly conserved protein of a virus or a bacterial pathogen. For this purpose, the epitope is selected among those that play the major role as targets for prevention of infection or tissue damage. In this paper, characteristics of the most important mABs that have been licensed and used or are in advanced stages of development for use in prophylaxis and therapy of infectious diseases are discussed. We showed that a great number of mABs effective against virus or bacterial infections have been developed, although only in a small number of cases these are licensed for use in clinical practice and have reached the market. Although some examples of therapeutic efficacy have been shown, not unlike more traditional antiviral or antibacterial treatments, their efficacy is significantly greater in prophylaxis or early post-exposure treatment. Although in many cases the use of vaccines is more effective and cost-effective than that of mABs, for many infectious diseases no vaccines have yet been developed and licensed. Furthermore, in emergency situations, like in epidemics or pandemics, the availability of mABs can be an attractive adjunct to our armament to reduce the impact. Finally, the availability of mABs against bacteria can be an important alternative, when multidrug-resistant strains are involved.
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Affiliation(s)
- Susanna Esposito
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Gayatri Amirthalingam
- Immunisation and Countermeasures Division, National Infection Service, Public Health England, London, United Kingdom
| | - Matteo Bassetti
- Division of Infectious Diseases, Department of Health Sciences (DISSAL), University of Genova, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Respiratory Unit and Cystic Fibrosis Center, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, Milan, Italy
| | | | - Natasha B. Halasa
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Ivan Hung
- Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
- Department of Infectious Disease and Microbiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Albert Osterhaus
- Research Center for Emerging Infections and Zoonoses, University of Veterinary Medicine Foundation, Hannover, Germany
| | - Tina Tan
- Division of Infectious Diseases, Feinberg School of Medicine of Northwestern University, Chicago, IL, United States
| | - Juan Pablo Torres
- Department of Pediatrics and Pediatric Surgery, Facultad de Medicina, University of Chile, Santiago, Chile
- Instituto Sistemas Complejos de Ingeniería (ISCI), Santiago, Chile
| | - Antonio Vena
- Division of Infectious Diseases, Department of Health Sciences (DISSAL), University of Genova, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
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13
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Lakshminrusimha S, Hedriana HL. Neonatal COVID-19 - The past, present and the future. Semin Fetal Neonatal Med 2023; 28:101456. [PMID: 37210285 DOI: 10.1016/j.siny.2023.101456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Affiliation(s)
| | - Herman L Hedriana
- Department of Obstetrics and Gynecology, UC Davis Health, Sacramento, CA, USA.
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14
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Abdulaziz-Opiela G, Sobieraj A, Sibrecht G, Bajdor J, Mroziński B, Kozłowska Z, Iciek R, Wróblewska-Seniuk K, Wender-Ożegowska E, Szczapa T. Prenatal and Neonatal Pulmonary Thrombosis as a Potential Complication of SARS-CoV-2 Infection in Late Pregnancy. Int J Mol Sci 2023; 24:ijms24087629. [PMID: 37108791 PMCID: PMC10146603 DOI: 10.3390/ijms24087629] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 04/18/2023] [Accepted: 04/19/2023] [Indexed: 04/29/2023] Open
Abstract
Neonatal venous thrombosis is a rare condition that can be iatrogenic or occur due to viral infections or genetic mutations. Thromboembolic complications are also commonly observed as a result of SARS-CoV-2 infections. They can affect pediatric patients, especially the ones suffering from multisystem inflammatory syndrome in children (MIS-C) or multisystem inflammatory syndrome in neonates (MIS-N). The question remains whether the maternal SARS-CoV-2 infection during pregnancy can lead to thromboembolic complications in fetuses and neonates. We report on a patient born with an embolism in the arterial duct, left pulmonary artery, and pulmonary trunk, who presented several characteristic features of MIS-N, suspecting that the cause might have been the maternal SARS-CoV2 infection in late pregnancy. Multiple genetic and laboratory tests were performed. The neonate presented only with a positive result of IgG antibodies against SARS-CoV-2. He was treated with low molecular weight heparin. Subsequent echocardiographic tests showed that the embolism dissolved. More research is necessary to evaluate the possible neonatal complications of maternal SARS-CoV-2 infection.
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Affiliation(s)
| | - Anna Sobieraj
- Faculty of Medicine, Poznan University of Medical Sciences, 61-701 Poznan, Poland
| | - Greta Sibrecht
- II Department of Neonatology, Poznan University of Medical Sciences, 61-701 Poznan, Poland
| | - Julia Bajdor
- Department of Radiology, Nicolaus Copernicus Hospital, 80-803 Gdansk, Poland
| | - Bartłomiej Mroziński
- Department of Pediatric Cardiology, Poznan University of Medical Sciences, 61-701 Poznan, Poland
| | - Zuzanna Kozłowska
- II Department of Neonatology, Poznan University of Medical Sciences, 61-701 Poznan, Poland
| | - Rafał Iciek
- Department of Reproduction, Poznan University of Medical Sciences, 61-701 Poznan, Poland
| | | | - Ewa Wender-Ożegowska
- Department of Reproduction, Poznan University of Medical Sciences, 61-701 Poznan, Poland
| | - Tomasz Szczapa
- II Department of Neonatology, Poznan University of Medical Sciences, 61-701 Poznan, Poland
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15
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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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16
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Abstract
The COVID-19 (SARS-Cov-2) pandemic has put a strain on healthcare systems around the world from December 2019 in China, and then rapidly spreading worldwide. The impact of the virus on the entire population and its differential effect on various age groups was unknown at the outset, specifically its severity in elders, children or those living with other comorbidities, thus defining the syndemic, rather than pandemic, character of the infection. The effort of clinicians was initially to organize differential paths to isolate cases or contacts. This impacted the maternal-neonatal care adding an additional burden to this dyad and raising several questions. Can SARS-Cov-2 infection in the first days of life put the health of the newborn at risk? Could the separation of a healthy newborn from an infected mother create further physical and psychological health problems in the dyad? The rapid and massive research effort in these three years of the pandemic has provided wide answers to these initial questions. In this review, we report epidemiological data, clinical features, complications, and management of the neonates affected by SARS-Cov-2 infection.
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Affiliation(s)
- Alfonso Galderisi
- Department of Woman and Child's Health, University of Padova, Padova, Italy; Yale University, Department of Pediatrics, New Haven, CT, USA
| | - Gianluca Lista
- Neonatal Intensive Care Unit, Buzzi Children's Hospital, Milan, Italy
| | | | - Daniele Trevisanuto
- Department of Woman and Child's Health, University of Padova, Padova, Italy.
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17
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Lee PI, Hsueh PR. Multisystem inflammatory syndrome in children: A dysregulated autoimmune disorder following COVID-19. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2023; 56:236-245. [PMID: 36720670 PMCID: PMC9841678 DOI: 10.1016/j.jmii.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/07/2022] [Accepted: 01/09/2023] [Indexed: 01/17/2023]
Abstract
Multisystem inflammatory syndrome in children (MIS-C) is a dysregulated autoimmune-mediated illness in genetically susceptible patients following COVID-19 with an interval of 2-6 weeks. The median age of patients with MIS-C is 6-11 years. Most common manifestations are involvement of gastrointestinal tract, cardiovascular system, hematological system, and mucocutaneous system. Respiratory tract, neurological system, musculoskeletal system, and kidney are less frequently affected. Mucocutaneous manifestations and coronary artery abnormalities characteristic for Kawasaki disease (KD) may be observed in a significant proportion of MIS-C patients that may make the differential diagnosis be difficult for some patients, especially in the post-pandemic era. The mortality rate is 1-3%. Management and prognosis of MIS-C are similar to that of KD. MIS-C and KD may share a common pathogenic process. Based on the observation of MIS-C-like illness in uninfected neonates, i.e. multisystem inflammatory syndrome in neonates, both MIS-C and KD may be a consequence of dysregulated, over-exaggerated humoral immune responses triggered by a specific infectious agent.
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Affiliation(s)
- Ping-Ing Lee
- Department of Pediatrics, National Taiwan University Children's Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Po-Ren Hsueh
- Division of Infectious Diseases, Department of Internal Medicine, China Medical University Hospital, China Medical University, Taichung, Taiwan; Department of Laboratory Medicine, China Medical University Hospital, China Medical University, Taichung, Taiwan; Ph.D Program for Aging, School of Medicine, China Medical University, Taichung, Taiwan; Departments of Laboratory Medicine and Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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18
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Ramaswamy VV, Abiramalatha T, Pullattayil S AK, Trevisanuto D. Multisystem inflammatory disease in neonates (MIS-N) due to maternal COVID-19. Semin Fetal Neonatal Med 2023; 28:101431. [PMID: 37061425 DOI: 10.1016/j.siny.2023.101431] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2023]
Abstract
Multisystem inflammatory disease in neonates (MIS-N) is a disease of immune dysregulation presenting in the newborn period. Thouvgh its etiopathogenesis is proposed to be similar to multisystem inflammatory disease in Children (MIS-C), the exact pathophysiology is largely unknown as of present. The definition of MIS-N is contentious. The evidence for its incidence, the clinical features, profile of raised inflammatory markers, treatment strategies and outcomes stem from case reports, case series and cohort studies with small sample sizes. Though the incidence of MIS-N in severe acute respiratory syndrome caused by the coronavirus CoVID-2 (SARS-CoV-2) infected asymptomatic neonates is low, its incidence in symptomatic neonates is relatively higher. Further, amongst the neonates who are treated as MIS-N, the mortality rate is high. The review also evaluates the various other unresolved aspects of MIS-N from limited published literature and identifies knowledge gaps which could be areas of future research.
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Affiliation(s)
| | | | | | - Daniele Trevisanuto
- Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy.
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19
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De Luca D, Vauloup-Fellous C, Benachi A, Vivanti A. Transmission of SARS-CoV-2 from mother to fetus or neonate: What to know and what to do? Semin Fetal Neonatal Med 2023; 28:101429. [PMID: 36935314 PMCID: PMC10010052 DOI: 10.1016/j.siny.2023.101429] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
Abstract
SARS-CoV-2 can be vertically transmitted from the mother to the fetus and the neonate. This transmission route is rare compared to the environmental or horizontal spread and therefore, the risk can be deemed inconsequential by some medical providers. However, severe, although just as rare, feto-neonatal consequences are possible: fetal demise, severe/critical neonatal COVID-19 and multi-inflammatory syndrome (MIS-N) have been described. Therefore, it is important for the clinicians to know the mechanism of vertical transmission, how to recognize this, and how to deal with neonatal COVID-19 and MIS-N. Our knowledge about this field has significantly increased in the last three years. This is a summary of the pathophysiology, diagnostics, and therapeutics of vertical SARS-CoV-2 transmission that clinicians apply in their clinical practice.
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Affiliation(s)
- Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, "Antoine Béclère" Hospital, Paris Saclay University Hospitals, APHP, Clamart, France.
| | - Christelle Vauloup-Fellous
- Division of Virology, "Paul Brousse" Hospital, Paris Saclay University Hospitals, APHP, Villejuif, France
| | - Alexandra Benachi
- Division of Obstetrics and Gynecology, "Antoine Béclère" Hospital, Paris Saclay University Hospitals, APHP, Clamart, France
| | - Alexandre Vivanti
- Division of Obstetrics and Gynecology, "Antoine Béclère" Hospital, Paris Saclay University Hospitals, APHP, Clamart, France
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20
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Multisystem inflammatory syndrome in neonates (MIS-N): a systematic review. Eur J Pediatr 2023; 182:2283-2298. [PMID: 36877274 PMCID: PMC9986661 DOI: 10.1007/s00431-023-04906-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/16/2023] [Accepted: 02/26/2023] [Indexed: 03/07/2023]
Abstract
Recently, a new pattern of multisystem inflammatory syndrome following an infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has emerged globally. The initial cases were described in the adult population followed by sporadic cases in the pediatric population also. By the end of 2020, similar reports were recognised in the neonatal age group. The purpose of this study was to systematically review clinical characteristics, laboratory parameters, treatment, and outcomes of neonates with multisystem inflammatory syndrome in neonates (MIS-N). A systematic review was conducted after registering with PROSPERO and electronic databases including MEDLINE, EMBASE, PubMed, SCOPUS, Google Scholar, and Web of Science were searched from January 1st 2020 till September 30th 2022. A total of 27 studies describing 104 neonates were analysed. The mean gestation age and birth weight was 35.9 ± 3.3 weeks and 2255.7 ± 783.7 g respectively. A large proportion (91.3%) of the reported cases belonged to the South-East Asian region. The median age of presentation was 2 days (range: 1-28 days) with cardiovascular system being the predominant system involved in 83.65% followed by respiratory (64.42%). Fever was noted in only 20.2%. Commonly elevated inflammatory markers were IL-6 in 86.7% and D-dimer in 81.1%. Echocardiographic evaluation suggested ventricular dysfunction in 35.8% and dilated coronary arteries in 28.3%. Evidence of SARS-CoV-2 antibodies (IgG or IgM) was seen in 95.9% neonates and evidence of maternal SARS-CoV-2 infection, either as history of COVID infection or positive antigen or antibody test, was noted in 100% of the cases. Early MIS-N was reported in 58 (55.8%) cases, late MIS-N in 28 (26.9%), and 18 cases (17.3%) did not report the timing of presentation. There was a statistically increased proportion of preterm infants (67.2%, p < 0.001), and a trend towards increased low birth weight infants, in the early MIS-N group when compared to the infants with late MIS-N. Fever (39.3%), central nervous system (50%), and gastrointestinal manifestations (57.1%) were significantly higher in the late MIS-N group (p = 0.03, 0.02, 0.01 respectively). The anti-inflammatory agents used for the treatment of MIS-N included steroids 80.8% which were given for a median of 10 (range 3-35) days and IVIg in 79.2% with a median of 2 (range 1-5) doses. The outcomes were available for 98 cases, of whom 8 (8.2%) died during treatment in hospital and 90 (91.8%) were successfully discharged home. Conclusion: MIS-N has a predilection for late preterm males with predominant cardiovascular involvement. The diagnosis is challenging in neonatal period due to overlap with neonatal morbidities and a high risk of suspicion is warranted, especially in presence of supportive maternal and neonatal clinical history. The major limitation of the review was inclusion of case reports and case series, and highlights need of global registries for MIS-N. What is Known: • A new pattern of multisystem inflammatory syndrome following SARS-CoV-2 infection has emerged in adult population with sporadic cases now being reported in neonates. What is New: • MIS-N is an emerging condition with a heterogeneous spectrum and has a predilection for late preterm male infants. Cardiovascular system is the predominant system involved followed by respiratory, however fever remains an uncommon presentation unlike other age-groups. There are two subtypes based on timing of presentation, with early MIS-N being reported more in preterm and low-birth weight infants.
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21
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Paediatric inflammatory multisystem syndrome in a neonate with CHD: case description and current issues in children with CHD. Cardiol Young 2023; 33:321-322. [PMID: 35876498 DOI: 10.1017/s1047951122001718] [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] [Indexed: 11/06/2022]
Abstract
We present a case of possible vertical COVID-19 transmission-related paediatric inflammatory multisystem syndrome in a neonate with CHD. Myocarditis and supraventricular tachycardia along with hepatic injury and renal failure were diagnosed on a background of mild aortic valve stenosis; the patient was successfully treated with immunomodulation. Since paediatric inflammatory multisystem syndrome can affect the heart, we could consider neonates with haemodynamically insignificant CHD to be at a higher risk of fatal outcomes. Issues related to early diagnosis and management need to be addressed.
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22
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Nanda D, Ragireddy A, Das R, Mallick B. An unusual course of pneumonia in a term neonate with suspected multisystem inflammatory syndrome secondary to severe acute respiratory syndrome coronavirus 2 infection. J Clin Neonatol 2023. [DOI: 10.4103/jcn.jcn_96_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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23
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Esposito S, Autore G, Argentiero A, Ramundo G, Perrone S, Principi N. Update on COVID-19 Therapy in Pediatric Age. Pharmaceuticals (Basel) 2022; 15:1512. [PMID: 36558963 PMCID: PMC9783267 DOI: 10.3390/ph15121512] [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: 11/04/2022] [Revised: 11/25/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022] Open
Abstract
With the extension of the COVID-19 pandemic, the large use of COVID-19 vaccines among adults and the emergence of SARS-CoV-2 variants means that the epidemiology of COVID-19 in pediatrics, particularly among younger children, has substantially changed. The prevalence of pediatric COVID-19 significantly increased, several severe cases among children were reported, and long-COVID in pediatric age was frequently observed. The main aim of this paper is to discuss which types of treatment are presently available for pediatric patients with COVID-19, which of them are authorized for the first years of life, and which are the most important limitations of COVID-19 therapy in pediatric age. Four different antivirals, remdesivir (RVD), the combination nirmatrelvir plus ritonavir (Paxlovid), molnupiravir (MPV), and the monoclonal antibody bebtelovimab (BEB), are presently approved or authorized for emergency use for COVID-19 treatment by most of the national health authorities, although with limitations according to the clinical relevance of disease and patient's characteristics. Analyses in the literature show that MPV cannot be used in pediatric age for the risk of adverse events regarding bone growth. The other antivirals can be used, at least in older children, and RDV can be used in all children except in neonates. However, careful research on pharmacokinetic and clinical data specifically collected in neonates and children are urgently needed for the appropriate management of pediatric COVID-19.
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Affiliation(s)
- Susanna Esposito
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Giovanni Autore
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Alberto Argentiero
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Greta Ramundo
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Serafina Perrone
- Neonatoloy Unit, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
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24
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De Luca D, Vauloup-Fellous C, Benachi A, Masturzo B, Manzoni P, Vivanti A. The Essentials about Neonatal Severe Acute Respiratory Syndrome Coronavirus 2 Infection and Coronavirus Disease: A Narrative Review. Am J Perinatol 2022; 39:S18-S22. [PMID: 36356589 DOI: 10.1055/s-0042-1758487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can occur in neonates as the virus can be transmitted both horizontally (from the environment) and vertically (during the pregnancy or at the delivery). Compared to the adult outbreak, neonatal infections do not represent a public health problem. Nonetheless, severe and life-threatening cases may rarely occur and both obstetricians and neonatologists should have a good knowledge of perinatal SARS-CoV-2 infection and related consequences. A high suspicion index must be applied and ruling out neonatal SARS-CoV-2 infection must become a part of the routine clinical workout. Moreover, neonates may be affected by the multisystem inflammatory syndrome, due to a dysregulated host response in the absence of any SARS-CoV-2 infection. We performed a narrative review to summarize here the available literature describing the essentials that should be known by every neonatologist and obstetrician, starting from what has been discovered in 2020 and adding what has been learned in the following years. The paper describes the mechanisms of transmission, clinical features, diagnostic tools, and criteria, as well as possible treatment and prevention strategies. The goal is to provide the practical points to be remembered at the bedside while caring for a pregnant woman or a neonate with suspected or proven coronavirus disease 2019 or multisystem inflammatory syndrome. KEY POINTS: · SARS-CoV-2 neonatal infections occur both vertically (30%) and horizontally (70%).. · Approximately, half of patients do not have clinical manifestations; clinical and laboratory signs are similar to those of adults but usually milder.. · Remdesivir and steroids can be used as a treatment..
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Affiliation(s)
- Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, "Antoine Béclère" Medical Centre, Paris Saclay University Hospitals, APHP, Clamart, France.,Physiopathology and Therapeutic Innovation Unit-INSERM U999, Paris Saclay University, Le Plessis Robinson, France
| | - Christelle Vauloup-Fellous
- Division of Virology, "Paul Brousse" Hospital, Paris Saclay University Hospitals, APHP, Villejuif, France
| | - Alexandra Benachi
- Division of Obstetrics and Gynecology, "Antoine Béclère" Hospital, Paris Saclay University Hospitals, APHP, Clamart, France
| | - Bianca Masturzo
- Division of Obstetrics and Gynecology, Department of Maternal, Neonatal and Infant Medicine, Nuovo Ospedale Degli Infermi, Biella, Italy
| | - Paolo Manzoni
- Division of Obstetrics and Gynecology, Department of Maternal, Neonatal and Infant Medicine, Nuovo Ospedale Degli Infermi, Biella, Italy
| | - Alexandre Vivanti
- Division of Obstetrics and Gynecology, "Antoine Béclère" Hospital, Paris Saclay University Hospitals, APHP, Clamart, France
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25
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Schwartz BN, Harahsheh AS, Krishnan A, Martin GR. Cardiac Effects of COVID-19 Infection, MIS-C, and the Vaccine in Infants and Children: What Is Known and Future Implications. Am J Perinatol 2022; 39:S1-S6. [PMID: 36307093 DOI: 10.1055/s-0042-1757238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The cardiac effects of novel coronavirus disease 2019 (COVID-19) infection on the pediatric heart has become an area of particular interest as elevated cardiac enzymes and abnormalities on echocardiogram and electrocardiogram were seen in a portion of children affected by the virus. In this article, we review the cardiac manifestations of acute COVID-19 infection, multisystem inflammatory syndrome in children, and postvaccine myocarditis. The limited research on the effects of COVID-19 on neonates and infants is also reported. KEY POINTS: · Cardiac involvement from MIS-C is much higher than the risk of COVID-19 vaccine-induced myocarditis.. · Neonates and infants have overall been less affected by COVID-19 than adults and older children.. · At this point in time, there is limited research on the cardiac effects of COVID-19 in neonates..
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Affiliation(s)
- Bryanna N Schwartz
- Division of Cardiology, Children's National Hospital, Washington, District of Columbia.,Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Ashraf S Harahsheh
- Division of Cardiology, Children's National Hospital, Washington, District of Columbia.,Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Anita Krishnan
- Division of Cardiology, Children's National Hospital, Washington, District of Columbia.,Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Gerard R Martin
- Division of Cardiology, Children's National Hospital, Washington, District of Columbia.,Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
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26
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Gaucher Disease Type 2 Manifested as Hemophagocytic Lymphohistiocytosis in a Neonate in the COVID-19 Era. J Pediatr Hematol Oncol 2022; 45:e506-e509. [PMID: 36162002 DOI: 10.1097/mph.0000000000002551] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 08/18/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND A term neonate presented with persistent severe thrombocytopenia, elevated liver enzymes, conjugated hyperbilirubinemia, hepatosplenomegaly, and mild hypotonia. OBSERVATIONS A thorough workup for infections, congenital thrombocytopenias, and neonatal malignancies was negative. Because of increased anti-SARS-CoV-2 IgG antibodies after maternal Covid-19, multisystem inflammatory syndrome of neonates was considered and intravenous immunoglobulin was administered. The clinical condition of the neonate deteriorated and due to laboratory evidence of hyperinflammation, hemophagocytic lymphohistiocytosis was suspected, and treatment with etoposide and dexamethasone was initiated with temporary stabilization. Gaucher disease type 2 was eventually diagnosed. CONCLUSION Gaucher disease can rarely present in neonates as hemophagocytic lymphohistiocytosis.
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27
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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: 33] [Impact Index Per Article: 16.5] [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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28
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Multiple drugs. REACTIONS WEEKLY 2022. [PMCID: PMC9184330 DOI: 10.1007/s40278-022-17157-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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29
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Buonsenso D. Partnerships in the Comprehensive Management of Multisystem Inflammatory Syndrome in Neonates (MIS-N): Translating 2 Years of Pediatric Practice to the Neonatal Wards. Am J Perinatol 2022. [PMID: 35240695 DOI: 10.1055/a-1787-8099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Danilo Buonsenso
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Center for Global Health Research Studies, Università Cattolica del Sacro Cuore, Roma, Italia.,Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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