Role of intravenous immunoglobulin therapy in the survival rate of pediatric patients with acute myocarditis: A systematic review and meta-analysis

Clinical Effect Analysis of Different Doses of Creatine Phosphate Sodium Combined with Immunoglobulin in the Treatment of Pediatric Viral Myocarditis

The purpose of this paper was to unravel the clinical effect analysis of different doses of creatine phosphate sodium (CPS) combined with immunoglobulin in the treatment of pediatric viral myocarditis (VMC). One hundred and twenty children with VMC were recruited and randomized into three groups (40 patients each). Group I received 1.0 g of CPS dissolved in 100 mL of 5% glucose injection intravenously 1 time/day; group II received 1.25 g of CPS dissolved in 125 mL of 5% glucose injection intravenously 1 time/day; group III received 1.5 g of CPS dissolved in 150 mL of 5% glucose injection intravenously 1 time/day; then all three groups were treated with combined use of immunoglobulin (300-400 mg/day) intravenously once a day; and all three groups were treated for 14 days. The clinical efficacy, cardiac function, serum inflammatory factor levels, immune function, and the occurrence of drug toxicity and adverse effects of the children in the three groups were compared after 14 days of treatment. All three groups achieved better therapeutic effects after treatment, in which the effective rate of the Group II and Group III was notably higher versus the Group I. Lower levels of cTnI, CK-MB, LDH, AST, IL-18, IL-6, IFN-γ, and LVEDD and higher CD3+, CD4+, and CD4+/CD8+, FS, and LVEF values were noted in the Group II and Group III versus the Group I, and the results were more pronounced in the high-dose group. The liver and kidney functions of the children in the three groups before and after treatment did not show any significant changes and the incidence of adverse reactions during the treatment period was low in all three groups. Children with VMC can be treated with high-dose CPS in combination with immunoglobulin, which can improve their cardiac function and immune function and reduce the inflammatory response with good overall therapeutic efficacy and fewer adverse effects.

Clinical Presentation, Diagnosis, Treatment, and Outcomes of Myocarditis in Children: A Tertiary Care Hospital Experience

Background Clinical presentation, diagnosis, and treatment of myocarditis in children can be highly challenging, and results can vary greatly. Research on the precise processes of myocardial injury, including the effects of viral infections and newly identified variables like COVID-19, is still underway. Though treatment approaches, such as immunosuppressive therapy, are still debatable, diagnostic methods such as cardiac MRI and biomarkers show promise in improving diagnostic accuracy. The purpose of this study is to describe the spectrum of pediatric acute myocarditis, assess existing therapy approaches, and develop regional guidelines based on the experience of a tertiary care institution.  Methods Children diagnosed with acute myocarditis over a six-month period were included in this retrospective and descriptive hospital-based study. Data on demographics, clinical presentations, diagnostic tests, treatments, and results were gathered and examined. Descriptive statistics, non-parametric tests for categorical variables, and Spearman's correlation tests for continuous data were used in the statistical analysis, with a significance level of p < 0.05.  Results Of the 99 patients included, the mean age was 2.37 years, with males making up the majority (n = 54, 54.55%). Clinical symptoms typically included shortness of breath (n = 998, 99.0%), vomiting (n = 63, 63.6%), and chest pain (n = 6, 6.1%). High levels of troponin I (n = 70, 70.7%), cardiomegaly on a chest X-ray (n = 97, 97.0%), and different degrees of ventricular dysfunction were found in the laboratory and in imaging studies. Methylprednisolone (n = 84, 84.8%) and IV immunoglobulin (n = 54, 54.5%) were the most often used treatment modalities, and there were no appreciable differences in the two treatment groups' outcomes. A weak negative association (Spearman's rho = -0.211, p = 0.036) was found in the correlation study between the administration of methylprednisolone and length of stay (LOS), indicating possible benefits in terms of shortening hospital stays.  Conclusion This research offers a significant understanding of the clinical manifestation, treatment, and complications of acute myocarditis in children. Methylprednisolone administration seems to be linked to a shorter length of stay (LOS), despite disagreements over treatment approaches. To confirm these results and provide guidance for evidence-based management guidelines for pediatric myocarditis in our setup, more studies are necessary.

The prevalence and influencing factors of frailty in patients with chronic kidney disease: a systematic review and meta-analysis

BACKGROUND

To investigate the prevalence and influencing factors of frailty and pre-frailty in chronic kidney disease (CKD) patients and thereby provide a scientific basis for effective avoidance of frailty in patients with CKD.

METHODS

PubMed, EMBASE, Web of Science, EBSCO, Cochrane Library, CNKI, VIP, CBMdisc, and Wanfang databases were searched for relevant studies published till December 31, 2021. The summary results were described as odds ratios (ORs) or standardized mean differences (SMDs) with 95% confidence intervals (CIs). A meta-analysis was performed using StataSE12.0.

RESULTS

Fifteen published studies, which enrolled a total of 3294 CKD patients, met the inclusion criteria. The combined prevalence of frailty in CKD patients was 38.1% (95% CI 29.7-46.5%) and pre-frailty was 37.9% (95% CI 32.7-43.1%). The main factors influencing frailty in CKD patients were age (SMD 0.524, 95% CI 0.326-0.723), diastolic blood pressure (SMD - 0.294, 95% CI - 0.518 to - 0.071), body mass index (BMI) (SMD - 0.267, 95% CI - 0.471 to - 0.064), grip strength (SMD - 0.929, 95% CI - 1.233 to - 0.626), hemoglobin level (SMD - 0.346, 95% CI - 0.448 to - 0.243), serum albumin level (SMD - 0.533, 95% CI - 0.655 to - 0.411), Charlson Comorbidity Index (SMD 0.421, 95% CI 0.150-0.692), multiple medications (SMD 0.625, 95% CI 0.354-0.895), Mini-Mental State Examination (MMSE) score (SMD - 0.563, 95% CI - 0.846 to - 0.280), and female (OR 2.391, 95% CI 1.236-4.627).

CONCLUSION

Frailty is common in CKD patients. The prevalence of frailty among CKD patients was related to age, diastolic blood pressure, BMI, grip strength, hemoglobin and serum albumin levels, Charlson Comorbidity Index, multiple medications, MMSE score, and female.

Advances in myocarditis management in the light of the latest research and recent guidelines of the European Society of Cardiology

Myocarditis remains an unknown disease with varying clinical manifestations, often leading to heart failure. The latest 2021 and 2022 guidelines of the European Society of Cardiology (ESC) are the first official European documents updating knowledge on the diagnosis and treatment of myocarditis since the 2013 ESC expert consensus statement. These guidelines and new studies allow standardization and improvements to the management of myocarditis. In this review, we discuss the most important aspects of myocarditis diagnosis, therapies and follow-up based on current knowledge.

Multifunctional nanoparticle-mediated combining therapy for human diseases

Combining existing drug therapy is essential in developing new therapeutic agents in disease prevention and treatment. In preclinical investigations, combined effect of certain known drugs has been well established in treating extensive human diseases. Attributed to synergistic effects by targeting various disease pathways and advantages, such as reduced administration dose, decreased toxicity, and alleviated drug resistance, combinatorial treatment is now being pursued by delivering therapeutic agents to combat major clinical illnesses, such as cancer, atherosclerosis, pulmonary hypertension, myocarditis, rheumatoid arthritis, inflammatory bowel disease, metabolic disorders and neurodegenerative diseases. Combinatorial therapy involves combining or co-delivering two or more drugs for treating a specific disease. Nanoparticle (NP)-mediated drug delivery systems, i.e., liposomal NPs, polymeric NPs and nanocrystals, are of great interest in combinatorial therapy for a wide range of disorders due to targeted drug delivery, extended drug release, and higher drug stability to avoid rapid clearance at infected areas. This review summarizes various targets of diseases, preclinical or clinically approved drug combinations and the development of multifunctional NPs for combining therapy and emphasizes combinatorial therapeutic strategies based on drug delivery for treating severe clinical diseases. Ultimately, we discuss the challenging of developing NP-codelivery and translation and provide potential approaches to address the limitations. This review offers a comprehensive overview for recent cutting-edge and challenging in developing NP-mediated combination therapy for human diseases.

Myocarditis: Etiology, Pathogenesis, and Their Implications in Clinical Practice

Myocarditis is an inflammatory disease of the myocardium caused by infectious or non-infectious agents. It can lead to serious short-term and long-term sequalae, such as sudden cardiac death or dilated cardiomyopathy. Due to its heterogenous clinical presentation and disease course, challenging diagnosis and limited evidence for prognostic stratification, myocarditis poses a great challenge to clinicians. As it stands, the pathogenesis and etiology of myocarditis is only partially understood. Moreover, the impact of certain clinical features on risk assessment, patient outcomes and treatment options is not entirely clear. Such data, however, are essential in order to personalize patient care and implement novel therapeutic strategies. In this review, we discuss the possible etiologies of myocarditis, outline the key processes governing its pathogenesis and summarize best available evidence regarding patient outcomes and state-of-the-art therapeutic approaches.

Role of Endomyocardial Biopsy in Diagnostics of Myocarditis

Endomyocardial biopsy as the cornerstone of diagnostics has been re-evaluated throughout the years, leaving unanswered questions on the precedence of it. The reported incidence of myocarditis has increased during the pandemic of coronavirus disease 2019 (COVID-19), reinforcing discussions on appropriate diagnostics of myocarditis. By analysis of evidence-based literature published within the last demi-decade, we aimed to summarize the most recent information in order to evaluate the current role of endomyocardial biopsy in diagnostics and management of myocarditis. For the most part, research published over the last five years showed ongoing uncertainty regarding the use, informativeness, safety and necessity of performing a biopsy. Special circumstances, such as fulminant clinical course or failure to respond to empirical treatment, were reconfirmed as justified indications, with a growing applicability of non-invasive diagnostic approaches for most other cases. We concluded that endomyocardial biopsy, if performed properly and with adjunct diagnostic methods, holds a critical role for treatment correction in specific histological subtypes of myocarditis and for differential diagnosis between immune-mediated myocarditis and secondary infections due to immunosuppressive treatment. A high level of possible misdiagnosing was detected, indicating the need to review terminology used to describe findings of myocardial inflammation that did not meet Dallas criteria.

Successful treatment of fulminant myocarditis with intra-aortic balloon pump counterpulsation combined with immunoglobulin and glucocorticoid in a young male adult

Background

Fulminant myocarditis (FM) is a serious non-specific inflammatory disease of the myocardium. FM tends to occur in adolescents and the course of the disease progresses rapidly. It is prone to cardiogenic shock (CGS) and multiple organ failure (MOF) with high mortality. We report a case of FM with CGS and MOF in a young male who was successfully treated with intra-aortic balloon pump counterpulsation (IABP) combined with intravenous immunoglobulin (IVIG) and glucocorticoid (GC).

Case summary

A 21-year-old previously healthy man presented with fever, headache, and chest tightness. He came to the hospital for emergency treatment. The laboratory data showed that the levels of serum cardiac troponin I (cTnI), N-terminal B-type natriuretic peptide (NT-proBNP), myocardial zymogram, and neutrophils increased. Echocardiography showed pericardial effusion and decreased left ventricular systolic function. ECG showed diffuse ST-segment elevation. He was clinically diagnosed with FM and admitted to the intensive care unit for treatment. Within 48 h of admission, the clinical course of the patient deteriorated rapidly, with CGS accompanied by MOF, high atrioventricular block (AVB), and ventricular tachycardia (VT). After using mechanical circulatory support (MCS) therapy with IABP, IVIG, GC, continuous renal replacement therapy (CRRT), and mechanical ventilation complicated with a temporary cardiac pacemaker, he recovered normal cardiac function. He made a full recovery and was discharged home on day 21.

Discussion

For patients with FM, early diagnosis, close monitoring, timely use of MCS devices, and active comprehensive treatment are very important. MCS devices such as IABP can become lifesaving tools for the treatment of FM.

American College of Rheumatology Clinical Guidance for Multisystem Inflammatory Syndrome in Children Associated With SARS-CoV-2 and Hyperinflammation in Pediatric COVID-19: Version 3

OBJECTIVE

To provide guidance on the management of Multisystem Inflammatory Syndrome in Children (MIS-C), a condition characterized by fever, inflammation, and multiorgan dysfunction that manifests late in the course of SARS-CoV-2 infection. Recommendations are also provided for children with hyperinflammation during COVID-19, the acute, infectious phase of SARS-CoV-2 infection.

METHODS

The Task Force is composed of 9 pediatric rheumatologists and 2 adult rheumatologists, 2 pediatric cardiologists, 2 pediatric infectious disease specialists, and 1 pediatric critical care physician. Preliminary statements addressing clinical questions related to MIS-C and hyperinflammation in COVID-19 were developed based on evidence reports. Consensus was built through a modified Delphi process that involved anonymous voting and webinar discussion. A 9-point scale was used to determine the appropriateness of each statement (median scores of 1-3 for inappropriate, 4-6 for uncertain, and 7-9 for appropriate). Consensus was rated as low, moderate, or high based on dispersion of the votes. Approved guidance statements were those that were classified as appropriate with moderate or high levels of consensus, which were prespecified before voting.

RESULTS

The guidance was approved in June 2020 and updated in November 2020 and October 2021, and consists of 41 final guidance statements accompanied by flow diagrams depicting the diagnostic pathway for MIS-C and recommendations for initial immunomodulatory treatment of MIS-C.

CONCLUSION

Our understanding of SARS-CoV-2-related syndromes in the pediatric population continues to evolve. This guidance document reflects currently available evidence coupled with expert opinion, and will be revised as further evidence becomes available.

Frailty in rheumatoid arthritis: a systematic review and meta-analysis

OBJECTIVE

Rheumatoid arthritis (RA) may cause damage to multiple organs and may further restrict the patient's physical, psychological and social functions. This meta-analysis aimed to explore the prevalence of frailty and prefrailty and the influential factors in RA patients.

METHODS

PubMed, Web of Science, Cochrane, Embase, and CNKI were searched to identify related articles. Articles published before July 23^rd, 2021 that assessed frailty in patients with RA qualified for the systematic review and meta-analysis. A quality appraisal of the studies was performed using the Agency for Healthcare Research and Quality and Newcastle-Ottawa Scales. The pooled results were displayed as odds ratios or standardized mean differences (ORs/SMDs) and 95% confidence intervals (CIs).

RESULTS

The article search generated 2,273 articles, of which 16 satisfied the inclusion criteria and were merged in the final review. A total of 8,556 RA patients were finally included. The pooled prevalence of frailty in the patients with RA was 33.5% (95% CI: 25.2-41.7%), and the pooled prevalence of prefrailty was 39.9% (95% CI: 29.4-50.3%). Subgroup analyses showed that frailty was more prevalent in females (24.7%) than in males (19.1%). The prevalence of prefrailty in females was similar to that in males among the RA patients. Frailty in RA was associated with the female sex (OR: 1.47, 95% CI: 1.04-2.07) and disease activity (OR: 1.47, 95% CI: 1.03-2.09).

CONCLUSION

Frailty is prevalent in RA patients. Female gender and disease activity are associated with the prevalence of frailty in RA patients.

Pediatric Acute Myocarditis With Short-Term Outcomes and Factors for Extracorporeal Membrane Oxygenation: A Single-Center Retrospective Cohort Study in Vietnam

Objective: Data on the management and outcomes of acute myocarditis treated with extracorporeal membrane oxygenation (ECMO) among low- and middle-income countries are limited. This study aimed to determine the short-term outcomes and also identify factors associated with ECMO use among children with acute myocarditis at a tertiary children's hospital in Vietnam. Methods: A single-center, retrospective observational study was conducted between January 2016 and February 2021. Pediatric patients with acute myocarditis, aged 1 month to 16 years, were included. Results: In total, 54 patients (male, 46%; median age, 7 years) with acute myocarditis were included; 37 of them received ECMO support. Thirty percent (16/54) of the patients died, and 12 of them received ECMO. Laboratory variables that differed between survivors and non-survivors included median left ventricular ejection fraction (LVEF) at 48 h (42 vs. 25%; p = 0.001), platelet count (304 g/L [interquartile range (IQR): 243-271] vs. 219 g/L [IQR: 167-297]; p = 0.014), and protein (60 g/dl [IQR: 54-69] vs. 55 [IQR: 50-58]; p = 0.025). Among patients who received ECMO, compared with the survivors, non-survivors had a low LVEF at 48 h (odds ratio (OR), 0.8; 95% confidence interval (CI): 0.6-0.9; p = 0.006) and high vasoactive-inotropic score (OR, 1.0; 95% CI: 1.0-1.0; p = 0.038) and lactate (OR, 2.8; 95% CI, 1.2-6.1; p = 0.013) at 24 h post-ECMO. Conclusions: The case fatality rate among children with acute myocarditis was 30 and 32% among patients requiring ECMO support. Arrhythmia was an indicator for ECMO in patients with cardiogenic shock.

Could the unfortunate outcome of pediatric acute myocarditis be predicted? Factors contributing to a poor outcome in myocarditis

OBJECTIVE

Myocarditis has spontaneous resolution in 50% of patients. Our study aimed to define risk factors for developing dilated cardiomyopathy (DCM) and death in pediatric patients with acute myocarditis (AM).

METHODS

The retrospective cohort study included all patients with treated AM. The Mother and Child Health Institute from January 2011 to March 2019.

RESULTS

In the study, 62 patients were included, 40 boys and 22 girls (11.15±5.86 years) with AM. Twelve out of sixty-two children had acute fulminant myocarditis. Four patients died in the acute phase of AM, and 11 developed DCM. Follow up was 27.14±36.52 months. Patients with poor outcome (DCM development) were under the age of seven (odds ratio [OR] 10.1; p=0.003), more likely to be girls (OR 4.6; p=0.03), and had fulminant myocarditis (OR 27.0; <0.001). An ejection fraction (EF) <55% and fractional shortening (FS) <30% increased risk of DCM 13- and 5-fold, respectively, but patients with EF between 40 and 55% remain at highest risk of developing DCM. There was a 12-fold increased risk for DCM in patients with left ventricular end-diastolic diameter Z score >2+. The receiver operator curve showed that the lactate dehydrogenase (LDH) cut-off value for developing DCM was 1780 mmol/l (sensitivity 80%, specificity 100%).

CONCLUSION

Acute fulminant myocarditis was an independent risk factor for DCM. Children with EF between 40 and 50% at admission were at highest risk of developing DCM. Lactate dehydrogenase value could be a significant prognostic value for the outcome of pediatric myocarditis.

The Immune and Inflammatory Basis of Acquired Pediatric Cardiac Disease

Children with acquired heart disease face significant health challenges, including a lifetime of strict medical management, multiple cardiac surgeries, and a high mortality risk. Though the presentation of these conditions is diverse, a unifying factor is the role of immune and inflammatory responses in their development and/or progression. For example, infectious agents have been linked to pediatric cardiovascular disease, leading to a large health burden that disproportionately affects low-income areas. Other implicated mechanisms include antibody targeting of cardiac proteins, infection of cardiac cells, and inflammation-mediated damage to cardiac structures. These changes can alter blood flow patterns, change extracellular matrix composition, and induce cardiac remodeling. Therefore, understanding the relationship between the immune system and cardiovascular disease can inform targeted diagnostic and treatment approaches. In this review, we discuss the current understanding of pediatric immune-associated cardiac diseases, challenges in the field, and areas of research with potential for clinical benefit.

Could the unfortunate outcome of pediatric acute myocarditis be predicted? Factors contributing to a poor outcome in myocarditis

OBJECTIVE

Myocarditis has spontaneous resolution in 50% of patients. Our study aimed to define risk factors for developing dilated cardiomyopathy (DCM) and death in pediatric patients with acute myocarditis (AM).

METHODS

The retrospective cohort study included all patients with treated AM. The Mother and Child Health Institute from January 2011 to March 2019.

RESULTS

In the study, 62 patients were included, 40 boys and 22 girls (11.15±5.86 years) with AM. Twelve out of sixty-two children had acute fulminant myocarditis. Four patients died in the acute phase of AM, and 11 developed DCM. Follow up was 27.14±36.52 months. Patients with poor outcome (DCM development) were under the age of seven (odds ratio [OR] 10.1; p=0.003), more likely to be girls (OR 4.6; p=0.03), and had fulminant myocarditis (OR 27.0; <0.001). An ejection fraction (EF) <55% and fractional shortening (FS) <30% increased risk of DCM 13- and 5-fold, respectively, but patients with EF between 40 and 55% remain at highest risk of developing DCM. There was a 12-fold increased risk for DCM in patients with left ventricular end-diastolic diameter Z score >2+. The receiver operator curve showed that the lactate dehydrogenase (LDH) cut-off value for developing DCM was 1780 mmol/l (sensitivity 80%, specificity 100%).

CONCLUSION

Acute fulminant myocarditis was an independent risk factor for DCM. Children with EF between 40 and 50% at admission were at highest risk of developing DCM. Lactate dehydrogenase value could be a significant prognostic value for the outcome of pediatric myocarditis.

The use of extracorporeal membrane oxygenation in the treatment of fulminant myocarditis: Current progress and clinical outcomes

Myocarditis is an inflammatory condition of the myocardium and is usually categorised as acute nonfulminant and acute fulminant myocarditis. Myocardial injury can result via viral infections, direct injury or immune responses. Fulminant myocarditis can be characterised by severe and sudden cardiac inflammation that may result from cardiogenic shock, ventricular arrhythmias or multi-organ system failure. Extracorporeal membrane oxygenation (ECMO), also known as extracorporeal life support, is an effective technique for patients with fulminant myocarditis, providing heart and lung support and adequate gas exchange or perfusion to sustain life. Essentially, ECMO pumps blood out of the body to an oxygenator that acts as an artificial lung, which adds oxygen to the blood and removes carbon dioxide. This report aims to review recent advances in ECMO and relate case studies of fulminant myocarditis patients. The types of ECMO, predictive factors for success, clinical studies and recent technological advances in the field will be discussed.

The Trilogy of SARS-CoV-2 in Pediatrics (Part 2): Multisystem Inflammatory Syndrome in Children

Multisystem Inflammatory Syndrome in Children (MIS-C) was first recognized as a novel illness in 2020 with manifestations similar to other hyperinflammatory syndromes, such as Kawasaki disease or macrophage activation syndrome. Severity varies from a self-limited febrile illness to shock requiring inotropes and mechanical ventilation. Gastrointestinal symptoms and persistent fevers are the most common clinical symptoms, with the addition of cardiac manifestations inclusive of ventricular dysfunction and coronary artery aneurysms. With no controlled trials or comparative effectiveness studies evaluating treatment of MIS-C to date, current treatment with immunomodulatory agents has mainly been derived from previous experience treating Kawasaki disease. This article provides a comprehensive review summarizing published data for the evaluation and management of MIS-C, with a focus on pharmacotherapy treatment considerations.

American College of Rheumatology Clinical Guidance for Multisystem Inflammatory Syndrome in Children Associated With SARS-CoV-2 and Hyperinflammation in Pediatric COVID-19: Version 2

OBJECTIVE

To provide guidance on the management of Multisystem Inflammatory Syndrome in Children (MIS-C), a condition characterized by fever, inflammation, and multiorgan dysfunction that manifests late in the course of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Recommendations are also provided for children with hyperinflammation during coronavirus disease 2019 (COVID-19), the acute, infectious phase of SARS-CoV-2 infection.

METHODS

The Task Force was composed of 9 pediatric rheumatologists and 2 adult rheumatologists, 2 pediatric cardiologists, 2 pediatric infectious disease specialists, and 1 pediatric critical care physician. Preliminary statements addressing clinical questions related to MIS-C and hyperinflammation in COVID-19 were developed based on evidence reports. Consensus was built through a modified Delphi process that involved anonymous voting and webinar discussion. A 9-point scale was used to determine the appropriateness of each statement (median scores of 1-3 for inappropriate, 4-6 for uncertain, and 7-9 for appropriate). Consensus was rated as low, moderate, or high based on dispersion of the votes. Approved guidance statements were those that were classified as appropriate with moderate or high levels of consensus, which were prespecified before voting.

RESULTS

The first version of the guidance was approved in June 2020, and consisted of 40 final guidance statements accompanied by a flow diagram depicting the diagnostic pathway for MIS-C. The document was revised in November 2020, and a new flow diagram with recommendations for initial immunomodulatory treatment of MIS-C was added.

CONCLUSION

Our understanding of SARS-CoV-2-related syndromes in the pediatric population continues to evolve. This guidance document reflects currently available evidence coupled with expert opinion, and will be revised as further evidence becomes available.

Multisystem inflammatory syndrome in children

PURPOSE OF REVIEW

Here we summarize current knowledge about multisystem inflammatory syndrome in children (MIS-C), a presumed postinfectious inflammatory condition that has emerged as an important COVID-19-associated complication, to help clinicians identify and manage cases.

RECENT FINDINGS

Clinical presentation of MIS-C is dominated by significant inflammation. Fever, gastrointestinal symptoms, cardiac dysfunction, and hypotension are common features. Kawasaki disease-like findings are common, but epidemiologic data and recent mechanistic studies suggest that distinct inflammatory pathways mediate Kawasaki disease and MIS-C. A broad diagnostic approach is recommended, given overlapping presentations between MIS-C and many other disease processes. Current management of MIS-C is highly variable, depending on illness severity, and can range from supportive care to aggressive immune modulation. A multidisciplinary approach with early involvement of multiple pediatric subspecialists is recommended for complicated cases.

SUMMARY

Several studies have described the clinical manifestations of MIS-C, but definitive diagnosis remains challenging. Robust information about long-term outcomes awaits further study, as do immunologic data to refine diagnostic and therapeutic strategies.

Fulminant Myocarditis in Covid 19 - Case report

Fulminant myocarditis (FM) is a syndrome characterized by sudden and severe diffuse cardiac inflammation often leading to death resulting from cardiogenic shock, ventricular arrhythmias, or multi-organ system failure. Clinical presentations vary widely, but the main characteristic is a rapidly progressive clinical course with the need of hemodynamic support. We present a clinical case of a patient with COVID-19 admitted to our cardiac intensive care unit with severely reduced left ventricular ejection fraction and worsening clinical course ending in cardiogenic shock in a very short time. The only available imaging technique in these fast-deteriorating patients is the bedside echocardiography, helping to provide accurate assessment and adequate treatment as soon as possible. Even though the current recommendations imply the use of cardiac magnetic resonance (CMR) and endomyocardial biopsy (EMB) as a diagnostic tool for myocarditis, their application in the COVID-19 pandemic is limited. The use of inotropes and mechanical support is the recommended and the final challenge as a bridge to recovery or bridge to transplant. In the settings where CMR and EMB are not feasible from an infection control standpoint, the diagnose should rely on the integration of clinical, laboratory (cardiac biomarkers), electrocardiographic (ST-segment changes), and echocardiographic -wall motion abnormalities, ejection fraction, and pericardial effusion- data. Keywords: myocarditis; COVID-19; cardiogenic shock; echocardiography; endomyocardial biopsy

Atrial Flutter-Unique Arrhythmia in Neonatal Population, Presentation of 3 Cases

BACKGROUND

Atrial flutter (AFL) is an uncommon arrhythmia in the pediatric population. It is defined as fast ordered atrial depolarization (about 250-500 beats/min). It occurs mainly in children with congenital heart defects; however, it may also manifest in fetuses and infants with an anatomically healthy heart. In neonates, AFL is most often revealed within the first 2 days after birth.

CLINICAL FINDINGS

In this case report, we present 3 neonates without complex congenital heart defects with AFL, along with the description of the course, diagnostic and therapeutic processes depending on the clinical condition of a child, and response to treatment.

PRIMARY DIAGNOSIS

Symptoms in this group of patients are nonspecific, that is, tachypnea, unwillingness to eat, and fatigue while feeding. The diagnostic process included thorough electro- and echocardiographic assessments. Each child was treated individually due to a different cause of arrhythmia and comorbidities.

INTERVENTIONS

Invasive (electrical cardioversion) and pharmacological methods were used in treatment to achieve conversion to sinus rhythm.

OUTCOMES

One patient required electrical cardioversion, one was treated with amiodarone and digoxin, and one infant received amiodarone. All children achieved conversion to sinus rhythm.

PRACTICE RECOMMENDATIONS

During the follow-up, each child maintained sinus rhythm, which shows that in the neonatal group, it is a unique, but well-controlled, arrhythmia once conversion to sinus rhythm is achieved.

Clinical characteristics and treatment effects of astragalus injection in non-pediatric patients with acute fulminant myocarditis

To explore the clinical characteristics of non-pediatric patients with acute fulminant myocarditis (AFM) and evaluate the treatment effects of astragalus injection on this disease.A total of 54 AFM patients were screened out from 586 patients with acute myocarditis, admitted to the department of cardiology between January 2011 to June 2018. The demographic and clinical data, investigations, treatments, and short-term outcomes were collected and retrospectively analyzed.The mean age of the 54 AFM patients was 34 ± 16.5 years old (range: 13-70 years), including 24 (44.5%) men and 30 (55.5%) women, with a high incidence in 2 age groups: 13-19 and 40-49 years old, despite an inverse trend to the increase of age. All these cases were admitted in emergency conditions: 26 (48.1%) cardiogenic shock, 18 (33.4%) malignant arrhythmias, 8 (14.8%) severe heart failure, and 2 (3.7%) acute pericardial tamponade. Apart from first-aid measures, 37 (68.5%) patients received astragalus injection. During hospitalization, 11 (20.4%) patients died, and 4 (36.3%) of them were from astragalus group while 7 (63.7%) of them from without-astragalus group (P=0.03). Furthermore, the levels of cardiac injury biomarkers, renal function and left ventricular ejection fraction of astragalus group were significantly improved compared with those of without-astragalus group at discharge (all P < .05).Middle-aged people were also prone to AFM. And cardiac shock was the most common, while acute pericardial tamponade was a rare presentation in non-pediatric AFM patients. Astragalus was a potential adjuvant medicine for the treatment of AFM.

American College of Rheumatology Clinical Guidance for Multisystem Inflammatory Syndrome in Children Associated With SARS-CoV-2 and Hyperinflammation in Pediatric COVID-19: Version 1

Objective

To provide guidance on the management of multisystem inflammatory syndrome in children (MIS‐C), a condition characterized by fever, inflammation, and multiorgan dysfunction that manifests late in the course of severe acute respiratory syndrome coronavirus 2 (SARS–CoV‐2) infection, and to provide recommendations for children with hyperinflammation during coronavirus disease 2019 (COVID‐19), the acute, infectious phase of SARS–CoV‐2 infection.

Methods

A multidisciplinary task force was convened by the American College of Rheumatology (ACR) to provide guidance on the management of MIS‐C associated with SARS–CoV‐2 and hyperinflammation in COVID‐19. The task force was composed of 9 pediatric rheumatologists, 2 adult rheumatologists, 2 pediatric cardiologists, 2 pediatric infectious disease specialists, and 1 pediatric critical care physician. Preliminary statements addressing clinical questions related to MIS‐C and hyperinflammation in COVID‐19 were developed based on evidence reports. Consensus was built through a modified Delphi process that involved 2 rounds of anonymous voting and 2 webinars. A 9‐point scale was used to determine the appropriateness of each statement (median scores of 1–3 for inappropriate, 4–6 for uncertain, and 7–9 for appropriate), and consensus was rated as low, moderate, or high based on dispersion of the votes along the numeric scale. Approved guidance statements were those that were classified as appropriate with moderate or high levels of consensus, as prespecified prior to voting.

Results

The ACR task force approved a total of 128 guidance statements addressing the management of MIS‐C and hyperinflammation in pediatric COVID‐19. These statements were refined into 40 final clinical guidance statements, accompanied by a flow diagram depicting the diagnostic pathway for MIS‐C.

Conclusion

Our understanding of SARS–CoV‐2–related syndromes in the pediatric population continues to evolve. The guidance provided in this “living document” reflects currently available evidence, coupled with expert opinion, and will be revised as further evidence becomes available.

Diagnosis, Evaluation, and Treatment of Myocarditis in Children

Myocarditis in the pediatric population can be a challenging diagnosis to make and often requires utilization of multiple diagnostic modalities. The cause is often due to a viral infection with activation of the innate and acquired immune response with either recovery or disease progression. Laboratory testing often includes inflammatory markers, cardiac troponin levels, and natriuretic peptides. Noninvasive testing should include electrocardiogram, echocardiogram, and possibly an MRI. Treatment of myocarditis remains controversial with most providers using immune modulators with intravenous immunoglobulin and corticosteroids.

Decreased sleep quality in patients with systemic lupus erythematosus: a meta-analysis

OBJECTIVES

To obtain a reliable estimation on the sleep quality in patients with systemic lupus erythematosus (SLE) and identify the main sleep problems, a meta-analysis was performed.

METHODS

Up to March 21, 2020, PubMed, EMBASE, and Cochrane Library were searched; quality evaluation were conducted with Newcastle-Ottawa Scale; statistical analyses were performed by stata14.0 software; results were expressed by weighted mean difference or standardized mean difference (WMD/SMD) and 95% confidence interval (CI).

RESULTS

Eighteen case-control studies were included in meta-analysis, 1086 SLE patients and 2866 controls were collected. The score of sleep quality in the case group was higher than that in the control group (SMD = 1.03, 95% CI: 0.80-1.27), and so was the Pittsburgh Sleep Quality Index (PSQI) (WMD = 3.45, 95% CI: 2.49-4.42). The first three complaints of sleep problems in PSQI were daytime dysfunction (WMD = 0.64, 95% CI: 0.36-0.92), subjective sleep quality (WMD = 0.62, 95% CI: 0.40-0.84), and habitual sleep efficiency (WMD = 0.54, 95% CI: 0.37-0.72). Subgroup analyses showed that the score of sleep quality in SLE patients were higher than controls among different regions, races, and disease duration. The sleep quality score of SLE patients with fibromyalgia (FM) was higher than that in general control, but no significant difference as compared with SLE patients without FM.

CONCLUSIONS

Our meta-analysis indicates that the sleep quality of SLE patients is worse than that of the general population; thus, more attention should be paid to the sleep status among this disease. Key Points •The sleep quality of SLE patients is worse than that of the general population. •Region, race, and disease duration are correlated with sleep quality in SLE patients.

A Systematic Review of COVID-19 and Myocarditis

BACKGROUND

The COVID-19 infection which emerged in December 2019, is caused by the virus SARS-CoV-2. Infection with this virus can lead to severe respiratory illness, however, myocarditis has also been reported. The purpose of this study is to identify the clinical features of myocarditis in COVID-19 patients.

METHODS

A systematic review was conducted to investigate characteristics of myocarditis in patients infected with COVID-19 using the search term "Coronavirus" or "COVID" and "myocarditis," "heart," or "retrospective." Case reports and retrospective studies were gathered by searching Medline/Pubmed, Google Scholar, CINAHL, Cochrane CENTRAL, and Web of Science databases. 11 articles were selected for review.

RESULTS

COVID-19 myocarditis affected patients over the age of 50 and incidences among both genders were equally reported. Patients presented with dyspnea, cough, fever with hypotension and chest pain. Laboratory tests revealed leukocytosis with increased C-reactive protein, while arterial blood gas analysis demonstrated respiratory acidosis. All cardiac markers were elevated. Radiographic imaging of the chest showed bilateral ground glass opacities or bilateral infiltrates, while cardiac magnetic resonance imaging produced late gadolinium enhancements. Electrocardiography demonstrated ST-segment elevation or inverted T waves, while echocardiography revealed reduced left ventricular ejection fraction with cardiomegaly or increased wall thickness. Management with corticosteroids was favored in most cases, followed by antiviral medication. The majority of studies reported either recovery or no further clinical deterioration.

CONCLUSION

Current available data on COVID-19 myocarditis is limited. Further research is needed to advance our understanding of COVID-19 myocarditis.

Changing trends in IVIG use in pediatric patients: A retrospective review of practices in a network of major USA pediatric hospitals

The use of immunoglobulins is gradually increasing. Intravenous immunoglobulins (IVIG) are used as replacement therapy for primary and secondary immune deficiencies, and as an anti-inflammatory and immunomodulatory medication for the treatment of neurologic, dermatologic, and rheumatologic diseases. The objective of this study was to analyze trends in the IVIG use in pediatric patients hospitalized to 47 US-based children's hospitals from 2007 to 2014. IVIG was used for the treatment of >2300 primary diagnoses in 53,648 unique patients. The number of IVIG admissions increased by 30.2% during the study period, while the mean rate of IVIG admissions/100,000 admissions increased only 5.8%. Most patients receiving IVIG were children and adolescents. IVIG was frequently used off-label or for the treatment of FDA-approved indications in children under two years of age and BMT patients <20 years of age. Primary immune deficiencies represented only 1.2% of all IVIG admissions. Pediatric patients with mucocutaneous lymph node syndrome (Kawasaki disease, KD) and idiopathic thrombocytopenic purpura (ITP) were two primary consumers of the IVIG. Another top-ranked indications were acute infectious polyneuritis (Guillain-Barré syndrome, GBS) and prophylaxis of infections in patients receiving antineoplastic chemotherapy. IVIG usage is a dynamic process guided by emerging evidence and FDA approval for new indications. IVIG was mostly prescribed for treatment of diseases with pathologic immune responses to foreign of self-antigens. These indications usually, require higher amounts of IVIG per admission. More studies are needed to understand whether IVIG treatments of off-label indications are effective and cost-efficient.