The Natural History of Severe Acute Respiratory Syndrome Coronavirus 2-Related Multisystem Inflammatory Syndrome in Children: A Systematic Review

Subcutaneous anakinra in the management of refractory MIS-C in France

Introduction

Multisystemic inflammatory syndrome in children (MIS-C) is a therapeutic emergency and can lead to myocardial dysfunction (17%-75%) and heart failure (52%-53%). Intravenous immunoglobulins (IVIG) and corticosteroids (CST) have been validated for the management of this condition. Recent reports suggest that an interleukin-1 (IL-1) receptor antagonist, namely anakinra, may be a valuable add-on to the 2019 novel coronavirus disease (COVID-19) treatment for refractory patients. The purpose of this study was to describe the clinico-biological characteristics of patients treated with anakinra as well as the efficacy and safety of subcutaneous anakinra therapy in this condition.

Methods

The prospective multicentre study of children hospitalized for MIS-C between March 2020 and September 2022, including 23 international paediatric centres, followed for a mean duration of 3.072 ± 3.508 months. The patient data were extracted from the Juvenile Inflammatory Rheumatism (JIR) cohort. The clinico-pathological characteristics, cardiac ultrasound data, and adverse events were reported in patients receiving anakinra.

Results

Of the 470 children admitted with MIS-C, 18 French patients (50% girls) with a mean age of 10.06 ± 3.9 years were treated with subcutaneous anakinra. Anakinra was used in two situations, macrophage activation syndrome (MAS) (4 patients) and heart failure (14 patients) with a median left ventricular ejection fraction (LVEF) of 39.5% (30%-45%). The average dose of anakinra received was 2.53 ± 1.3 mg/kg/day for a median duration of 3 days. Prior to introduction, 78% (n = 14/18) of the patients had received CST and 56% (n = 10/18) had received IVIG. Only two patients received IVIG alone and six received CST alone plus anakinra. In 10% of cases, IVIG was poorly tolerated from a cardiovascular point of view and was discontinued. Transient elevations in serum transaminases were noted in four patients on anakinra without the need for treatment or dose modification. In all patients, rapid (48 h) improvement in myocardial function was observed (LVEF > 55%) with a concomitant significant decrease in myocardial enzymes (p < 0.05). All patients survived with complete recovery of cardiac function without sequelae.

Conclusions

Subcutaneous anakinra appears to be a safe and effective treatment for the management of heart failure or MAS in MIS-C patients. The value of IVIG in these two situations remains to be reviewed.

Navigating the Spectrum of Two Pediatric COVID-19 Complications: Multi-System Inflammatory Syndrome in Children and Post-Acute Sequelae of SARS-CoV-2 Infection

PURPOSE

This review summarizes the current scope of understanding associated with two common post-infectious complications associated with COVID-19 infection: Multi-System Inflammatory Syndrome in Children (MIS-C) and Post-Acute Sequelae of SARS-CoV-2 infection (PASC). It identifies current gaps in the knowledge and issues that may limit the ability to fill these gaps. This review provides a framework to drive continued research.

METHODS

A comprehensive review of the current literature was performed, identifying seminal articles describing the emergence of MIS-C and PASC, and works from the literature focused on the clinical implications and pathophysiologic understanding of these disorders.

FINDINGS

Although pediatric patients experienced few severe cases of acute COVID-19 infection, the burden of disease from post-infectious sequelae is substantial. Mortality is low, but morbidity is significant. There are still numerous unknowns about the pathophysiology of both MIS-C and PASC; however, with widespread immunity developing after increased vaccination and prior infection, it may be difficult to perform adequate prospective studies to answer pathophysiologic questions. Long-term sequalae of MIS-C seem to be minimal whereas, by definition, PASC is an ongoing problem and may be severe.

IMPLICATIONS

The rapid sharing of information regarding novel conditions such as MIS-C and PASC are key to interventions related to future post-infectious sequelae outside of those stemming from COVID-19. Although MIS-C seems unlikely to return as a clinical condition in substantial numbers, there is still significant learning that can be gleaned from existing patients about general aspects of epidemiology, equity, and pathophysiology. There is significant morbidity associated with PASC and additional resources need to be dedicated to determining appropriate and effective therapies moving forward.

Comparison of Eosinophil Counts in Inflammatory Conditions: Multisystem Inflammatory Syndrome in Children, Kawasaki Disease, and Infectious Mononucleosis

This study examined the distinctions between multisystem inflammatory syndrome associated with coronavirus disease 2019, Kawasaki disease, and infectious mononucleosis. These three inflammatory disorders have commonalities according to clinical and laboratory results, particularly in relation to eosinophil levels. In this retrospective, single-center study, we documented the examination records (acute phase reactants and complete blood count) and clinical and cardiological findings of 130 patients diagnosed with multisystem inflammatory syndrome, Kawasaki disease, and infectious mononucleosis. These patients were treated and received follow-up care in our hospital from March 12, 2020, to September 13, 2022, as per the hospital records. Statistical analyses were performed using NCSS 2007, version 1 software. Eosinopenia was more prevalent in children with multisystem inflammatory syndrome than in those with Kawasaki disease, who showed normal or elevated eosinophil counts. The eosinophil counts in patients with infectious mononucleosis typically fell within the normal range. Our study found no correlation between the eosinophil counts and cardiac involvement in pediatric patients with either condition. These findings indicate a higher prevalence of eosinopenia in patients with multisystem inflammatory syndrome, irrespective of cardiac involvement, than in those with Kawasaki disease. Despite similarities in clinical findings, Kawasaki disease and multisystem inflammatory syndrome in children necessitate further studies for distinct characteristic elucidation.

Clinical Impact of a Standardized Risk-Stratified Thromboprophylaxis Protocol for Multisystem Inflammatory Syndrome in Children

OBJECTIVE

To evaluate the clinical impact of an institutional thromboprophylaxis protocol in patients with multisystem inflammatory syndrome in children (MIS-C), who are at increased risk for thromboembolism (TE).

STUDY DESIGN

We conducted a single-center retrospective cohort study of children less than 18 years between March 2020 and December 2021. Eligible patients were confirmed with MIS-C and were managed with a standardized multidisciplinary treatment approach that included a thromboprophylaxis protocol to guide and unify clinical practice. For high-risk patients, prophylactic dose enoxaparin (target anti-Factor Xa 0.1-0.3 U/mL) was added. In high-risk patients with TE risk factors persistent at hospital discharge, thromboprophylaxis was prescribed for an additional 30 days.

RESULTS

Of 135 patients with MIS-C, 124 (92%) required intensive care unit stay and 64 (47%) required a central venous catheter for a median duration of 5 days (IQR, 4-7). Prophylactic dose enoxaparin was initiated in 116 out of 121 patients (96%) deemed high-risk per our protocol at a median of 1 day after admission [IQR, 0-3] achieving target levels at a median of 1 day [IQR, 1-2]. The median initial anti-Factor Xa level was 0.13 u/mL [IQR, 0.05-0.19]. One patient (0.7%) developed symptomatic noncatheter related superficial vein thrombosis requiring therapeutic anticoagulation. Thromboprophylaxis was extended for 30 days after discharge in 108 out of 135 patients (80%). Bleeding events occurred in 5 patients during hospitalization (4.2%). All bleeding events were clinically relevant nonmajor bleeding. There were no deaths.

CONCLUSIONS

Implementation of an institutional standardized thromboprophylaxis protocol in MIS-C was feasible and led to timely initiation of prophylactic anticoagulation and low rates of TEs and bleeding complications.

Expanding the Differential for Alternative Diagnoses in the Workup of Multisystem Inflammatory Syndrome in Children

BACKGROUND

Multisystem inflammatory syndrome in children (MIS-C) is a rare inflammatory syndrome associated with SARS-CoV-2 infection. Children are increasingly admitted for MIS-C evaluation, but instead found to have alternative diagnoses.

METHODS

Retrospective study of all pediatric patients <21 years of age hospitalized between August 1, 2020, and July 31, 2021, with clinical concern for MIS-C at the time of presentation were identified through use of an institutional computerized MIS-C order entry set. Final diagnoses were then collected through primary review of the medical record from the time of initial presentation through 1-month postdischarge.

RESULTS

Of 359 cases identified through the MIS-C order entry set, 126 (35.1%) met criteria for MIS-C, 28 had Kawasaki Disease (KD) (7.8%), and 11 cases met criteria for both MIS-C and KD (3.1%), leaving 194 (54.0%) patients ruled out and categorized as "MIS-C mimickers." Infectious diagnoses were the most common MIS-C mimickers (78.9%). Of the infectious etiologies, bacterial (51.0%) and viral (52.3%) etiologies were seen with similar frequency.

CONCLUSIONS

We describe MIS-C mimickers spanning multiple subspecialties, with infectious etiologies predominating, which can aid clinicians in the consideration of diagnostic testing, with the goal of achieving timely and accurate diagnoses.

Thromboprophylaxis for Coagulopathy Related to COVID-19 in Pediatrics: A Narrative Review

In addition to harming the respiratory system, COVID-19 can affect multiple organs. Children may develop a specific complication of COVID-19 called multisystem inflammatory syndrome in children (MIS-C) which could influence the vascular system of children and cause multiple coagulopathies in the body. Information on the use of thromboprophylaxis in this condition was collected via the review of various articles. In general, different factors in immune system responses can trigger the initiation of thrombotic events. Studies have shown that starting anticoagulant prophylaxis, which contributes to decreased thrombotic events, is dependent on the patient's condition and D-dimer levels. However, further studies on pediatric populations are needed to establish the role of anticoagulants in children with this condition.

Changes in retinal and choroidal capillary dynamics in patients with multisystem inflammatory syndrome in children

PURPOSE

To evaluate patients with multisystemic inflammatory syndrome in children (MIS-C) associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection using optical coherence tomography angiography (OCTA) during and after resolution of inflammation to investigate the effect of this entity on the retinal and choroidal circulation.

METHODS

The study included 38 eyes of 19 patients diagnosed as having MIS-C between March 2021 and June 2021. OCTA measurements of choroidal thickness and vessel density in the radial peripapillary capillary plexus (RPCP), superficial capillary plexus (SCP), and deep capillary plexus (DCP) obtained at time of diagnosis and 60 days later were compared. Correlations between C-reactive protein (CRP) levels at diagnosis and retinochoroidal involvement were investigated.

RESULTS

Compared to post-recovery follow-up examinations, patients with active MIS-C showed foveal avascular zone enlargement (p = 0.031), decreased vessel density in the temporal parafoveal SCP (p = 0.047) and all parafoveal areas of the DCP (p < 0.05 for all), and increased choroidal thickness (p = 0.021). Correlation analysis between CRP levels and OCTA changes during MIS-C revealed significant negative correlations with all parafoveal sectors of the SCP and DCP and a significant positive correlation with CT.

CONCLUSION

There were especially marked effects on the DCP and choroid in MIS-C patients. Our findings also correlate with CRP levels. The use of optical coherence tomography angiography in patients with multisystemic inflammatory syndrome may have potential future implications for detecting ocular microvascular changes that occur before permanent damage develops. Clinical Trial Registration Number and Date: 77/1340; March 1, 2021.

Conservative treatment with mouthwashes followed by tongue photo biomodulation therapy in Covid-19: a case report

Background

Oral manifestations of coronavirus disease 2019 (COVID-19), including ulcers, herpetiform lesions, macules, and petechiae, among others, are becoming increasingly recognized, but there is little guidance on their treatment. Reported cases have described treatment with various mouthwashes containing antivirals, antifungals, antibiotics, anesthetics, or steroids. Our case report is unique in that we provide guidance on the judicious use of these medications, followed by photobiomodulation therapy if the manifestations are treatment resistant.

Case presentation

We describe a 30-year-old Caucasian woman who tested positive for COVID-19 after developing nasal congestion and cough. Ten days after testing positive, she developed a systemic rash on her extremities and torso. At the same time, she developed swelling of the tongue lasting 1 hour, with subsequent appearance of oral lesions that resembled geographic tongue. She also had an irritable sensation on her tongue and some mild loss of sense of taste. We opted for conservative therapy, including mouth rinses containing lidocaine to be used every 6 hours. The patient used the mouth rinse therapy for 1 month and experienced a 90% improvement in her oral lesions and tongue sensitivity. However, she had repeated flares every 3 weeks over a 6-month period, and the steroid mouthwash achieved incomplete resolution. After three sessions of photobiomodulation therapy, she had no further flares or tongue sensitivity and the lesions healed.

Conclusions

The implication of our report is that we promote the judicious use of topical antibiotics, antivirals, antifungals, and steroids for when they are indicated. We propose lidocaine-containing mouth rinses and steroid mouthwash as an initial, symptomatic treatment regimen for ‘COVID-19 tongue.’ If there is failure of resolution, we recommend photobiomodulation therapy.

Kidney health in the COVID-19 pandemic: An umbrella review of meta-analyses and systematic reviews

Background

This umbrella review aims to consolidate evidence from systematic reviews and meta-analyses investigating the impact of the coronavirus disease-2019 (COVID-19) on kidney health, and the associations between kidney diseases and clinical outcomes in COVID-19 patients.

Methods

Five databases, namely, EMBASE, PubMed, Web of Science, the Cochrane Database of Systematic Reviews and Ovid Medline, were searched for meta-analyses and systematic reviews from January 1, 2020 to June 2, 2022. Two reviewers independently selected reviews, identified reviews for inclusion and extracted data. Disagreements were resolved by group discussions. Two reviewers independently assessed the methodological quality of all included reviews using ROBIS tool. A narrative synthesis was conducted. The characteristics and major findings of the included reviews are presented using tables and forest plots. The included meta-analyses were updated when necessary. The review protocol was prospectively registered in PROSPERO (CRD42021266300).

Results

A total of 103 reviews were identified. Using ROBIS, 30 reviews were rated as low risk of bias. Data from these 30 reviews were included in the narrative synthesis. Ten meta-analyses were updated by incorporating 119 newly available cohort studies. Hospitalized COVID-19 patients had a notable acute kidney injury (AKI) incidence of 27.17%. AKI was significantly associated with mortality (pooled OR: 5.24) and severe conditions in COVID-19 patients (OR: 14.94). The pooled prevalence of CKD in COVID-19 patients was 5.7%. Pre-existing CKD was associated with a higher risk of death (pooled OR: 2.21) and disease severity (pooled OR: 1.87). Kidney transplant recipients were susceptible to SARS-CoV-2 infection (incidence: 23 per 10,000 person-weeks) with a pooled mortality of 18%.

Conclusion

Kidney disease such as CKD or recipients of kidney transplants were at increased risk of contracting COVID-19. Persons with COVID-19 also had a notable AKI incidence. AKI, the need for RRT, pre-existing CKD and a history of kidney transplantation are associated with adverse outcomes in COVID-19.

Systematic review registration

www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021266300, identifier: CRD42021266300.

Coagulation Abnormalities and Clinical Complications in Children With SARS-CoV-2: A Systematic Review of 48,322 Patients

Given the limited information on the coagulation abnormalities of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in pediatric patients, we designed a systematic review to evaluate this topic. A comprehensive literature search was conducted for "SARS-CoV-2," "coagulopathy," and "pediatrics." Two authors independently screened the articles that the search returned for bleeding, thrombosis, anticoagulant and/or antiplatelet usage, and abnormal laboratory markers in pediatric patients with SARS-CoV-2, and the authors then extracted the relevant data. One hundred twenty-six publications were included. Thirty-four (27%) studies reported thrombotic complications in 504 patients. Thirty-one (25%) studies reported bleeding complications in 410 patients. Ninety-eight (78%) studies reported abnormal laboratory values in 6580 patients. Finally, 56 (44%) studies reported anticoagulant and/or antiplatelet usage in 3124 patients. The variety of laboratory abnormalities and coagulation complications associated with SARS-CoV-2 presented in this review highlights the complexity and variability of the disease presentation in infants and children.

Ocular manifestations of COVID-19 in the pediatric age group

The coronavirus disease 2019 (COVID-19) is now known to be associated with several ocular manifestations. The literature thoroughly discussed those that affect adults, with a lesser focus in the pediatric age group. We aim to outline the various pediatric ocular manifestations described in the literature. The manifestations may be divided into isolated events attributed to COVID-19 or occurring in the new multisystem inflammatory syndrome in children (MIS-C), a novel entity associated by COVID-19 infection. Ocular manifestations have virtually affected all ages. They manifested in neonates, infants, children, and adolescents. Episcleritis, conjunctivitis, optic neuritis, cranial nerve palsies, retinal vein occlusion, retinal vasculitis, retinal changes, orbital myositis, orbital cellulitis were reported in the literature with this emerging viral illness. Conjunctivitis was the most common ocular manifestation in MIS-C in nearly half of the patients. Other ocular manifestations in MIS-C were anterior uveitis, corneal epitheliopathy, optic neuritis, idiopathic intracranial hypertension, and retinitis. The clinical outcome was favorable, and children regain their visual ability with minimal or no deficits in most of the cases. Further follow-up may be warranted to better understand the long-term effects and visual prognosis.

Coagulation Abnormalities and Management in Hospitalized Pediatric Patients With COVID-19

BACKGROUND

The incidence and severity of coagulation abnormalities have not been extensively studied in pediatric populations with coronavirus disease 2019 (COVID-19). Moreover, their association with an increased risk for thromboembolic events remains unclear, and there is a lack of evidence for optimal prophylactic antithrombotic management. The aim of our study was to present our experience in evaluation, management, and long-term outcomes of coagulation abnormalities in pediatric hospitalized patients with COVID-19.

METHODS

A prospective study was performed in all children hospitalized for COVID-19 during a 6-month period focusing on patients' coagulation abnormalities, the normalization of the coagulation profile with or without anticoagulation prophylaxis and the clinical outcome of the disease.

RESULTS

Two hundred twenty-three patients (median age: 11.4 months) were enrolled in the study. Coagulation abnormalities were detected in 92.4% of patients with increased D-dimer levels to be the most common abnormality detected in 84.3% of patients. Prophylactic anticoagulation was initiated only in 7 (3.1%) selected patients with severe COVID-19 and at least 2 risk factors for venous thromboembolism (VTE) and in all patients with previous history of VTE. Follow-up coagulation profile in 85 patients showed that changes over time had a tendency towards normalization irrespectively of the initiation of anticoagulant thromboprophylaxis. No thrombotic complications were observed 3 months upon discharge.

CONCLUSIONS

Although abnormal findings in coagulation profile were very common, they were not associated with risk for VTE even in severe cases. A trend of normalization early in the course of the disease was observed regardless of the use of anticoagulant thromboprophylaxis.

Determination of Factors to Distinguish MIS-C from Acute Appendicitis in Children with Acute Abdominal Pain

INTRODUCTION

 The aim of this study was to make the differential diagnosis between acute appendicitis and multisystem inflammatory syndrome in children (MIS-C) for patients presenting with the complaint of acute abdominal pain (AAP) and to identify the determining factors for the diagnosis of MIS-C.

MATERIALS AND METHODS

 Eighty-one children presenting with AAP/suspected AAP were evaluated. Of these, 24 (29.6%) were included in the MIS-C group (MIS-C/g) and 57 were included in the suspected appendicitis group (S-A/g), which consisted of two subgroups: appendicitis group (A/g) and control observation group (CO/g).

RESULTS

 Comparing MIS-C/g, A/g, and CO/g, duration of abdominal pain (2.4, 1.5, 1.8 days), high-grade fever (38.8, 36.7, 37°C), severe vomiting, and severe diarrhea were higher in MIS-C/g. Lymphocytes count (LC) was lower, while values of C-reactive protein (CRP), ferritin, and coagulopathy were higher in MIS-C/g (p < 0.05). The optimal cutoffs for the duration of abdominal pain was 2.5 days; the duration of fever, 1.5 days; peak value of fever, 39°C; neutrophil count, 13,225 × 1,000 cell/µMoL; LC, 600 × 1,000 cell/µMoL; ferritin, 233 µg/L; and D-dimer, 16.4 mg/L (p < 0.05). The optimal cutoff for CRP was 130 mg/L (sensitivity 88.9, specificity 100%, positive predictive value 100%, NPV, negative predictive value 92.5%, p < 0.001). All patients in MIS-C/g tested positive by serology by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

CONCLUSION

 The duration of abdominal pain, presence of high-grade and prolonged fever, and evaluation of hemogram in terms of high neutrophil count and low LC exhibit high sensitivity and negative predictive value for MIS-C presenting with AAP. In case of doubt, inflammatory markers such as CRP, ferritin, D-dimer, and serology for SARS-CoV-2 should be studied to confirm the diagnosis.

Neurological Manifestations in Pediatric Patients Hospitalized for COVID-19: Experiences of the National Medical Center “20 de Noviembre” in Mexico City

COVID-19 has affected millions of children and, while it was previously considered as a respiratory disease, neurologic involvement has also been documented. The objective of this study was to identify the neurological manifestations (NMs) and the outcomes of children with COVID-19 who attended the National Medical Center “20 de Noviembre”. Methods: A retrospective cohort study of children hospitalized for COVID-19 from April 2020 to March 2021 was conducted. Clinical-demographic data were registered. Neurologic manifestations were defined as any clinical neurological expression of the central and/or peripheral nervous system that occurred during admission or hospitalization. Results: In total, 46 children with a confirmed COVID-19 result, 26 (56.5%) boys and 20 (43.5%) girls with a median age of 8.9 ± 4.6 years, constituted the study population. Half of the children showed some NMs, and this group of patients concomitantly showed acute lymphoblastic leukemia (ALL, 56%), obesity (17.3%), or acute myeloblastic leukemia (AML, 4.3%). The most frequently described NMs were headache (13, 56%), encephalopathy (10, 43.47%), and epilepsy (4, 17.39%). The mortality rate in children with NMs was 21.7% and they had a higher mortality rate when compared to those without NM p ≤ 0.025. Conclusions: NMs occurred predominantly in male children aged 6 to 12 years; ALL was the most frequent comorbidity. Headache prevailed and hypoxemia, hypocalcemia, elevated ferritin, and C-reactive protein were associated with NM. Finally, NMs were a risk factor for mortality.

Epidemiology, Clinical Features, and Outcomes of Multisystem Inflammatory Syndrome in Children (MIS-C) and Adolescents—a Live Systematic Review and Meta-analysis

Purpose of Review

A multisystem inflammatory condition occurring in children and adolescents with COVID-19 has become increasingly recognized and widely studied globally. This review aims to investigate and synthesize evolving evidence on its clinical characteristics, management, and outcomes in pediatric patients.

Recent Findings

We retrieved data from PubMed, EMBASE, Cochrane Library, WHO COVID-19 Database, Google Scholar, and preprint databases, covering a timeline from December 1, 2019, to July 31, 2021. A total of 123 eligible studies were included in the final descriptive and risk factor analyses. We comprehensively reviewed reported multisystem inflammatory syndrome in children (MIS-C) cases from published and preprint studies of various designs to provide an updated evidence on epidemiology, clinical, laboratory and imaging findings, management, and short-term outcomes. Latest evidence suggests that African black and non-Hispanic white are the two most common ethnic groups, constituting 24.89% (95% CI 23.30–26.48%) and 25.18% (95% CI 23.51–26.85%) of the MIS-C population, respectively. Typical symptoms of MIS-C include fever (90.85%, 95% CI 89.86–91.84%), not-specified gastrointestinal symptoms (51.98%, 95% CI 50.13–53.83%), rash (49.63%, 95% CI 47.80–51.47%), abdominal pain (48.97%, 95% CI 47.09–50.85%), conjunctivitis (46.93%, 95% CI 45.17–48.69%), vomiting (43.79%, 95% CI 41.90–45.68%), respiratory symptoms (41.75%, 95% CI 40.01–43.49%), and diarrhea (40.10%, 95% CI 38.23–41.97%). MIS-C patients are less likely to develop conjunctivitis (OR 0.27, 95% CI 0.11–0.67), cervical adenopathy (OR 0.21, 95% CI 0.07–0.68), and rash (OR 0.44, 95% CI 0.26–0.77), in comparison with Kawasaki disease patients. Our review revealed that the majority of MIS-C cases (95.21%) to be full recovered while only 2.41% died from this syndrome. We found significant disparity between low- and middle-income countries and high-income countries in terms of clinical outcomes.

Summary

MIS-C, which appears to be linked to COVID-19, may cause severe inflammation in organs and tissues. Although there is emerging new evidence about the characteristics of this syndrome, its risk factors, and clinical prognosis, much remains unknown about the causality, the optimal prevention and treatment interventions, and long-term outcomes of the MIS-C patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40124-022-00264-1.

Comparison of Multisystem Inflammatory Syndrome in Children-Related Myocarditis, Classic Viral Myocarditis, and COVID-19 Vaccine-Related Myocarditis in Children

Background Although rare, classic viral myocarditis in the pediatric population is a disease that carries significant morbidity and mortality. Since 2020, myocarditis has been a common component of multisystem inflammatory syndrome in children (MIS-C) following SARS-CoV-2 infection. In 2021, myocarditis related to mRNA COVID-19 vaccines was recognized as a rare adverse event. This study aims to compare classic, MIS-C, and COVID-19 vaccine-related myocarditis with regard to clinical presentation, course, and outcomes. Methods and Results In this retrospective cohort study, we compared patients aged <21 years hospitalized at our institution with classic viral myocarditis from 2015 to 2019, MIS-C myocarditis from March 2020 to February 2021, and vaccine-related myocarditis from May 2021 to June 2021. Of 201 total participants, 43 patients had classic myocarditis, 149 had MIS-C myocarditis, and 9 had vaccine-related myocarditis. At presentation, ejection fraction was lowest for those with classic myocarditis, with ejection fraction <55% present in 58% of patients. Nearly all patients with MIS-C myocarditis (n=139, 93%) and all patients with vaccine-related myocarditis (n=9, 100%) had normal left ventricular ejection fraction at the time of discharge compared with 70% (n=30) of the classic myocarditis group (P<0.001). At 3 months after discharge, of the 21 children discharged with depressed ejection fraction, none of the 10 children with MIS-C myocarditis had residual dysfunction compared with 3 of the 11 (27%) patients in the classic myocarditis group. Conclusions Compared with classic myocarditis, those with MIS-C myocarditis had better clinical outcomes, including rapid recovery of cardiac function. Patients with vaccine-related myocarditis had prompt resolution of symptoms and improvement of cardiac function.

Multisystem Inflammatory Syndrome Temporally Related to COVID-19 in Children From Latin America and the Caribbean Region: A Systematic Review With a Meta-Analysis of Data From Regional Surveillance Systems

Background

With the emergence of the COVID-19 pandemic, increasing numbers of cases of the multisystem inflammatory syndrome in children (MIS-C) have been reported worldwide; however, it is unclear whether this syndrome has a differential pattern in children from Latin America and the Caribbean (LAC). We conducted a systematic review and meta-analysis to analyze the epidemiological, clinical, and outcome characteristics of patients with MIS-C in LAC countries.

Methods

A systematic literature search was conducted in the main electronic databases and scientific meetings from March 1, 2020, to June 30, 2021. Available reports on epidemiological surveillance of countries in the region during the same period were analyzed.

Results

Of the 464 relevant studies identified, 23 were included with 592 patients with MIS-C from LAC. Mean age was 6.6 years (IQR, 6-7.4 years); 60% were male. The most common clinical manifestations were fever, rash, and conjunctival injection; 59% showed Kawasaki disease. Pool proportion of shock was 52%. A total of 47% of patients were admitted to the pediatric intensive care unit (PICU), 23% required mechanical ventilation, and 74% required vasoactive drugs. Intravenous gamma globulin alone was administered in 87% of patients, and in combination with steroids in 60% of cases. Length of hospital stay was 10 days (IQR, 9-10) and PICU stay 5.75 (IQR, 5-6). Overall case fatality ratio was 4% and for those hospitalized in the PICU it was 7%.

Conclusion

Limited information was available on the clinical outcomes. Improvements in the surveillance system are required to obtain a better epidemiologic overview in the region.

SARS-CoV-2-Associated Multisystem Inflammatory Syndrome in a Child in Uganda: A Paediatric Experience in a Resource-Limited Setting

SARS-CoV-2-associated Multisystem Inflammatory Syndrome in children (MIS-C) has been described in developed settings that have reported a high burden of COVID-19 cases. However, to date, there are few published cases of MIS-C that have been described in the African region. MIS-C has high morbidity and even mortality without a prompt diagnosis. We report a case of a 9-year-old girl who presented with typical clinical features of MIS-C in Uganda but had a delay in diagnosis. This case report aims to raise awareness among health providers in similar settings to improve clinical suspicion of MIS-C, facilitate prompt diagnosis and treatment, and thus improve outcomes.

Autopsy Histopathologic Cardiac Findings in Two Adolescents Following the Second COVID-19 Vaccine Dose

CONTEXT

- Myocarditis in adolescents has been diagnosed clinically following the administration of the second dose of an mRNA vaccine for coronavirus disease 2019 (COVID-19).

OBJECTIVE

- To examine the autopsy microscopic cardiac findings in adolescent deaths that occurred shortly following administration of the second Pfizer-BioNTech COVID-19 dose to determine if the "myocarditis" described in these instances has the typical histopathology of myocarditis.

DESIGN

- Clinical and autopsy investigation of two teenage boys who died shortly following administration of the second Pfizer-BioNTech COVID-19 dose.

RESULTS

- The microscopic examination revealed features resembling a catecholamine-induced injury, not typical myocarditis pathology.

CONCLUSIONS

- The myocardial injury seen in these post-vaccine hearts is different from typical myocarditis and has an appearance most closely resembling a catecholamine-mediated stress (toxic) cardiomyopathy. Understanding that these instances are different from typical myocarditis and that cytokine storm has a known feedback loop with catecholamines may help guide screening and therapy.

The Role of Anti-IL-1 Medications in Autoinflammatory Disease

The interleukin (IL) -1 family of cytokines are involved in different aspects of inflammation with IL-1 beta being the best known and most powerful proinflammatory cytokine. Dysregulation of IL-1 beta and other family members results in autoinflammatory conditions such as systemic juvenile idiopathic arthritis and familial Mediterranean fever. The growing understanding and knowledge of the pathophysiology of many autoinflammatory diseases have led to the development and use of IL-1 blocking medications for many chronic and disabling diseases. In this article, we present the anti-IL-1 agents and their major indications in pediatric rheumatology. [Pediatr Ann. 2022;51(2):e72-e76.].

Acute Vision Loss and Conjunctival Hemorrhage as Telltale Symptoms of PIMS-TS

There is a global concern about children presenting with inflammatory syndrome with variable clinical features during the ongoing COVID-19 pandemic. This paper reports the first pediatric case of bilateral serous retinal detachment and conjunctival hemorrhage as a revealing pattern of the pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS). Despite the severity of multisystemic involvement, the management with steroids was very successful. Complete remission was obtained within 3 months of acute onset.

The Role of Lung Ultrasound in Diagnosing COVID-19-Related Multisystemic Inflammatory Disease: A Preliminary Experience

BACKGROUND

To date, there are no data regarding the systematic application of Point-of-Care Lung Ultrasound (PoC-LUS) in children with Multisystem Inflammatory Syndrome in Children (MIS-C). The main aim of this study is to show the role of Point-of-Care Lung Ultrasound as an additional aid in the diagnosis of COVID-19-related Multisystem Inflammatory Syndrome in Children (MIS-C).

METHODS

Between April 2020 and April 2021, patients aged 0-18 years referred to our emergency department for fever, and later hospitalized without a specific diagnosis, underwent PoC-LUS. Ultrasound images of patients with a final diagnosis of MIS-C were retrospectively evaluated.

RESULTS

Ten patients were enrolled. All were described to have pleural irregularities and B-lines. In particular: 8/10 children presented with isolated B-lines in at least half of the lung areas of interest; 8/10 presented with multiple B-lines and 3/8 had them in at least 50% of lung areas; 5/10 had a white lung appearance in at least one lung area and 1/5 had them in half of the areas of interest. Pleural effusion was described in 9/10.

CONCLUSIONS

During the ongoing COVID-19 pandemic, we suggest performing PoC-LUS in febrile patients with high levels of inflammatory indices and clinical suspicion of MIS-C, or without a certain diagnosis; the finding of many B-lines and pleural effusion would support the diagnosis of a systemic inflammatory disease.

Thromboembolism in children with multisystem inflammatory syndrome: a literature review

Multisystem inflammatory syndrome in children (MIS-C) is a hyperinflammatory response observed in children several weeks to months after acute infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). On review of all published cases of thromboembolism (TE) as a complication of MIS-C, 33 cases of TE were found with incidence ranging from 1.4 to 6.5%. TE occurred mostly in children aged 12 years and above. One-third of the cases were cerebral infarcts and the remaining cases included intracardiac and radial arterial thromboses, upper and lower extremity deep vein thrombosis, pulmonary embolism, and splenic infarcts. Five were asymptomatic cases and 3/33 (9%) patients (all three with cerebral infarcts) died. To conclude, TE appears to be a significant complication of MIS-C caused by SARS-CoV-2 infection, associated with morbidity and/or mortality. Patients ≥12 years are affected more often, and TE occurs despite thromboprophylaxis in some patients. Thromboprophylaxis should be considered in all cases after reviewing the concomitant bleeding risk. Prospective studies are needed to confirm the role of standard-dose thromboprophylaxis and to explore whether higher-dose thromboprophylaxis is required in certain high-risk patients with MIS-C. IMPACT: Compiles all cases of thromboembolism associated with COVID-19-related MIS-C, a report that has not been published to date.

Hospitalized children with SARS-CoV-2 infection and MIS-C in Jamaica: A dive into the first 15 months of the novel pandemic

OBJECTIVES

COVID-19 in children was initially mild until the emergence of Multisystem Inflammatory Syndrome in Children (MIS-C). We describe pediatric COVID-19 in a developing country within the Caribbean.

METHODS

Jamaican children who were hospitalized with SARS-CoV-2 infection, in one Caribbean regional academic referral center from April 2020 through June 2021 were included. Prospective surveillance and pediatric infectious disease consultations were performed using the CDC's MIS-C case definition. Data were extracted from patients' hospital charts using WHO's reporting form, entered into the RedCap database, and SPSS 28 was used for analysis. MIS-C and non-MIS-C patients were compared using independent sample t-tests for continuous variables and Fisher's exact test for categorical variables, p values < 0.05 were statistically significant.

RESULTS

Seventy-nine children with COVID-19 with/without MIS-C presented to UHWI. Thirty-eight (48%) were mild ambulatory cases. Hospitalizations occurred in 41 (52%) children, with median age of 10 1 2 years. SARS-CoV-2 RT-PCR positivity was present in 26 (63%), Immunoglobulin M, or Immunoglobulin G (IgM/IgG) positivity in 8 (20%), with community exposures in 7 (17%). Eighteen (44%) MIS-C positive patients were significantly more likely than 23 MIS-C negative patients (56%) to present with fever (94% vs. 30%; p < 0.001), fatigue/lethargy (41% vs. 4%; p = 0.006), lymphadenopathy (33% vs. 0%; p = 0.003), elevated neutrophils (100% vs. 87%; p = 0.024), and ESR (78% vs. 9%; p = 0.002). Involvement of > two organ systems occurred more frequently in MIS-C positive cases (100% vs. 34%; p < 0.001), including gastrointestinal (72% vs. 17%; p < 0.001); vomiting/nausea (39% vs. 9%; p < 0.028); hematological/coagulopathic (67% vs. 4%; p < 0.001); dermatologic involvement (56% vs. 0%; p < 0.001); and mucositis (28% vs. 0%; p = 0.001). MIS-C patients had Kawasaki syndrome (44%), cardiac involvement (17%), and pleural effusions (17%). MIS-C patients had >4 abnormal inflammatory biomarkers including D-dimers, C-reactive protein, ESR, ferritin, troponins, lactate dehydrogenase, neutrophils, platelets, lymphocytes, and albumen (72%). MIS-C patients were treated with intravenous immune gamma globulin (78%), aspirin (68%), steroids (50%), and non-invasive ventilation (11%). None required inotropes/vasopressors. MIS-C negative patients received standard care. All recovered except one child who was receiving renal replacement therapy and developed myocardial complications.

CONCLUSIONS

In this first report of COVID-19 from the Caribbean, children and adolescents with and without MIS-C were not very severe. Critical care interventions were minimal and outcomes were excellent.

An Arab Adolescent with Multisystem Inflammatory Syndrome Associated with COVID-19: A Report from Syria

Multisystem inflammatory syndrome in children (MIS-C) is a rare and critical condition that affects children following exposure to severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) infection, leading to multiorgan dysfunction and shock. MIS-C has been reported from different parts of the world but rarely from Arab countries. In this report, we describe a 15-year-old Arab boy who was admitted to the ICU during the surge of Coronavirus transmission in Syria with a clinical picture consistent with MIS-C, including high-grade fever, gastrointestinal symptoms, rash, multiorgan dysfunction, and shock. Laboratory profile showed significant elevation of inflammatory markers, negative SARS-CoV-2 RT-PCR testing but positive serologic testing for SARS-CoV-2. The patient received intravenous immunoglobulins (IVIG) and glucocorticoids with remarkable cardiac improvement and significant alleviation in inflammatory markers. To our knowledge, this is the first reported case of MIS-C from Syria, which adds to the epidemiological data about this new syndrome.

Coagulation profiles and viscoelastic testing in multisystem inflammatory syndrome in children

OBJECTIVE

To characterize viscoelastic testing profiles of children with multisystem inflammatory syndrome in children (MIS-C).

METHODS

This single-center retrospective review included 30 patients diagnosed with MIS-C from March 1 to September 1, 2020. Thromboelastography (TEG) with platelet mapping was performed in 19 (63%) patients and compared to age- and sex-matched controls prior to cardiac surgery. Relationships between TEG parameters and inflammatory markers were assessed using correlation.

RESULTS

Patients with MIS-C had abnormal TEG results compared to controls, including decreased kinetic (K) time (1.1 vs. 1.7 minutes, p < .01), increased alpha angle (75.0° vs. 65.7°, p < .01), increased maximum amplitude (70.8 vs. 58.3 mm, p < .01), and decreased lysis in 30 minutes (Ly30) (1.1% vs. 3.7%, p = .03); consistent with increased clot formation rate and strength, and reduced fibrinolysis. TEG maximum amplitude was moderately correlated with erythrocyte sedimentation rate (ESR) (r = 0.60, p = .02), initial platelet count (r = 0.67, p < .01), and peak platelet count (r = 0.51, p = .03). TEG alpha angle was moderately correlated with peak platelet count (r = 0.54, p = .02). Seventeen (57%) patients received aspirin (ASA) and anticoagulation, five (17%) received only ASA, and three (10%) received only anticoagulation. No patients had a symptomatic thrombotic event. Six (20%) patients had a bleeding event, none of which was major.

CONCLUSIONS

Patients with MIS-C had evidence of hypercoagulability on TEG. Increased ESR and platelets were associated with higher clot strength. Patients were prophylactically treated with ASA or anticoagulation with no symptomatic thrombosis or major bleeding. Further multicenter study is required to characterize the rate of thrombosis and optimal thromboprophylaxis algorithm in this patient population.

COVID-19 in Pediatrics

This article reviews the diagnosis and treatment of infection with severe acute respiratory syndrome coronavirus 2, which causes coronavirus disease 2019, as well as a new inflammatory syndrome after severe acute respiratory syndrome coronavirus 2 infection, called multisystem inflammatory syndrome in children.

Top 10 acral skin manifestations associated with COVID-19: A scoping review

COVID‐19‐associated cutaneous manifestations are one of the most important and relatively common extra‐respiratory presentations of SARS‐COV‐2 infection. The exact identification and classification of these lesions can facilitate the accurate diagnosis and treatment. There are several case reports and small case series which describe cutaneous lesions in hands and feet. Currently, there is no scoping review about acral skin manifestations associated with COVID‐19. This paper covers the COVID‐related acral skin manifestations in 10 entities including acral papulo‐vesicular eruption, acral urticarial lesion, acral non‐inflammatory purpura and necrosis, acro‐ischemia associated COVID‐19, acral vasculitis, chilblain‐like lesion (COVID Toe), acral erythema multiform (EM) like lesion, hand and foot skin lesions associated with multisystem inflammatory syndrome in children (MISC), acral peeling conditions and red half‐moon nail sign. Future studies should focus on exact investigation of etiologies of these lesions including role of immune senescence, environment, gender, immunogenetics and relation of these lesion with major organ involvements.

Cutaneous manifestations in children with SARS-CoV-2 infection and/or COVID-19: what do we know after 10 months under this pandemic?

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become a global crisis. However, cutaneous manifestations in children with SARS-CoV-2 infection have received little attention.

OBJECTIVE

Our study was aimed to present clinical and cutaneous manifestations of children with SARS-CoV-2 and to provide the basis for early diagnosis.

METHODS

We analyzed the clinical data of COVID-19 infected (CI) children worldwide from December 2019 to October 6, 2020, by using search terms "COVID-19," "SARS-CoV-2," "Coronavirus" in combination with "cutaneous," "lesion," "rash," "skin," "dermatology," "epidermis," "dermis," "multisystem inflammatory syndrome." We collected and analyzed the general information, clinical symptoms, cutaneous manifestations, laboratory examination results, history of close contact with CI patients or suspected CI patients, and outcome in CI children.

RESULTS

Among 90 CI children, there were 46 boys (59%) and 32 girls (41%). Erythema was the most frequent lesion, followed by conjunctivitis, and edematous lesions. Face was the most commonly affected location including lips, conjunctivae, tongue, eyes, and eyelids. Sixty-three (73.3%) patients had multisystem inflammatory syndrome (MIS-C). As for clinical symptoms, 70 (81.4%) CI children suffered fever, and 34 (39.5%) patients had lung involvement. Meanwhile, 65.1% of patients had cardiac involvement, 4.7% of patients were asymptomatic, and 71.6% of patients received intravenous immunoglobulin, as well as 31.1% of CI children received systemic corticosteroids. Three children were dead. The most frequent route of infection was familial clustering. As silent virus carriers of CI children, it is important to find out the clinical and cutaneous manifestations in CI children to prevent and control COVID-19 transmission.

Does Covid-19 in children have a milder course than Influenza?

BACKGROUND

In December 2019, a novel type of coronavirus infection emerged in the Wuhan province of China and began to spread rapidly. In this study, we aimed to determine the differences between COVID-19 disease and Influenza.

METHODS

This retrospective study included 164 children with COVID-19, as well as 46 children with Influenza. The two groups were compared with respect to clinical and laboratory parameters and the rates of intensive care and mechanical ventilation requirement.

RESULTS

In both groups, the most common admission complaints were fever and cough. As compared to the COVID-19 group, the Influenza group had significantly higher rates of cough (37 [80.4%] and 38 [23.2%]), fever (31 [67.4%] and 34 [20.7%]), muscle pain (34 [73.9%] and 31 [18.9%]), vomiting (13 [28.9%] and 8 [4.9%]) and tachypnea (32 [69.6%] and 3 [1.8%]) (P < .01 for all comparisons). The mean WBC count (7.10 ± 1.08 vs. 10.90 ± 1.82), mean neutrophil count (3.19 ± 0.58 vs. 6.04 ± 0.97), APTT, CRP, procalcitonin, ALT, and LDH levels were significantly lower in the COVID-19 group compared to the Influenza group (P < .05 for all comparisons). There was, however, no significant difference between the mean lymphocyte counts of both groups. The Influenza group had significantly higher rates of intensive care requirement (19 [41.3%] vs. 3 [1.8%]) and mechanical ventilation requirement (16 [34.8%] vs. 2 [1.2%]) as well as a significantly higher mortality rate (7 [15.2%] vs. 2 [1.2%]) than the COVID-19 group (P < .01).

CONCLUSION

COVID-19 and Influenza may share similar clinical features. According to our findings, however, we believe that COVID-19 disease has a milder clinical and laboratory course than Influenza in children.

Clinical features of multisystem inflammatory syndrome in children

PURPOSE OF REVIEW

To review diagnosis, clinical characteristics and treatment of multisystem inflammatory syndrome in children (MIS-C) associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

RECENT FINDINGS

MIS-C emerged in spring 2020 as a hyperinflammatory syndrome following SARS-CoV-2 exposure in children. Despite growing awareness of MIS-C, diagnosis remains challenging due to the range of phenotypes and severity. Fever accompanied by shock, cardiac dysfunction, gastrointestinal symptoms, or mucocutaneous signs suggestive of Kawasaki disease, especially in the presence of known or suspected coronavirus disease 2019 exposure, should trigger consideration of MIS-C. However, clinical presentations are highly varied and may overlap with other infectious diseases. Clinicians must maintain a high index of suspicion for MIS-C and be aware that patients may develop coronary artery aneurysms and myocarditis even with few or no Kawasaki disease symptoms. More precise diagnostic criteria and specific biomarkers are needed to aid diagnosis. Intravenous immunoglobulin (IVIG) is first-line therapy, and steroids should be considered as initial adjunctive treatment for patients with severe manifestations or other risk factors. Prompt treatment is essential, as patients may worsen acutely, though overall prognosis is reassuring.

SUMMARY

MIS-C associated with SARS-CoV-2 has varied clinical manifestations. Clinicians must be aware of the common presentation and potential for decompensation and cardiac sequalae to guide appropriate evaluation and treatment.

MIS-C-Implications for the Pediatric Surgeon: An Algorithm for Differential Diagnostic Considerations

BACKGROUND

multisystem inflammatory syndrome in children (MIS-C) is a new disease associated with a recent infection with severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2). Affected children can present predominantly with abdominal symptoms, fever and high inflammatory parameters that might lead to a consult by the pediatric surgeon and an indication for surgery.

METHODS

clinical data of three patients with MIS-C that underwent surgery were collected. Histopathological analysis of the appendix was performed.

RESULTS

we present the clinical course of three children with fever, abdominal pain and vomiting for several days. Clinical examination and highly elevated inflammation markers led to indication for laparoscopy; appendectomy was performed in two patients. Because of intraoperative findings or due to lack of postoperative improvement, all patients were reevaluated and tested positive for MIS-C associated laboratory parameters and were subsequently treated with corticosteroids, intravenous immunoglobulins, acetyl salicylic acid and/or light molecular weight heparin.

CONCLUSIONS

we discuss the implications of MIS-C as a new differential diagnosis and stress the importance of assessing the previous medical history, identifying patterns of symptoms and critically surveilling the clinical course. We implemented an algorithm for pediatric surgeons to consider MIS-C as a differential diagnosis for acute abdomen that can be integrated into the surgical workflow.

Current Understanding of Multisystem Inflammatory Syndrome (MIS-C) Following COVID-19 and Its Distinction from Kawasaki Disease

PURPOSE OF REVIEW

In this article, I have reviewed current reports that explore differences and similarities between multisystem inflammatory syndrome in children (MIS-C) and other known multisystem inflammatory diseases seen in children, particularly Kawasaki disease.

RECENT FINDINGS

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a human coronavirus causing the COVID-19 disease which emerged in China in December 2019 and spread rapidly to the entire country and quickly to other countries. Currently, there is a pandemic of SARS-CoV-2 infection that results in 20% of patients admitted to hospital with illness, with 3% developing intractable acute respiratory distress syndrome (ARDS) with high mortality. However, pediatric COVID-19 is still reported to be a mild disease, affecting only 8% of children. Pathogenesis in children is comparable to adults. There are suggested impaired activation of IFN-alpha and IFN regulator 3, decreased cell response causing impaired viral defense, yet the clinical course is mild, and almost all children recover from the infection without major complications. Interestingly, there is a subset of patients that develop a late but marked immunogenic response to COVID-19 and develop MIS-C. Clinical features of MIS-C resemble certain pediatric rheumatologic diseases, such as Kawasaki disease (mucocutaneous lymph node syndrome) which affects small-medium vessels. Other features of MIS-C resemble those of macrophage activation syndrome (MAS). However, recent research suggests distinct clinical and laboratory differences between MIS-C, Kawasaki disease, and MAS. Since the start of the SARS-CoV-2 pandemic, MIS-C has become the candidate for the most common cause of acquired heart disease in children.

Ocular and Systemic Manifestations in Paediatric Multisystem Inflammatory Syndrome Associated with COVID-19

This study aimed to achieve a better understanding of the epidemiological and clinical characteristics of multisystem inflammatory syndrome in children (MIS-C) following coronavirus disease 2019 (COVID-19). We searched PubMed and Embase between December 2019 and March 2021 and included only peer-reviewed clinical studies or case series. The proportions of patients who had conjunctivitis, systemic symptoms/signs (s/s), Kawasaki disease (KD), and exposure history to suspected/confirmed COVID-19 cases were obtained. Moreover, positive rates of the nasopharyngeal real-time reverse transcriptase polymerase chain reaction (RT-PCR) and serum antibody for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were recorded. Overall, 32 studies with 1458 patients were included in the pooled analysis. Around half of the patients had conjunctivitis. The five most common systemic manifestations were fever (96.4%), gastrointestinal s/s (76.7%), shock (61.5%), rash (57.1%), and neurological s/s (36.8%). Almost one-third presented complete KD and about half had exposure history to COVID-19 cases. The positivity of the serology (82.2%) was higher than that of the nasopharyngeal RT-PCR (37.0%). MIS-C associated with COVID-19 leads to several features similar to KD. Epidemiological and laboratory findings suggest that post-infective immune dysregulation may play a predominant role. Further studies are crucial to elucidate the underlying pathogenesis.

COVID-19 associated Multisystem Inflammatory Syndrome in Children (MIS-C) guidelines; revisiting the Western New York approach as the pandemic evolves

Multisystem inflammatory syndrome of children (MIS-C) continues to be a highly concerning diagnosis in those recently infected with SARS-CoV-2. The diagnosis of MIS-C cases will likely become even more challenging as vaccine uptake and natural immunity in previously infected persons leads to lower circulating rates of SARS-CoV-2 infection and will make cases sporadic. Febrile children presenting with cardiac dysfunction, symptoms overlapping Kawasaki disease or significant gastrointestinal complaints warrant a thorough screen in emergency departments, urgent care centers, and outpatient pediatric or family medicine practices. An increased index of suspicion and discussion regarding higher level of care (transferring to pediatric tertiary care centers or to intensive care) continues to be recommended. Herein we outline a broad approach with a multidisciplinary team for those meeting the case definition and believe such an approach is crucial for successful outcomes.

Clinical and radiological findings for the new multisystem inflammatory syndrome in children associated with COVID-19

The World Health Organization defines the multisystem inflammatory syndrome in children (MIS-C) as a new syndrome reported in patients aged <19 years old who have a history of exposure to SARS-CoV-2. The onset of this syndrome is characterized by persistent fever that is associated with lethargy, abdominal pain, vomiting and/or diarrhea, and, less frequently, rash and conjunctivitis. The course and severity of the signs and symptoms vary; in some children, MIS-C worsens rapidly and can lead to hypotension, cariogenic shock, or even damage to multiple organs. The characteristic laboratory findings are elevated markers of inflammation and heart dysfunction. The most common radiological findings are cardiomegaly, pleural effusion, signs of heart failure, ascites, and inflammatory changes in the right iliac fossa. In the context of the current COVID-19 pandemic, radiologists need to know the clinical, laboratory, and radiological characteristics of this syndrome to ensure the correct diagnosis.

Skin disorders associated with the COVID-19 pandemic: A review

Introduction

In December 2019, a new coronavirus has emerged out of China, the SARS‐CoV‐2 virus, causing a disease known as COVID‐19, which steadily has progressed into a pandemic. This coronavirus affects many organs, including the skin, whose manifestations are a consequence of the disease itself, as well as the preventative measures taken to avoid the infection. This paper reviews the cutaneous manifestations which currently have been encountered during this pandemic.

Methods

A search was conducted on PubMed, and all relevant articles were included.

Results

The results show the occurrence of many cutaneous findings, ranging from those related to the infection itself and to various dermatitides related to the use of personal protective equipment (PPE) utilized by healthcare workers while attending to infected patients.

Discussion

Recognizing these findings is important for the accurate diagnosis of those infected with COVID‐19 as well as the prompt treatment of the side effects caused by PPE that might further impair the effectiveness of healthcare workers.

COVID-19-Associated Pulmonary Embolism in Pediatric Patients

BACKGROUND AND OBJECTIVES

Coronavirus disease 2019 (COVID-19) is associated with pulmonary embolism in adults, but the clinical circumstances surrounding its presence are unknown in children. The objectives of this study are to determine the prevalence of pulmonary embolism in pediatric subjects with COVID-19, evaluate patient characteristics, and describe treatments applied.

METHODS

We performed a retrospective cohort study using TriNetX electronic health record data of subjects aged <18 years who were diagnosed with COVID-19 infection (International Classification of Diseases, 10th Revision, code U07.1). Pulmonary embolism was identified by using International Classification of Diseases, 10th Revision, code I26. We additionally collected data on age, sex, race, ethnicity, all diagnostic codes, medications, procedures, laboratory results, comorbidities, and outcomes.

RESULTS

During the study period, 24 723 pediatric subjects were reported to have a COVID-19 infection diagnosis among 41 health care organizations, of which 693 (2.8%) were hospitalized. Eight subjects (0.03% overall and 1.2% of hospitalized patients) were diagnosed with pulmonary embolism. The median age (25th to 75th percentile) of patients diagnosed with pulmonary embolism was 16.5 years, and median (25th to 75th percentile) BMI was 22.1 (19.6-47.9). Three (37.5%) received critical care services, and 1 (12.5%) underwent mechanical ventilation. Five (62.5%) subjects had potentially significant risk factors (obesity, malignancy, recent surgery, and oral contraceptive use). All patients received anticoagulation, but none underwent thrombolysis. There were no reported deaths.

CONCLUSIONS

Although pulmonary embolism is diagnosed less commonly in children than in adults, its occurrence appears to be more frequent in children hospitalized with COVID-19, as compared with previous reports in hospitalized children in general. All patients survived, with only 1 requiring mechanical ventilation.

Immune profiling of COVID-19: preliminary findings and implications for the pandemic

SARS-CoV-2 infection can have widely diverse clinical outcomes, from asymptomatic infection to death, with many possible clinical symptoms and syndromes. It is thus essential to understand how the virus interacts with the host immune system to bring about these varied outcomes and to inform vaccine development. We now know that both antibody and T cell responses are induced in the majority of infected individuals, and that cross-reactive responses from other coronaviruses also exist in the uninfected population. Innate immune responses are a key focus of research and may influence the course of disease and the character of subsequent adaptive responses. Finally, baseline immune profiles and changes during early acute infection may be key to predicting the course of disease. Understanding all these aspects can help to create better immune monitoring tools for COVID-19, including tools for predicting disease severity or specific sequelae, perhaps even prior to infection.

Neurologic Involvement in Children and Adolescents Hospitalized in the United States for COVID-19 or Multisystem Inflammatory Syndrome

Importance

Coronavirus disease 2019 (COVID-19) affects the nervous system in adult patients. The spectrum of neurologic involvement in children and adolescents is unclear.

Objective

To understand the range and severity of neurologic involvement among children and adolescents associated with COVID-19.

Setting, Design, and Participants

Case series of patients (age <21 years) hospitalized between March 15, 2020, and December 15, 2020, with positive severe acute respiratory syndrome coronavirus 2 test result (reverse transcriptase-polymerase chain reaction and/or antibody) at 61 US hospitals in the Overcoming COVID-19 public health registry, including 616 (36%) meeting criteria for multisystem inflammatory syndrome in children. Patients with neurologic involvement had acute neurologic signs, symptoms, or diseases on presentation or during hospitalization. Life-threatening involvement was adjudicated by experts based on clinical and/or neuroradiologic features.

Exposures

Severe acute respiratory syndrome coronavirus 2.

Main Outcomes and Measures

Type and severity of neurologic involvement, laboratory and imaging data, and outcomes (death or survival with new neurologic deficits) at hospital discharge.

Results

Of 1695 patients (909 [54%] male; median [interquartile range] age, 9.1 [2.4-15.3] years), 365 (22%) from 52 sites had documented neurologic involvement. Patients with neurologic involvement were more likely to have underlying neurologic disorders (81 of 365 [22%]) compared with those without (113 of 1330 [8%]), but a similar number were previously healthy (195 [53%] vs 723 [54%]) and met criteria for multisystem inflammatory syndrome in children (126 [35%] vs 490 [37%]). Among those with neurologic involvement, 322 (88%) had transient symptoms and survived, and 43 (12%) developed life-threatening conditions clinically adjudicated to be associated with COVID-19, including severe encephalopathy (n = 15; 5 with splenial lesions), stroke (n = 12), central nervous system infection/demyelination (n = 8), Guillain-Barré syndrome/variants (n = 4), and acute fulminant cerebral edema (n = 4). Compared with those without life-threatening conditions (n = 322), those with life-threatening neurologic conditions had higher neutrophil-to-lymphocyte ratios (median, 12.2 vs 4.4) and higher reported frequency of D-dimer greater than 3 μg/mL fibrinogen equivalent units (21 [49%] vs 72 [22%]). Of 43 patients who developed COVID-19-related life-threatening neurologic involvement, 17 survivors (40%) had new neurologic deficits at hospital discharge, and 11 patients (26%) died.

Conclusions and Relevance

In this study, many children and adolescents hospitalized for COVID-19 or multisystem inflammatory syndrome in children had neurologic involvement, mostly transient symptoms. A range of life-threatening and fatal neurologic conditions associated with COVID-19 infrequently occurred. Effects on long-term neurodevelopmental outcomes are unknown.

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.

Use of ECMO for Cardiogenic Shock in Pediatric Population

In children with severe advanced heart failure where medical management has failed, mechanical circulatory support in the form of veno-arterial extracorporeal membrane oxygenation (VA ECMO) or ventricular assist device represents life-sustaining therapy. This review provides an overview of VA ECMO used for cardiovascular support including medical and surgical heart disease. Indications, contraindications, and outcomes of VA ECMO in the pediatric population are discussed.VA ECMO provides biventricular and respiratory support and can be deployed in rapid fashion to rescue patient with failing physiology. There have been advances in conduct and technologic aspects of VA ECMO, but survival outcomes have not improved. Stringent selection and optimal timing of deployment are critical to improve mortality and morbidity of the patients supported with VA ECMO.

Selected 2020 Highlights in Congenital Cardiac Anesthesia

This article is a review of the highlights of pertinent literature published during the 12 months of 2020 that are of interest to the congenital cardiac anesthesiologist. After a search of the US National Library of Medicine's PubMed database, several topics emerged for which significant contributions were made in 2020. The authors of the present article considered the following topics noteworthy to be included in this review: pediatric cardiac care in the coronavirus disease 2019 era, the use of mechanical circulatory support in coronavirus disease 2019-related multisystem inflammatory syndrome in children, transfusion and coagulation management in children undergoing congenital heart surgery, and pulmonary vein stenosis.

Clinical and radiological findings for the new multisystem inflammatory syndrome in children associated with COVID-19

El síndrome inflamatorio multisistémico pediátrico vinculado a la COVID-19 (SIM-PedS) es, según la Organización Mundial de la Salud, un nuevo síndrome descrito en pacientes menores de 19 años con historia previa de exposición a SARS-CoV-2. La presentación inicial de este síndrome se caracteriza por fiebre persistente que asocia debilidad, dolor abdominal, vómitos y/o diarrea. Menos frecuentemente los pacientes pueden presentar también erupción cutánea y conjuntivitis. El cuadro clínico tiene expresividad y evolución variables, por lo que algunos pacientes pediátricos afectados pueden empeorar rápidamente, desarrollando desde hipotensión y shock cardiogénico a daño multiorgánico. Los hallazgos analíticos característicos del síndrome consisten en elevación de marcadores inflamatorios y disfunción cardíaca. Los hallazgos radiológicos más frecuentes son cardiomegalia, derrame pleural, signos de insuficiencia cardíaca, ascitis y cambios inflamatorios en la fosa ilíaca derecha. En la pandemia actual por COVID-19 es necesario que el radiólogo conozca las características clínico-analíticas y radiológicas de este síndrome para realizar un correcto diagnóstico.

SARS-COV-2-associated coagulopathy and thromboembolism prophylaxis in children: A single-center observational study

BACKGROUND

Multiple investigators have described an increased incidence of thromboembolic events in SARS-CoV-2-infected individuals. Data concerning hemostatic complications in children hospitalized for COVID-19/multisystem inflammatory syndrome in children (MIS-C) are scant.

OBJECTIVES

To share our experience in managing SARS-CoV-2-associated pro-coagulant state in hospitalized children.

METHODS

D-dimer values were recorded at diagnosis in children hospitalized for SARS-CoV-2-related manifestations. In moderately to critically ill patients and MIS-C cases, coagulation and inflammatory markers were checked at multiple time points and median results were compared. Pro-thrombotic risk factors were appraised for each child and thromboprophylaxis was started in selected cases.

RESULTS

Thirty-five patients were prospectively enrolled. D-dimer values did not discriminate COVID-19 of differing severity, whereas were markedly different between the COVID-19 and the MIS-C cohorts. In both cohorts, D-dimer and C-reactive protein levels increased upon clinical worsening but were not accompanied by decreased fibrinogen or platelet values, with all parameters returning to normal upon disease resolution. Six patients had multiple thrombotic risk factors and were started on pharmacological thromboprophylaxis. No deaths or thrombotic or bleeding complications occurred.

CONCLUSIONS

COVID-19 pediatric patients show mildly altered coagulation and inflammatory parameters; on the other hand, MIS-C cases showed laboratory signs of an inflammatory driven pro-coagulant status. Universal anticoagulant prophylaxis in hospitalized children with SARS-CoV-2-related manifestations is not warranted, but may be offered to patients with other pro-thrombotic risk factors in the context of a multi-modal therapeutic approach.

SARS-CoV-2 vaccine testing and trials in the pediatric population: biologic, ethical, research, and implementation challenges

As the nation implements SARS-CoV-2 vaccination in adults at an unprecedented scale, it is now essential to focus on the prospect of SARS-CoV-2 vaccinations in pediatric populations. To date, no children younger than 12 years have been enrolled in clinical trials. Key challenges and knowledge gaps that must be addressed include (1) rationale for vaccines in children, (2) possible effects of immune maturation during childhood, (3) ethical concerns, (4) unique needs of children with developmental disorders and chronic conditions, (5) health inequities, and (6) vaccine hesitancy. Because COVID-19 is minimally symptomatic in the vast majority of children, a higher acceptable risk threshold is required when evaluating pediatric clinical trials. Profound differences in innate and adaptive immunity during childhood and adolescence are known to affect vaccine responsiveness for a variety of childhood diseases. COVID-19 and the accompanying social disruption, such as the school shutdowns, has been disproportionately damaging to minority and low-income children. In this commentary, we briefly address each of these key issues, specify research gaps, and suggest a broader learning health system approach to accelerate testing and clinical trial development for an ethical and effective strategy to implement a pediatric SARS-CoV-2 vaccine as rapidly and safely as possible. IMPACT: As the US begins an unprecedented implementation of SARS-CoV-2 vaccination, substantial knowledge gaps have yet to be addressed regarding vaccinations in the pediatric population. Maturational changes in the immune system during childhood have influenced the effectiveness of pediatric vaccines for other diseases and conditions, and could affect SARS-CoV-2 vaccine responsiveness in children. Given that COVID-19 disease is far milder in the majority of children than in adults, the risk-benefit of a pediatric SARS-CoV-2 vaccine must be carefully weighed. The needs of children with developmental disabilities and with chronic disease must be addressed. Minority and low-income children have been disproportionately adversely affected by the COVID-19 pandemic; care must be taken to address issues of health equity regarding pediatric SARS-CoV-2 vaccine trials and allocation. Research and strategies to address general vaccine hesitancy in communities must be addressed in the context of pediatric SARS-CoV-2 vaccines.

The wide spectrum of Kawasaki-like disease associated with SARS-CoV-2 infection

Introduction: On June 2020, the first case of concurrent Covid-19 and Kawasaki disease (KD) was published. After this first description, further works reported new cases of children affected by KD and KD-like syndrome after SARS-CoV-2 infection. The clinical and biochemical features of these patients differed from the historical cohorts of KD, suggesting the possibility of a new multi-systemic inflammatory syndrome. Is still unclear if this new clinical entity, often referred as pediatric inflammatory multisystem syndrome (PIMS) or multi-system inflammatory syndrome in children (MIS-C), could be considered as part of the KD spectrum or is a new disease with different pathogenic mechanisms and uniquely linked to SARS-CoV-2 infection. The authors searched the available literature in MedLine (via Pubmed) with the terms ('coronaviruses' OR 'coronavirus') AND ('Kawasaki disease') for English studies without any temporal limit. Areas covered: This review aims to comprehensively describe multisystem inflammatory syndromes affecting children during Coronaviruses outbreak, and to evaluate the possible pathogenic role of human Coronaviridae in KD and KD-like syndromes. Expert opinion: An increased incidence of PIMS-TS, during the Covid-19 pandemic has been reported, suggesting that SARS-CoV-2 may trigger a severe hyper-inflammatory syndrome in childhood. The pathophysiological mechanisms of this disease are still unclear. Based on these findings, SARS-CoV-2 may be considered another trigger in the complex mosaic about the relationship among infectious agents and the occurrence of systemic hyper-inflammation related syndromes.