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Areti S, Parrillo M, Baker L, Meszaros A, Dram A, Remy KE. Multisystem inflammatory syndrome in children: an evolving understanding of a syndrome amid the inflammatory continuum. Minerva Pediatr (Torino) 2024; 76:545-555. [PMID: 37335186 DOI: 10.23736/s2724-5276.23.07279-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
Multisystem inflammatory syndrome in children (MIS-C) is a rare hyperinflammatory and immunosuppressed condition affecting children exposed to COVID-19. MIS-C has been associated with an over-exaggerated innate and adaptive immune response characterized by a 'selective' cytokine production and T cell suppression. As COVID-19 information has evolved, the knowledge and field surrounding MIS-C is ever evolving. Thus, a comprehensive clinical review that concisely presents current literature findings regarding common clinical presentations and comparisons with similar conditions, associations with the COVID-19 vaccine effects and relevant epigenetic markers and evaluates treatment and long-term outcomes to help guide future studies is needed and provided.
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Affiliation(s)
- Sathya Areti
- Department of Medicine, Case Western University School of Medicine, University Hospitals of Cleveland, Cleveland, OH, USA
- Department of Pediatrics, Case Western University School of Medicine, Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Marissa Parrillo
- Department of Pediatrics, Case Western University School of Medicine, Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Lena Baker
- Department of Pediatrics, Case Western University School of Medicine, Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Alexandra Meszaros
- Division of Basic Research, Washington University in St. Louis, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Alexandra Dram
- Division of Basic Research, Washington University in St. Louis, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Kenneth E Remy
- Department of Medicine, Case Western University School of Medicine, University Hospitals of Cleveland, Cleveland, OH, USA -
- Department of Pediatrics, Case Western University School of Medicine, Rainbow Babies and Children's Hospital, Cleveland, OH, USA
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Shhada E, Hamdar H, Nahle AA, Mourad D, Khalil B, Ali S. Clinical presentation and management of multisystem inflammatory syndrome in children associated with covid-19: a retrospective observational descriptive study in a pediatric hospital in Syria. BMC Infect Dis 2024; 24:322. [PMID: 38491367 PMCID: PMC10943909 DOI: 10.1186/s12879-024-09197-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 03/06/2024] [Indexed: 03/18/2024] Open
Abstract
OBJECTIVE Multisystem Inflammatory Syndrome in Children (MIS-C) associated with COVID-19 is a rare and serious medical condition. This study aims to review the clinical presentation, laboratory parameters, outcomes, and management of MIS-C cases in a pediatric hospital in Syria. METHODS This retrospective observational study aimed to investigate MIS-C between May 2020 and October 2021. Data collection involved extracting information from medical records, and patients were identified based on the case definition established by the World Health Organization (WHO). Various laboratory investigations, diagnostic evaluations, clinical presentations, and treatments were performed to assess patients. Descriptive statistical analysis was conducted using Microsoft Excel. RESULTS A total of 232 COVID-19 cases were reported with COVID-19 Infection. Among these cases, 25 (10.77%) were identified as MIS-C. The median age of the patients was 5.5 years, with the majority being male patients (72%). Patients experienced fever (100%), bilateral conjunctivitis (88%), rash (84%), gastrointestinal symptoms (76%), and cardiac dysfunction (72%). Other notable findings included oral cavity changes (64%), edema (36%), cervical lymphadenopathy (36%), and neurological manifestations (28%). Respiratory symptoms were uncommon (16%). All patients recovered, with no recorded deaths. CONCLUSION The predominant presence of positive SARS-CoV-2 IgG in the majority of patients in this study supports the post-infectious nature of MIS-C. Respiratory symptoms were less prevalent in both pediatric COVID-19 and MIS-C patients. Early supportive care is crucial in management, although additional research is needed to establish definitive guidelines. Larger studies are necessary to overcome the limitations of this study and to enhance our understanding of MIS-C in pediatric COVID-19 patients.
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Affiliation(s)
- Eman Shhada
- Pediatric Intensive Care Department, Faculty of Medicine, Children's Hospital, Damascus University, Damascus, Syria
| | - Hussein Hamdar
- Faculty of Medicine, Damascus University, Damascus, Syria.
| | | | - Diana Mourad
- Pediatric Department, Children's Damascus University Hospital, Damascus University, Damascus, Syria
| | - Basheer Khalil
- Rheumatology Pediatric Department, Children's Damascus University Hospital, Damascus University, Damascus, Syria
| | - Sawssan Ali
- Pulmonary Pediatrics Department, Children's Damascus University Hospital, Damascus University, Damascus, Syria
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Lam FW, Brown CA, Ronca SE. Recombinant Rod Domain of Vimentin Reduces SARS-CoV-2 Viral Replication by Blocking Spike Protein-ACE2 Interactions. Int J Mol Sci 2024; 25:2477. [PMID: 38473724 PMCID: PMC10931652 DOI: 10.3390/ijms25052477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/18/2024] [Accepted: 01/26/2024] [Indexed: 03/14/2024] Open
Abstract
Although the SARS-CoV-2 vaccination is the primary preventive intervention, there are still few antiviral therapies available, with current drugs decreasing viral replication once the virus is intracellular. Adding novel drugs to target additional points in the viral life cycle is paramount in preventing future pandemics. The purpose of this study was to create and test a novel protein to decrease SARS-CoV-2 replication. We created the recombinant rod domain of vimentin (rhRod) in E. coli and used biolayer interferometry to measure its affinity to the SARS-CoV-2 S1S2 spike protein and the ability to block the SARS-CoV-2-ACE2 interaction. We performed plaque assays to measure rhRod's effect on SARS-CoV-2 replication in Vero E6 cells. Finally, we measured lung inflammation in SARS-CoV-2-exposed K18-hACE transgenic mice given intranasal and intraperitoneal rhRod. We found that rhRod has a high affinity for the S1S2 protein with a strong ability to block S1S2-ACE2 interactions. The daily addition of rhRod decreased viral replication in Vero E6 cells starting at 48 h at concentrations >1 µM. Finally, SARS-CoV-2-infected mice receiving rhRod had decreased lung inflammation compared to mock-treated animals. Based on our data, rhRod decreases SARS-CoV-2 replication in vitro and lung inflammation in vivo. Future studies will need to evaluate the protective effects of rhRod against additional viral variants and identify the optimal dosing scheme that both prevents viral replication and host lung injury.
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Affiliation(s)
- Fong Wilson Lam
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA (S.E.R.)
- Center for Translational Research on Inflammatory Diseases, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX 77030, USA
| | - Cameron August Brown
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA (S.E.R.)
- Department of Pathology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Shannon Elizabeth Ronca
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA (S.E.R.)
- William T. Shearer Center for Human Immunobiology, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX 77030, USA
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Chen LN, Shou ZX, Jin X. Interaction Between Genetic Susceptibility and COVID-19 Pathogenesis in Pediatric Multisystem Inflammatory Disorders: The Role of Immune Responses. Viral Immunol 2024; 37:1-11. [PMID: 38271561 DOI: 10.1089/vim.2023.0074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024] Open
Abstract
Numerous studies have highlighted the emergence of coronavirus disease (COVID-19) symptoms reminiscent of Kawasaki disease in children, including fever, heightened multisystem inflammation, and multiorgan involvement, posing a life-threatening complication. Consequently, extensive research endeavors in pediatric have aimed to elucidate the intricate relationship between COVID-19 infection and the immune system. COVID-19 profoundly impacts immune cells, culminating in a cytokine storm that particularly inflicts damage on the pulmonary system. The gravity and vulnerability to COVID-19 are closely intertwined with the vigor of the immune response. In this context, the human leukocyte antigen (HLA) molecule assumes pivotal significance in shaping immune responses. Genetic scrutiny of HLA has unveiled the presence of at least one deleterious allele in children afflicted with multisystem inflammatory syndrome in children (MIS-C). Furthermore, research has demonstrated that COVID-19 exploits the angiotensin-converting enzyme 2 (ACE-2) receptor, transmembrane serine protease type 2, and various other genes to gain entry into host cells, with individuals harboring ACE-2 polymorphisms being at higher risk. Pediatric studies have employed diverse genetic methodologies, such as genome-wide association studies (GWAS) and whole exome sequencing, to scrutinize target genes. These investigations have pinpointed two specific genomic loci linked to the severity and susceptibility of COVID-19, with the HLA locus emerging as a notable risk factor. In this comprehensive review article, we endeavor to assess the available evidence and consolidate data, offering insights into current clinical practices and delineating avenues for future research. Our objective is to advance early diagnosis, stabilization, and appropriate management strategies to mitigate genetic susceptibility's impact on the incidence of COVID-19 in pediatric patients with multisystem inflammation.
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Affiliation(s)
- Li-Na Chen
- Department of Pediatric, Affiliated Hospital of Shaoxing University, Shaoxing, China
| | - Zhang-Xuan Shou
- Department of Pharmacy, The Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Xue Jin
- Department of Pharmacy, Center for Clinical Pharmacy, Cancer Center, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, China
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Broberg MC, Mazer MB, Cheifetz IM. Cardiovascular effects of COVID-19 in children. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2023; 52:533-541. [PMID: 38920204 DOI: 10.47102/annals-acadmedsg.202386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
Introduction Although severe acute respiratory failure is the primary cause of morbidity and mortality in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, this viral infection leads to cardiovascular disease in some individuals. Cardiac effects of the virus include myocarditis, pericarditis, arrhythmias, coronary aneurysms and cardiomyopathy, and can result in cardiogenic shock and multisystem organ failure. Method This review summarises cardiac manifesta-tions of SARS-CoV-2 in the paediatric population. We performed a scoping review of cardiovascular disease associated with acute coronavirus disease 2019 (COVID-19) infection, multisystem inflammatory syndrome in children (MIS-C), and mRNA COVID-19 vaccines. Also examined are special considerations for paediatric athletes and return to play following COVID-19 infection. Results Children presenting with acute COVID-19 should be screened for cardiac dysfunction and a thorough history should be obtained. Further cardiovascular evaluation should be considered following any signs/symptoms of arrhythmias, low cardiac output, and/or myopericarditis. Patients admitted with severe acute COVID-19 should be monitored with continuous cardiac monitoring. Laboratory testing, as clinically indicated, includes tests for troponin and B-type natriuretic peptide or N-terminal pro-brain natriuretic peptide. Echocardiography with strain evaluation and/or cardiac magnetic resonance imaging should be considered to evaluate diastolic and systolic dysfunction, coronary anatomy, the pericardium and the myocardium. For patients with MIS-C, combination therapy with intravenous immunoglobulin and glucocorticoid therapy is safe and potentially disease altering. Treatment of MIS-C targets the hyperimmune response. Supportive care, including mechanical support, is needed in some cases. Conclusion Cardiovascular disease is a striking feature of SARS-CoV-2 infection. Most infants, children and adolescents with COVID-19 cardiac disease fully recover with no lasting cardiac dysfunction. However, long-term studies and further research are needed to assess cardiovascular risk with variants of SARS-CoV-2 and to understand the pathophysiology of cardiac dysfunction with COVID-19.
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Affiliation(s)
- Meredith Cg Broberg
- Division of Cardiac Critical Care, UH Rainbow Babies & Children's Hospital, Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
| | - Monty B Mazer
- Division of Cardiac Critical Care, UH Rainbow Babies & Children's Hospital, Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
| | - Ira M Cheifetz
- Division of Cardiac Critical Care, UH Rainbow Babies & Children's Hospital, Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
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Kapoor R, Chandra T, Singh CP, Singh R, Pandey I. Multisystem Inflammatory Syndrome in Children (MIS-C) Related to SARS-CoV-2 and 1-Year Follow-up. Indian J Pediatr 2023; 90:1008-1012. [PMID: 36482236 PMCID: PMC9734509 DOI: 10.1007/s12098-022-04385-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 08/18/2022] [Accepted: 09/12/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To study the demographics, clinical profile, management, outcome and 1-y follow-up of children with multisystem inflammatory syndrome in children (MIS-C). METHODS This was a retrospective observational study of 54 Children satisfying the WHO MIS-C criteria admitted during the study period. RESULTS Fifty-four children were included in the study, median age was 5.5 (IQR 8.75), 68.5% were males. PICU admissions were 77%. Most involved organ was gastrointestinal (92%), followed by cardiovascular 85%, central nervous system (CNS) 74%, respiratory 72%, mucocutaneous 59%, and renal 31%, and hypotension was the presenting symptom in 43%. Coronary artery dilatation was seen in 1 (1.8%) child. All patients presented with more than three organs involvement. Raised procalcitonin was seen in 100%, raised BNP in 31.5%, low ejection fraction in 83.3%, and abnormal radiograph in 59%. All children were positive for anti-SARS-CoV-2 antibodies and negative for cultures. Methylprednisolone or intravenous immunoglobulin (IVIg) was used in 77%, mechanical ventilation in 18.5%, and inotropic support in 77%. Aspirin was used in 48% and low molecular weight heparin (LMWH) in 54%. The median stay in hospital was 7 d (IQR 2). There was 1 mortality (1.8%). On 7-d follow-up, 98% children had a normal echocardiography; on 6 mo and 1-y follow-up, all children had normal echocardiography. CONCLUSION MIS-C is an important complication of COVID-19 infection. Cardiac involvement resolves completely. Coronary artery involvement is not common.
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Affiliation(s)
- Rashmi Kapoor
- Department of Pediatrics, Regency Hospital, A-2, Sarvodaya Nagar, Kanpur, Uttar Pradesh, 208005, India.
| | - Tarun Chandra
- Department of Pediatrics, Regency Hospital, A-2, Sarvodaya Nagar, Kanpur, Uttar Pradesh, 208005, India
| | - Chandra Prakash Singh
- Department of Pediatrics, Regency Hospital, A-2, Sarvodaya Nagar, Kanpur, Uttar Pradesh, 208005, India
| | - Ruchira Singh
- Department of Pediatrics, Regency Hospital, A-2, Sarvodaya Nagar, Kanpur, Uttar Pradesh, 208005, India
| | - Ishita Pandey
- Department of Pediatrics, Regency Hospital, A-2, Sarvodaya Nagar, Kanpur, Uttar Pradesh, 208005, India
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Silva Luz M, Lemos FFB, Rocha Pinheiro SL, Marques HS, de Oliveira Silva LG, Calmon MS, da Costa Evangelista K, Freire de Melo F. Pediatric multisystem inflammatory syndrome associated with COVID-19: Insights in pathogenesis and clinical management. World J Virol 2023; 12:193-203. [PMID: 37396702 PMCID: PMC10311577 DOI: 10.5501/wjv.v12.i3.193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 04/28/2023] [Accepted: 05/24/2023] [Indexed: 06/21/2023] Open
Abstract
The pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been a major challenge to be faced in recent years. While adults suffered the highest morbidity and mortality rates of coronavirus disease 2019, children were thought to be exclusively asymptomatic or to present with mild conditions. However, around April 2020, there was an outbreak of a new clinical syndrome related to SARS-CoV-2 in children - multisystemic inflammatory syndrome in children (MIS-C) - which comprises a severe and uncon-trolled hyperinflammatory response with multiorgan involvement. The Centers for Disease Control and Prevention considers a suspected case of MIS-C an individual aged < 21 years presenting with fever, high inflammatory markers levels, and evidence of clinically severe illness, with multisystem (> 2) organ involvement, no alternative plausible diagnoses, and positive for recent SARS-CoV-2 infection. Despite its severity, there are no definitive disease management guidelines for this condition. Conversely, the complex pathogenesis of MIS-C is still not completely understood, although it seems to rely upon immune dysregulation. Hence, in this study, we aim to bring together current evidence regarding the pathogenic mechanisms of MIS-C, clinical picture and management, in order to provide insights for clinical practice and implications for future research directions.
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Affiliation(s)
- Marcel Silva Luz
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Vitória da Conquista 45029-094, Bahia, Brazil
| | - Fabian Fellipe Bueno Lemos
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Vitória da Conquista 45029-094, Bahia, Brazil
| | - Samuel Luca Rocha Pinheiro
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Vitória da Conquista 45029-094, Bahia, Brazil
| | - Hanna Santos Marques
- Campus Vitória da Conquista, Universidade Estadual do Sudoeste da Bahia, Vitória da Conquista 45029-094, Bahia, Brazil
| | | | - Mariana Santos Calmon
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Vitória da Conquista 45029-094, Bahia, Brazil
| | | | - Fabrício Freire de Melo
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia, Vitória da Conquista 45029-094, Bahia, Brazil
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García-Salido A, Flores-Pérez P, González-Murillo Á, Sánchez-Marcos E, Leoz-Gordillo I, Cano-Fernández J, Castillo-Robleda A, Nieto-Moro M, Jiménez-García R. IgG antispike persistence and immunophenotype in children infected by SARS-CoV-2. Acta Paediatr 2023; 112:805-812. [PMID: 36772991 DOI: 10.1111/apa.16705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 01/09/2023] [Accepted: 02/08/2023] [Indexed: 02/12/2023]
Abstract
AIM The immune status of children recovering from SARS-CoV-2 infection is not completely understood. We describe IgG antispike persistence in children infected during the first two pandemic waves. In addition, we compared with healthy controls their leukocyte populations and CD64 expression. METHODS Cross-sectional study. Carried out from October 2021 to February 2022 in nonreinfected and nonvaccinated children with SARS-CoV-2 in 2020. The presence of antispike IgG was studied using chemiluminescent immunoassay. Leukocyte populations were analysed using flow cytometry and marked for CD45, CD4, CD8 and CD64. Statistical minor than 0.05 was considered significant. RESULTS One hundred and eighty-three control and 77 patients were included. IgG antispike determinations were performed after a median of 501 days (262-464); 52 of 77 children were positive. Cases showed significantly higher percentages of monocytes, lymphocytes, CD8+ and CD4+ . In addition, CD64 expression was higher in monocytes and neutrophils. The presence of IgG antispike was accompanied by a higher percentage of CD64+ neutrophils. CONCLUSION In our series, the SARS-CoV-2 IgG antispike protein was usually positive beyond 1 year after infection. Furthermore, leukocyte populations from cases differ from controls, with higher CD64 expression on neutrophils and monocytes. Prospective clinical observations are required to confirm the implications of these findings.
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Affiliation(s)
- Alberto García-Salido
- Pediatric Critical Care Unit, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | | | - África González-Murillo
- Pediatric Oncohematology Unit, Flow Cytometry Laboratory, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | | | - Inés Leoz-Gordillo
- Pediatric Critical Care Unit, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | | | - Ana Castillo-Robleda
- Pediatric Oncohematology Unit, Flow Cytometry Laboratory, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Montserrat Nieto-Moro
- Pediatric Critical Care Unit, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
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Clinical Characteristics and Laboratory Findings in Children with Multisystem Inflammatory Syndrome (MIS-C)-A Retrospective Study of a Tertiary Care Center from Constanta, Romania. Healthcare (Basel) 2023; 11:healthcare11040544. [PMID: 36833078 PMCID: PMC9957378 DOI: 10.3390/healthcare11040544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 02/08/2023] [Accepted: 02/09/2023] [Indexed: 02/15/2023] Open
Abstract
A new hyper-inflammatory syndrome in children was identified after SARS-CoV-2 infection as a post-infectious complication that is temporally associated with coronavirus disease (COVID-19). Fever, rash, conjunctival hyperemia, and gastrointestinal problems are all clinical manifestations of multisystem inflammatory syndrome in children. This condition, in some cases, causes multisystem involvement, affecting multiple organ systems and necessitating admission to a pediatric intensive care unit. Due to limited clinical studies, it is necessary to analyze the characteristics of the pathology in order to improve the management and long-term follow-up of high-risk patients. The objective of the study was to analyze the clinical and paraclinical characteristics of children diagnosed with MIS-C. The clinical study is a retrospective, observational, descriptive research work that includes patients diagnosed with MIS-C, temporally associated with coronavirus disease, and it contains clinical characteristics, laboratory data, and demographic information. The majority of patients had normal or slightly increased leukocyte counts, which were associated with neutrophilia, lymphocytopenia, and significantly elevated inflammatory markers, including high levels of C-reactive protein, fibrinogen, the erythrocyte sedimentation rate, serum ferritin, and IL 6 and elevated levels of the cardiac enzymes NT-proBNP and D-dimers, owing to the cardiovascular system involvement in the pro-inflammatory process. At the same time, renal system involvement led to raised creatinine and high proteinuria in association with hypoalbuminemia. This characteristic of the pro-inflammatory status as well as multisystem impairment are highly suggestive of the post-infection immunological reaction of the multisystem syndrome temporally associated with SARS-CoV-2 infection.
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Santos-Rebouças CB, Piergiorge RM, dos Santos Ferreira C, Seixas Zeitel RD, Gerber AL, Rodrigues MCF, Guimarães APDC, Silva RM, Fonseca AR, Souza RC, de Souza ATAM, Rossi ÁD, Porto LCDMS, Cardoso CC, de Vasconcelos ATR. Host genetic susceptibility underlying SARS-CoV-2-associated Multisystem Inflammatory Syndrome in Brazilian Children. Mol Med 2022; 28:153. [PMID: 36510129 PMCID: PMC9742658 DOI: 10.1186/s10020-022-00583-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 12/01/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Multisystem Inflammatory Syndrome in Children (MIS-C) is a life-threatening complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, which manifests as a hyper inflammatory process with multiorgan involvement in predominantly healthy children in the weeks following mild or asymptomatic coronavirus disease 2019 (COVID-19). However, host monogenic predisposing factors to MIS-C remain elusive. METHODS Herein, we used whole exome sequencing (WES) on 16 MIS-C Brazilian patients to identify single nucleotide/InDels variants as predisposition factors associated with MIS-C. RESULTS We identified ten very rare variants in eight genes (FREM1, MPO, POLG, C6, C9, ABCA4, ABCC6, and BSCL2) as the most promising candidates to be related to a higher risk of MIS-C development. These variants may propitiate a less effective immune response to infection or trigger the inflammatory response or yet a delayed hyperimmune response to SARS-CoV-2. Protein-Protein Interactions (PPIs) among the products of the mutated genes revealed an integrated network, enriched for immune and inflammatory response mechanisms with some of the direct partners representing gene products previously associated with MIS-C and Kawasaki disease (KD). In addition, the PPIs direct partners are also enriched for COVID-19-related gene sets. HLA alleles prediction from WES data allowed the identification of at least one risk allele in 100% of the MIS-C patients. CONCLUSIONS This study is the first to explore host MIS-C-associated variants in a Latin American admixed population. Besides expanding the spectrum of MIS-C-associated variants, our findings highlight the relevance of using WES for characterising the genetic interindividual variability associated with COVID-19 complications and ratify the presence of overlapping/convergent mechanisms among MIS-C, KD and COVID-19, crucial for future therapeutic management.
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Affiliation(s)
- Cíntia Barros Santos-Rebouças
- grid.412211.50000 0004 4687 5267Departamento de Genética, Instituto de Biologia Roberto Alcantara Gomes, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Rafael Mina Piergiorge
- grid.412211.50000 0004 4687 5267Departamento de Genética, Instituto de Biologia Roberto Alcantara Gomes, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Cristina dos Santos Ferreira
- grid.452576.70000 0004 0602 9007Laboratório de Bioinformática - LABINFO, Laboratório Nacional de Computação Científica, LNCC/MCTIC, Getúlio Vargas, Av., 333, Quitandinha, Zip Code: 25651‑075 Petrópolis, Rio de Janeiro, Brazil
| | - Raquel de Seixas Zeitel
- grid.411332.60000 0004 0610 8194UTI Pediátrica, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Alexandra Lehmkuhl Gerber
- grid.452576.70000 0004 0602 9007Laboratório de Bioinformática - LABINFO, Laboratório Nacional de Computação Científica, LNCC/MCTIC, Getúlio Vargas, Av., 333, Quitandinha, Zip Code: 25651‑075 Petrópolis, Rio de Janeiro, Brazil
| | - Marta Cristine Felix Rodrigues
- grid.8536.80000 0001 2294 473XServiço de Reumatologia Pediátrica, Instituto de Puericultura e Pediatria Martagão Gesteira - IPPMG, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ana Paula de Campos Guimarães
- grid.452576.70000 0004 0602 9007Laboratório de Bioinformática - LABINFO, Laboratório Nacional de Computação Científica, LNCC/MCTIC, Getúlio Vargas, Av., 333, Quitandinha, Zip Code: 25651‑075 Petrópolis, Rio de Janeiro, Brazil
| | - Rodrigo Moulin Silva
- grid.411332.60000 0004 0610 8194UTI Pediátrica, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Adriana Rodrigues Fonseca
- grid.8536.80000 0001 2294 473XServiço de Reumatologia Pediátrica, Instituto de Puericultura e Pediatria Martagão Gesteira - IPPMG, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Rangel Celso Souza
- grid.452576.70000 0004 0602 9007Laboratório de Bioinformática - LABINFO, Laboratório Nacional de Computação Científica, LNCC/MCTIC, Getúlio Vargas, Av., 333, Quitandinha, Zip Code: 25651‑075 Petrópolis, Rio de Janeiro, Brazil
| | - Ana Tereza Antunes Monteiro de Souza
- grid.411332.60000 0004 0610 8194UTI Pediátrica, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Átila Duque Rossi
- grid.8536.80000 0001 2294 473XLaboratório de Virologia Molecular, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Cynthia Chester Cardoso
- grid.8536.80000 0001 2294 473XLaboratório de Virologia Molecular, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ana Tereza Ribeiro de Vasconcelos
- grid.452576.70000 0004 0602 9007Laboratório de Bioinformática - LABINFO, Laboratório Nacional de Computação Científica, LNCC/MCTIC, Getúlio Vargas, Av., 333, Quitandinha, Zip Code: 25651‑075 Petrópolis, Rio de Janeiro, Brazil
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Abstract
OBJECTIVES To characterize the prevalence of pediatric critical illness from multisystem inflammatory syndrome in children (MIS-C) and to assess the influence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) strain on outcomes. DESIGN Retrospective cohort study. SETTING Database evaluation using the Virtual Pediatric Systems Database. PATIENTS All children with MIS-C admitted to the PICU in 115 contributing hospitals between January 1, 2020, and June 30, 2021. MEASUREMENTS AND MAIN RESULTS Of the 145,580 children admitted to the PICU during the study period, 1,338 children (0.9%) were admitted with MIS-C with the largest numbers of children admitted in quarter 1 (Q1) of 2021 ( n = 626). The original SARS-CoV-2 viral strain and the D614G Strain were the predominant strains through 2020, with Alpha B.1.1.7 predominating in Q1 and quarter 2 (Q2) of 2021. Overall, the median PICU length of stay (LOS) was 2.7 days (25-75% interquartile range [IQR], 1.6-4.7 d) with a median hospital LOS of 6.6 days (25-75% IQR, 4.7-9.3 d); 15.2% received mechanical ventilation with a median duration of mechanical ventilation of 3.1 days (25-75% IQR, 1.9-5.8 d), and there were 11 hospital deaths. During the study period, there was a significant decrease in the median PICU and hospital LOS and a decrease in the frequency of mechanical ventilation, with the most significant decrease occurring between quarter 3 and quarter 4 (Q4) of 2020. Children admitted to a PICU from the general care floor or from another ICU/step-down unit had longer PICU LOS than those admitted directly from an emergency department. CONCLUSIONS Overall mortality from MIS-C was low, but the disease burden was high. There was a peak in MIS-C cases during Q1 of 2021, following a shift in viral strains in Q1 of 2021. However, an improvement in MIS-C outcomes starting in Q4 of 2020 suggests that viral strain was not the driving factor for outcomes in this population.
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12
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Davitt E, Davitt C, Mazer MB, Areti SS, Hotchkiss RS, Remy KE. COVID-19 disease and immune dysregulation. Best Pract Res Clin Haematol 2022; 35:101401. [PMID: 36494149 PMCID: PMC9568269 DOI: 10.1016/j.beha.2022.101401] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 10/11/2022] [Indexed: 12/15/2022]
Abstract
The SARS-CoV-2 virus has complex and divergent immune alterations in differing hosts and over disease evolution. Much of the nuanced COVID-19 disease immune dysregulation was originally dominated by innate cytokine changes, which has since been replaced with a more complex picture of innate and adaptive changes characterized by simultaneous hyperinflammatory and immunosuppressive phenomena in effector cells. These intricacies are summarized in this review as well as potential relevance from acute infection to a multisystem inflammatory syndrome commonly seen in children. Additional consideration is made for the influence of variant to variant host cellular changes and the impact of potential vaccination upon these phenotypes. Finally, therapeutic benefit for immune alterations are discussed.
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Affiliation(s)
- Ethan Davitt
- School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Colin Davitt
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Monty B. Mazer
- Department of Pediatrics, University Hospitals of Cleveland, Cleveland, OH, USA,School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Sathya S. Areti
- Department of Internal Medicine, University Hospitals of Cleveland, Cleveland, OH, USA
| | - Richard S. Hotchkiss
- School of Medicine, Washington University in St. Louis, St. Louis, MO, USA,Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Kenneth E. Remy
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA,Department of Pediatrics, University Hospitals of Cleveland, Cleveland, OH, USA,Department of Internal Medicine, University Hospitals of Cleveland, Cleveland, OH, USA,School of Medicine, Case Western Reserve University, Cleveland, OH, USA,Corresponding author.Department of Internal Medicine, Case Western Reserve University, School of Medicine, University Hospitals of Cleveland, 11100 Euclid Ave, Cleveland, OH, USA
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13
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Angurana SK, Kumar V, Nallasamy K, Kumar MR, Naganur S, Kumar M, Goyal K, Ghosh A, Bansal A, Jayashree M. Clinico-Laboratory Profile, Intensive Care Needs and Short-Term Outcome of Multisystem Inflammatory Syndrome in Children (MIS-C): Experience during First and Second Waves from North India. J Trop Pediatr 2022; 68:6680455. [PMID: 36048462 DOI: 10.1093/tropej/fmac068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To describe the clinico-laboratory profile, intensive care needs and outcome of multisystem inflammatory syndrome in children (MIS-C) during the first and second waves. METHODOLOGY This retrospective study was conducted in the paediatric emergency and paediatric intensive care unit (PICU) of a tertiary care teaching hospital in North India involving 122 children with MIS-C admitted during the first wave (September 2020-January 2021, n = 40) and second wave (February 2021-September 2021, n = 82) of coronavirus disease 2019 (COVID-19). RESULTS The median (interquartile range) age was 7 (4-10) years and 67% were boys. Common manifestations included fever (99%), abdominal symptoms (81%), rash (66%) and conjunctival injection (65%). Elevated C-reactive protein (97%), D-dimer (89%), procalcitonin (80%), IL-6 (78%), ferritin (56%), N-terminal pro B-type natriuretic peptide (84%) and positive severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) antibody (81%) were common laboratory abnormalities. Cardiovascular manifestations included myocardial dysfunction (55%), shock (48%) and coronary artery changes (10%). The treatment included intensive care support (57%), non-invasive (33%) and invasive (18%) ventilation, vasoactive drugs (47%), intravenous immunoglobulin (IVIG) (83%), steroids (85%) and aspirin (87%). The mortality was 5% (n = 6). During the second wave, a significantly higher proportion had positive SARS-CoV-2 antibody, contact with COVID-19 and oral mucosal changes; lower markers of inflammation; lower proportion had lymphopenia, elevated IL-6 and ferritin; lower rates of shock, myocardial dysfunction and coronary artery changes; lesser need of PICU admission, fluid boluses, vasoactive drugs and IVIG; and shorter hospital stay. CONCLUSION MIS-C is a febrile multisystemic disease characterized by hyperinflammation, cardiovascular involvement, temporal relationship to SARS-CoV-2 and good outcome with immunomodulation and intensive care. During the second wave, the severity of illness, degree of inflammation, intensive care needs, and requirement of immunomodulation were less as compared to the first wave.
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Affiliation(s)
- Suresh Kumar Angurana
- Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Vijay Kumar
- Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Karthi Nallasamy
- Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Manoj Rohit Kumar
- Department of Cardiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Sanjeev Naganur
- Department of Cardiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Mahendra Kumar
- Department of Immunopathology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Kapil Goyal
- Department of Virology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Arnab Ghosh
- Department of Virology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Arun Bansal
- Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Muralidharan Jayashree
- Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
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14
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15
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Aydin Y, Vemuri B, Vajta Gomez JP, Challa PK, Zhang H. Fatal Gets More Fatal: A COVID-19 Infection With Macrophage Activation Syndrome. Cureus 2022; 14:e25591. [PMID: 35795500 PMCID: PMC9250044 DOI: 10.7759/cureus.25591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2022] [Indexed: 11/24/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) continues to be fatal despite advances in the understanding of characteristics of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), global prevention strategies, new anti-viral treatments, and worldwide vaccination programs. The exact underlying mechanism through which SARS-CoV-2 leads to acute respiratory distress syndrome (ARDS) resulting in intensive care unit admission, mechanical ventilation, and eventually death remains elusive. Cytokine storm is one of the most favorable mechanisms that scientists show remarkable interest to target in randomized clinical trials with promising outcomes. Macrophage activation syndrome (MAS), the most serious form of cytokine storm, requires early recognition and treatment regardless of etiology. Here, we report a 59-year-old gentleman with a COVID-19 infection complicated by MAS. Our aim is to increase awareness of this condition among health care providers as it necessitates prompt diagnosis and treatment due to an extremely poor prognosis.
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16
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Chin SE, Bhavsar SM, Corson A, Ghersin ZJ, Kim HS. Cardiac Complications Associated with COVID-19, MIS-C, and mRNA COVID-19 Vaccination. Pediatr Cardiol 2022; 43:483-488. [PMID: 35258639 PMCID: PMC8902276 DOI: 10.1007/s00246-022-02851-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 02/12/2022] [Indexed: 12/29/2022]
Abstract
The COVID-19 vaccine is now approved for individuals greater than 5 years of age, but vaccination rates remain lower than expected in the pediatric age group. Misinformation and widespread reporting of vaccine-related myocarditis are contributing to vaccine hesitancy. When compared to severe cardiac complications that are associated with COVID-19, vaccine-related myocarditis has a milder presentation, is easily treated, and has a good prognosis. Acute COVID-19 has been associated with higher rates of myocarditis and myocardial injury. Multisystem inflammatory syndrome in children occurs weeks after initial infection with SARS-CoV-2 and can be associated with severe cardiovascular complications and death. Cardiac complications associated with acute COVID-19 and MIS-C are more severe and occur more frequently than myocarditis after mRNA COVID-19 vaccination. Furthermore, some of the academic and social disruptions caused by the pandemic expect to be eased by widespread vaccination. For all these reasons, COVID-19 vaccination is strongly recommended for all eligible age groups.
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Affiliation(s)
- Stephanie E Chin
- K. Hovnanian Children's Hospital at Jersey Shore University Medical Center, Neptune, NJ, USA.
- Hackensack Meridian School of Medicine, Nutley, NJ, USA.
- Alpert Zales Castro Pediatric Cardiology, 1623 Route 88, Brick, NJ, 08724, USA.
| | - Sejal M Bhavsar
- Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack, NJ, USA
- Hackensack Meridian School of Medicine, Nutley, NJ, USA
| | - Andrew Corson
- K. Hovnanian Children's Hospital at Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Zelda J Ghersin
- K. Hovnanian Children's Hospital at Jersey Shore University Medical Center, Neptune, NJ, USA
- Hackensack Meridian School of Medicine, Nutley, NJ, USA
| | - Hannah S Kim
- Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack, NJ, USA
- Hackensack Meridian School of Medicine, Nutley, NJ, USA
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17
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Suskun C, Kilic O, Yilmaz Ciftdogan D, Guven S, Karbuz A, Ozkaya Parlakay A, Kara Y, Kacmaz E, Sahin A, Boga A, Kizmaz Isancli D, Gulhan B, Kanik-Yuksek S, Kiral E, Bozan G, Arslanoglu MO, Kizil MC, Dinleyici M, Us T, Varis A, Kaya M, Vandenplas Y, Dinleyici EC. Intestinal microbiota composition of children with infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and multisystem inflammatory syndrome (MIS-C). Eur J Pediatr 2022; 181:3175-3191. [PMID: 35585256 PMCID: PMC9117086 DOI: 10.1007/s00431-022-04494-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/28/2022] [Accepted: 04/30/2022] [Indexed: 02/07/2023]
Abstract
UNLABELLED Microbiota composition may play a role in the development, prognosis, or post-infection of COVID-19. There are studies evaluating the microbiota composition at the time of diagnosis and during the course of COVID-19, especially in adults, while studies in children are limited and no study available in children with multisystem inflammatory syndrome in children (MIS-C). This study was planned to compare intestinal microbiota composition in children diagnosed with MIS-C and acute COVID-19 infection with healthy children. In this prospective multicenter study, 25 children diagnosed with MIS-C, 20 with COVID-19 infection, and 19 healthy children were included. Intestinal microbiota composition was evaluated by 16 s rRNA gene sequencing. We observed changes of diversity, richness, and composition of intestinal microbiota in MIS-C cases compared to COVID-19 cases and in the healthy controls. The Shannon index was higher in the MIS-C group than the healthy controls (p < 0.01). At phylum level, in the MIS-C group, a significantly higher relative abundance of Bacteroidetes and lower abundance of Firmicutes was found compared to the control group. Intestinal microbiota composition changed in MIS-C cases compared to COVID-19 and healthy controls, and Faecalibacterium prausnitzii decreased; Bacteroides uniformis, Bacteroides plebeius, Clostridium ramosum, Eubacterium dolichum, Eggerthella lenta, Bacillus thermoamylovorans, Prevotella tannerae, and Bacteroides coprophilus were dominant in children with MIS-C. At species level, we observed decreased Faecalibacterium prausnitzii, and increased Eubacterium dolichum, Eggerthella lenta, and Bacillus thermoamylovorans in children with MIS-C and increased Bifidobacterium adolescentis and Dorea formicigenerasus in the COVID-19 group. Our study is the first to evaluate the microbiota composition in MIS-C cases. There is a substantial change in the composition of the gut microbiota: (1) reduction of F. prausnitzii in children with MIS-C and COVID-19; (2) an increase of Eggerthella lenta which is related with autoimmunity; and (3) the predominance of E. dolichum is associated with metabolic dysfunctions and obesity in children with MIS-C. CONCLUSIONS Alterations of the intestinal microbiota might be part of pathogenesis of predisposing factor for MIS-C. It would be beneficial to conduct more extensive studies on the cause-effect relationship of these changes in microbiota composition and their effects on long-term prognosis. WHAT IS KNOWN • Microbiota composition may play a role in the development, prognosis, or post-infection of COVID-19. • However, the number of studies on children is limited, and no study on multisystem inflammatory syndrome in children is currently available (MIS-C). WHAT IS NEW • In individuals with MIS-C, the composition of the gut microbiota changed dramatically. • Decreased Faecalibacterium prausnitzii have been observed, increased Eggerthella lenta, which was previously linked to autoimmunity, and predominance of Eubacterium dolichum which was linked to metabolic dysfunction and obesity.
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Affiliation(s)
- Cansu Suskun
- grid.164274.20000 0004 0596 2460Department of Pediatrics, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, TR-26040 Turkey
| | - Omer Kilic
- grid.164274.20000 0004 0596 2460Department of Pediatric Infectious Disease, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
| | - Dilek Yilmaz Ciftdogan
- grid.411795.f0000 0004 0454 9420Department of Pediatric Infectious Disease, Izmir Katip Celebi University Faculty of Medicine, Izmir, Turkey
| | - Sirin Guven
- grid.414850.c0000 0004 0642 8921Department of Pediatrics, Prof. Dr Ilhan Varank Training and Research Hospital, Istanbul, Turkey
| | - Adem Karbuz
- Department of Pediatric Infectious Disease, Dr. Cemil Tascioglu City Hospital, Istanbul, Turkey
| | - Aslinur Ozkaya Parlakay
- grid.512925.80000 0004 7592 6297Yildirim Beyazit University Faculty of Medicine Department of Pediatric Infectious Disease, Ankara City Hospital Department of Pediatric Infectious Disease, Ankara, Turkey
| | - Yalcın Kara
- grid.164274.20000 0004 0596 2460Department of Pediatric Infectious Disease, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
| | - Ebru Kacmaz
- grid.164274.20000 0004 0596 2460Pediatric Intensive Care Unit, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
| | - Aslihan Sahin
- grid.411795.f0000 0004 0454 9420Department of Pediatric Infectious Disease, Izmir Katip Celebi University Faculty of Medicine, Izmir, Turkey
| | - Aysun Boga
- grid.414850.c0000 0004 0642 8921Department of Pediatrics, Prof. Dr Ilhan Varank Training and Research Hospital, Istanbul, Turkey
| | - Didem Kizmaz Isancli
- Department of Pediatric Infectious Disease, Dr. Cemil Tascioglu City Hospital, Istanbul, Turkey
| | - Belgin Gulhan
- grid.512925.80000 0004 7592 6297Department of Pediatric Infectious Disease, Ankara City Hospital, Ankara, Turkey
| | - Saliha Kanik-Yuksek
- grid.512925.80000 0004 7592 6297Department of Pediatric Infectious Disease, Ankara City Hospital, Ankara, Turkey
| | - Eylem Kiral
- grid.164274.20000 0004 0596 2460Pediatric Intensive Care Unit, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
| | - Gurkan Bozan
- grid.164274.20000 0004 0596 2460Pediatric Intensive Care Unit, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
| | - Mehmet Ozgür Arslanoglu
- grid.164274.20000 0004 0596 2460Pediatric Intensive Care Unit, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
| | - Mahmut Can Kizil
- grid.164274.20000 0004 0596 2460Department of Pediatric Infectious Disease, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
| | - Meltem Dinleyici
- grid.164274.20000 0004 0596 2460Department of Social Pediatrics, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
| | - Tercan Us
- grid.164274.20000 0004 0596 2460Department of Microbiology, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
| | | | | | - Yvan Vandenplas
- grid.8767.e0000 0001 2290 8069KidZ Health Castle, UZ Brussels, Vrije Universiteit Brussel, Brussels, Belgium
| | - Ener Cagri Dinleyici
- grid.164274.20000 0004 0596 2460Department of Pediatrics, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, TR-26040 Turkey
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