1
|
Li DT, Yang Q, Xia CY, Zhang YF, Cai Y, Wu SQ, Jiang Q, Hu P. The changes of coagulation profiles in Kawasaki disease and its associations with clinical classification, intravenous immunoglobulin responsiveness and coronary artery involvement. Clin Exp Med 2024; 24:177. [PMID: 39105936 DOI: 10.1007/s10238-024-01430-z] [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: 05/13/2024] [Accepted: 07/08/2024] [Indexed: 08/07/2024]
Abstract
Coagulation disorders are common in Kawasaki disease (KD). The main objectives of the present study were to probe the associations of coagulation profiles with clinical classification, IVIG responsiveness, coronary artery abnormalities (CAAs) in the acute episode of KD. A total of 313 KD children were recruited and divided into six subgroups, including complete KD (n = 217), incomplete KD (n = 96), IVIG-responsive KD (n = 293), IVIG-nonresponsive KD (n = 20), coronary artery noninvolvement KD (n = 284) and coronary artery involvement KD (n = 29). Blood samples were collected within 24-h pre-IVIG therapy and 48-h post-IVIG therapy. Coagulation profiles, conventional inflammatory mediators and blood cell counts were detected. Echocardiography was performed during the period from 2- to 14-day post-IVIG infusion. In addition, 315 sex- and age-matched healthy children were enrolled as the controls. (1) Before IVIG therapy, coagulation disorders were more prone to appear in KD patients than in healthy controls, and could be overcome by IVIG therapy. FIB and DD significantly increased in the acute phase of KD, whereas reduced to normal levels after IVIG therapy. (2) PT and APTT were significantly longer in patients with complete KD when compared with their incomplete counterparts after IVIG therapy. (3) The larger δDD, δFDP and the smaller δPT, δINR predicted IVIG nonresponsiveness. (4) The higher δDD and δFDP correlated with a higher risk for CAAs (DD: r = -0.72, FDP: r = -0.54). Coagulation disorders are correlated with complete phenotype, IVIG nonresponsiveness and CAA occurrence in the acute episode of KD, and can be rectified by synergistic effects of IVIG and aspirin.
Collapse
Affiliation(s)
- Dao Ting Li
- Department of Paediatrics, The First Affiliated Hospital of Anhui Medical University, No. 218 Ji-Xi Road, Hefei, 230022, Anhui Province, People's Republic of China
| | - Qian Yang
- Department of Paediatrics, The First Affiliated Hospital of Anhui Medical University, No. 218 Ji-Xi Road, Hefei, 230022, Anhui Province, People's Republic of China
| | - Cai Yun Xia
- Department of Paediatrics, The First Affiliated Hospital of Anhui Medical University, No. 218 Ji-Xi Road, Hefei, 230022, Anhui Province, People's Republic of China
| | - Yan Fang Zhang
- Department of Paediatrics, The First Affiliated Hospital of Anhui Medical University, No. 218 Ji-Xi Road, Hefei, 230022, Anhui Province, People's Republic of China
| | - Ying Cai
- Department of Paediatrics, The First Affiliated Hospital of Anhui Medical University, No. 218 Ji-Xi Road, Hefei, 230022, Anhui Province, People's Republic of China
| | - Shu Qi Wu
- Department of Paediatrics, The First Affiliated Hospital of Anhui Medical University, No. 218 Ji-Xi Road, Hefei, 230022, Anhui Province, People's Republic of China
| | - Qi Jiang
- Department of Paediatrics, The First Affiliated Hospital of Anhui Medical University, No. 218 Ji-Xi Road, Hefei, 230022, Anhui Province, People's Republic of China
| | - Peng Hu
- Department of Paediatrics, The First Affiliated Hospital of Anhui Medical University, No. 218 Ji-Xi Road, Hefei, 230022, Anhui Province, People's Republic of China.
| |
Collapse
|
2
|
Mercolini F, Abram N, Cesaro S. Managing acute COVID-19 in immunocompromised pediatric patients. Expert Rev Clin Immunol 2024; 20:349-357. [PMID: 38099388 DOI: 10.1080/1744666x.2023.2295982] [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: 05/14/2023] [Accepted: 12/13/2023] [Indexed: 03/16/2024]
Abstract
INTRODUCTION SARS-CoV-2 infection is a potentially life-threatening infection in immunocompromised pediatric patients, and its management has rapidly evolved during the pandemic. To control SARS-CoV-2 infection over time, the scenario changed for the better with the introduction of specific treatments such as antiviral drugs, vaccines, and monoclonal antibodies, together with drugs blocking the inflammatory cytokine cascade and improvements in supportive care. AREAS COVERED This paper discusses the therapeutic strategies to apply for patients affected by COVID-19 in the pediatric population, with a focus on the immunocompromised patients. EXPERT OPINION Treatment in pediatric patients retraces the therapies investigated and approved in adults and must be calibrated on the basis of the severity of the infection (anti-spike monoclonal antibody, antivirals, anti-inflammatory drugs, and immunomodulators). Transmission prevention policies and vaccination reduce the risk of infection, while early intervention in the immunocompromised patients at high-risk of progression to severe-critical COVID-19 may reduce the period of viral shedding and the need for hospitalization, intensive care admission, and death. In hemato-oncological patients, the delayed treatment of SARS-CoV-2 infection or COVID-19 disease represents a frequent complication and its impact on the patient outcome remains a matter of research for the next few years.
Collapse
Affiliation(s)
- Federico Mercolini
- Pediatric Oncology and Hematology "Lalla Seràgnoli", IRCCS, Azienda Ospedaliero-Universitaria di Bologna institution, Bologna, Italy
| | - Nicoletta Abram
- Pediatric Oncology and Hematology "Lalla Seràgnoli", IRCCS, Azienda Ospedaliero-Universitaria di Bologna institution, Bologna, Italy
| | - Simone Cesaro
- Pediatric Hematology Oncology, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| |
Collapse
|
3
|
Kumar R, Rivkin MJ, Raffini L. Thrombotic complications in children with Coronavirus disease 2019 and Multisystem Inflammatory Syndrome of Childhood. J Thromb Haemost 2023; 21:2313-2326. [PMID: 37268064 PMCID: PMC10232718 DOI: 10.1016/j.jtha.2023.05.020] [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: 04/04/2023] [Revised: 05/22/2023] [Accepted: 05/23/2023] [Indexed: 06/04/2023]
Abstract
Coronavirus disease 2019 (COVID-19) associated coagulopathy is multifactorial and involves inflammation driven hypercoagulability, endothelial dysfunction, platelet activation, and impaired fibrinolysis. Hospitalized adults with COVID-19 are at an increased risk of both venous thromboembolism and ischemic stroke, resulting in adverse outcomes, including increased mortality. Although COVID-19 in children follows a less severe course, both arterial and venous thromboses have been reported in hospitalized children with COVID-19. Additionally, some children develop a postinfectious, hyperinflammatory illness termed multisystem inflammatory syndrome of childhood (MIS-C), which is also associated with hypercoagulability and thrombosis. Several randomized trials have evaluated the safety and efficacy of antithrombotic therapy in adults with COVID-19, although similar pediatric data are lacking. In this narrative review, we discuss the postulated pathophysiology of COVID-19 coagulopathy and summarize principal findings of the recently completed adult trials of antithrombotic therapy. We provide an up-to-date summary of pediatric studies investigating the rate of venous thromboembolism and ischemic stroke in COVID-19 and multisystem inflammatory syndrome of childhood in addition to reviewing the findings of the single, nonrandomized pediatric trial investigating the safety of prophylactic anticoagulation. Lastly, we outline adult and pediatric consensus guidelines on the use of antithrombotic therapy in this cohort. A detailed discussion of the practical implementation and current limitations of published data will hopefully address the knowledge deficits surrounding the use of antithrombotic therapy in children with COVID-19 and generate hypotheses for future research.
Collapse
Affiliation(s)
- Riten Kumar
- Dana Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.
| | - Michael J Rivkin
- Department of Neurology, Stroke and Cerebrovascular Center, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA
| | - Leslie Raffini
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
4
|
Rubino C, Bechini C, Stinco M, Lasagni D, Indolfi G, Trapani S. COVID-19 and Thromboembolic Events in the Pandemic and Pre-Pandemic Era: A Pediatric Cohort. Viruses 2023; 15:1554. [PMID: 37515240 PMCID: PMC10383326 DOI: 10.3390/v15071554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 07/09/2023] [Accepted: 07/14/2023] [Indexed: 07/30/2023] Open
Abstract
The Coronavirus disease 2019 (COVID-19) and multisystem inflammatory syndrome in children (MIS-C) have been variably associated with thromboembolic events (TEs) in children. The aim of our study was to assess the prevalence of TEs in children hospitalized during a five-year period in a tertiary pediatric hospital, particularly in patients with COVID-19 and MIS-C. Overall, 38 patients were discharged with the diagnosis of TE: 20 in the pre-pandemic and 18 in the pandemic period. The prevalence of TEs was the same (0.08%) in the pre-pandemic and pandemic periods. The occurrence of TEs was higher in patients with COVID-19 or MIS-C (6/517, 1.16%) when compared to children without these conditions in the pandemic and in the pre-pandemic periods. The prevalence of TEs in children with MIS-C was significantly higher than the prevalence in patients with COVID-19. Five out of six of the patients with COVID-19 or MIS-C developing a TE had at least one predisposing factor to thrombosis. In conclusion, our study shows an increased prevalence of TEs in children hospitalized with COVID-19 or MIS-C, if compared to children without COVID-19 or MIS-C in the pandemic period and in the pre-pandemic period. The prevalence of TEs was significantly higher in patients with MIS-C.
Collapse
Affiliation(s)
- Chiara Rubino
- Pediatric Unit, Meyer Children's Hospital IRCCS, Viale Pieraccini 24, 50139 Florence, Italy
| | - Camilla Bechini
- Pediatric Unit, Meyer Children's Hospital IRCCS, Viale Pieraccini 24, 50139 Florence, Italy
| | - Mariangela Stinco
- Pediatric Unit, Meyer Children's Hospital IRCCS, Viale Pieraccini 24, 50139 Florence, Italy
| | - Donatella Lasagni
- Pediatric Unit, Meyer Children's Hospital IRCCS, Viale Pieraccini 24, 50139 Florence, Italy
| | - Giuseppe Indolfi
- Pediatric Unit, Meyer Children's Hospital IRCCS, Viale Pieraccini 24, 50139 Florence, Italy
- Department of NEUROFARBA, University of Florence, Viale Pieraccini 24, 50139 Florence, Italy
| | - Sandra Trapani
- Pediatric Unit, Meyer Children's Hospital IRCCS, Viale Pieraccini 24, 50139 Florence, Italy
- Department of Health Sciences, University of Florence, Viale Pieraccini 24, 50139 Florence, Italy
| |
Collapse
|
5
|
Pegoraro F, Lasagni D, Trapani S, Mastrolia MV, Simonini G, Indolfi G, Resti M. Anticoagulation and Thrombotic Events in the Multisystem Inflammatory Syndrome in Children: Experience of a Single-center Cohort and Review of the Literature. J Pediatr Hematol Oncol 2023; 45:256-261. [PMID: 36657031 DOI: 10.1097/mph.0000000000002590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 10/07/2022] [Indexed: 01/21/2023]
Abstract
The multisystem inflammatory syndrome in children (MIS-C) is a severe clinical entity affecting the coagulative system; although thromboembolic events (TEs) are not common, most patients receive anticoagulation. We retrospectively assessed patients below 18 years admitted with MIS-C at Meyer Children's Hospital (Florence, Italy). Data on baseline clinical and laboratory presentation, treatment, and outcome, including differences between patients with and without thrombotic prophylaxis, were analyzed. Thirty-two children 1 to 15 years were included. Seventeen patients (53.1%) required intensive care admission, 2 (8.7%) had obesity, 7 (30.4%) a central venous catheter, and 14 (43.8%) an impaired cardiac function. Twelve patients (37.5%) received prophylactic anticoagulation: they had more frequent cardiac involvement (91.7 vs. 50%, P =0.02) and higher ferritin levels (median 1240 vs. 501.5 ng/mL, P <0.001). No differences were found in median d -dimers between the 2 groups. Twenty-one patients (65.6%) had d -dimers >5×upper limit of normal but the indication for anticoagulation was not driven by d -dimers. No patient had hemorrhagic events and only 1 patient (3.1%) had a superficial thrombotic event (under thromboprophylaxis). Our series and the available literature data on MIS-C and thromboembolic events suggest that TEs are a rare complication of MIS-C that is frequently associated with high d -dimer values. However, also in MIS-C, the well-established risk factors of pediatric TEs (ie, older age, central venous catheter, obesity, and cancer) should guide thromboembolic risk assessment.
Collapse
Affiliation(s)
| | | | | | | | - Gabriele Simonini
- Neurofarba Department, University of Florence
- Rheumatology Unit, Meyer Children's Hospital, Florence, Italy
| | | | | |
Collapse
|
6
|
Sahrai H, Hemmati-Ghavshough M, Shahrabi M, Jafari-Rouhi AH, Solduzian M. Thromboprophylaxis for Coagulopathy Related to COVID-19 in Pediatrics: A Narrative Review. Paediatr Drugs 2023:10.1007/s40272-023-00566-x. [PMID: 37142896 PMCID: PMC10158690 DOI: 10.1007/s40272-023-00566-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/27/2023] [Indexed: 05/06/2023]
Abstract
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.
Collapse
Affiliation(s)
- Hadi Sahrai
- Student research committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Marzieh Shahrabi
- Department of Clinical Pharmacy, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Mohammad Solduzian
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran.
| |
Collapse
|
7
|
Guner Ozenen G, Akaslan Kara A, Boncuoglu E, Kiymet E, Cem E, Sahinkaya S, Yilmaz Celebi M, Gulderen M, Kacar P, Uras M, Hilkay Karapinar T, Oymak Y, Bayram N, Devrim I. Evaluation of antithrombotic prophylaxis and thrombotic events in children with COVID-19 or MIS-C: A tertiary pediatric center experience. Arch Pediatr 2023; 30:172-178. [PMID: 36907731 PMCID: PMC9902296 DOI: 10.1016/j.arcped.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 08/26/2022] [Accepted: 01/15/2023] [Indexed: 02/09/2023]
Abstract
OBJECTIVES COVID-19 and multisystem inflammatory syndrome in children (MIS-C) are associated with a risk of hypercoagulability and thrombotic events. We aimed (a) to evaluate the demographic, clinical, and laboratory findings as well as the incidence of thrombotic events of COVID-19 and MIS-C in children and (b) to determine the role of antithrombotic prophylaxis. METHODS A single-center retrospective study evaluated hospitalized children with COVID-19 or MIS-C. RESULTS The study group consisted of 690 patients, 596 (86.4%) diagnosed with COVID-19 and 94 (13.6%) diagnosed with MIS-C. Antithrombotic prophylaxis was used for 154 (22.3%) patients: 63 patients (10.6%) in the COVID-19 group and 91 (96.8%) patients in the MIS-C group. Use of antithrombotic prophylaxis was statistically higher in the MIS-C group (p<0.001). Patients who received antithrombotic prophylaxis were of older median age, were more commonly male, and had more frequent underlying diseases than those without prophylaxis (p<0.001, p<0.012, p<0.019, respectively). The most common underlying condition was obesity in patients who received antithrombotic prophylaxis. Thrombosis was observed in one (0.2%) patient in the COVID-19 group with a thrombus in the cephalic vein, two (2.1%) patients in the MIS-C group, with a dural thrombus in one patient and a cardiac thrombus in the other patient. The patients with thrombotic events were previously healthy and had mild disease. CONCLUSION In our study, thrombotic events were rare compared with previous reports. We used antithrombotic prophylaxis for most children with underlying risk factors; perhaps for this reason, we did not observe thrombotic events in children with underlying risk factors. We suggest that patients diagnosed with COVID-19 or MIS-C be closely monitored for thrombotic events.
Collapse
Affiliation(s)
- G Guner Ozenen
- Department of Pediatric Infectious Diseases, University of Health Sciences, Dr. Behçet Uz Children's Hospital, İzmir, Turkey.
| | - A Akaslan Kara
- Department of Pediatric Infectious Diseases, University of Health Sciences, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - E Boncuoglu
- Department of Pediatric Infectious Diseases, University of Health Sciences, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - E Kiymet
- Department of Pediatric Infectious Diseases, University of Health Sciences, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - E Cem
- Department of Pediatric Infectious Diseases, University of Health Sciences, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - S Sahinkaya
- Department of Pediatric Infectious Diseases, University of Health Sciences, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - M Yilmaz Celebi
- Department of Pediatric Infectious Diseases, University of Health Sciences, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - M Gulderen
- Department of Pediatric Infectious Diseases, University of Health Sciences, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - P Kacar
- Department of Pediatric Infectious Diseases, University of Health Sciences, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - M Uras
- Department of Pediatrics, University of Health Sciences, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - T Hilkay Karapinar
- Department of Pediatric Hematology and Oncology, University of Health Sciences, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - Y Oymak
- Department of Pediatric Hematology and Oncology, University of Health Sciences, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - N Bayram
- Department of Pediatric Infectious Diseases, University of Health Sciences, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - I Devrim
- Department of Pediatric Infectious Diseases, University of Health Sciences, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| |
Collapse
|
8
|
Thromboprophylaxis Outcome in Childhood SARS-CoV-2 Infection: A Single-Center Experience. J Pediatr Hematol Oncol 2023; 45:e97-e102. [PMID: 36162044 DOI: 10.1097/mph.0000000000002557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 07/22/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND The SARS-CoV-2 infection has been associated with potentially endothelial damage and coagulation cascade activation that cause thrombosis. There is limited information on thrombosis and anticoagulant therapy in children with coronavirus disease 2019 (COVID-19). AIMS This study evaluates the outcome of thromboprophylaxis in children younger than 18-year old with COVID-19 infection. METHODS A retrospective study was conducted on 184 hospitalized pediatric patients with confirmed COVID-19 infection. A designed questionnaire was made to collect all demographic, clinical, and laboratory data. According to World Health Organization, the patients were classified as asymptomatic/mild, moderate, severe, and critically ill. RESULTS The mean age of the patients was 7.04±5.9 (1 wk to younger than 18 y). Overall, 33 patients received anticoagulant therapy. All patients who passed away (n=19) belonged to the critical group. One patient (1.28%) was complicated with deep vein thrombosis despite taking thromboprophylaxis, and 1 (1.28%) with pulmonary thromboembolism while the patient did not take an anticoagulant. CONCLUSIONS Our data showed a lower rate of thrombosis (1.4%) than adult patients with COVID-19. It may underline the role of anticoagulants in moderate to severe/critically ill children with COVID-19 infection. Expert opinion and personal experience are necessary, while we have a significant knowledge gap in understanding COVID-19-associated coagulopathy and thrombotic risk in children.
Collapse
|
9
|
Zabeida A, Winikoff R, Pelland‐Marcotte M, Charlebois J, Sabapathy C. COVID-19-associated coagulopathy in children: A multicenter observational cohort study. Pediatr Blood Cancer 2023; 70:e30079. [PMID: 36326142 PMCID: PMC9878209 DOI: 10.1002/pbc.30079] [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: 03/05/2022] [Revised: 09/18/2022] [Accepted: 10/09/2022] [Indexed: 11/06/2022]
Abstract
SARS-CoV-2 infection (coronavirus disease 2019 [COVID-19]) induces a stark procoagulant state, with many hospitalized adults developing thrombosis despite prophylactic anticoagulation. This study aimed to characterize hemostatic parameters and associated clinical outcomes of COVID-19, such as thrombosis and bleeding, in children and to assess thromboprophylaxis use. This multicenter observational cohort study included 79 patients aged up to 18 years admitted to all pediatric hospitals in Québec, Canada, with SARS-CoV-2 infection during a 5-month period. D-dimers were elevated in 18/19 patients (94.7%) and fibrinogen in 15/26 patients (60%). Eleven patients (13.9%) received anticoagulant thromboprophylaxis. One thrombotic event and one major bleed were observed.
Collapse
Affiliation(s)
- Alexandra Zabeida
- Division of Pediatric Hematology‐OncologyMontreal Children's HospitalMcGill University Health CentreMontrealQuébecCanada,Division of Pediatric Haematology‐OncologyThe Hospital for Sick ChildrenTorontoOntarioCanada
| | - Rochelle Winikoff
- Department of Pediatric Hematology‐OncologyCentre Hospitalier Universitaire Sainte‐JustineMontrealQuébecCanada
| | - Marie‐Claude Pelland‐Marcotte
- Division of Pediatric Hematology‐OncologyCentre Hospitalier Universitaire de Québec/Centre mère‐enfant SoleilQuébec CityQuébecCanada
| | - Janie Charlebois
- Division of Pediatric Hematology‐OncologyCentre Hospitalier Universitaire de SherbrookeSherbrookeQuébecCanada
| | - Christine Sabapathy
- Division of Pediatric Hematology‐OncologyMontreal Children's HospitalMcGill University Health CentreMontrealQuébecCanada
| |
Collapse
|
10
|
Nadua KD, Chong CY, Kam KQ, Mok YH, Choo JTL, Lam JCM, Li J, Tan NWH, Yung CF, Chan SWB, Teh KL, Das L, Arkachaisri T, Thoon KC. Multisystem inflammatory syndrome in children in Singapore. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2022. [DOI: 10.47102/annals-acadmedsg.202283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Introduction: Multisystem inflammatory syndrome in children (MIS-C) is a rare inflammatory syndrome with multisystem involvement affecting children exposed to COVID-19. This condition is rarely reported in East Asia and was not detected in Singapore until 2021. We present 12 cases of MIS-C diagnosed in KK Women’s and Children’s Hospital (KKH) from October 2021 to December 2021.
Method: We conducted an observational study on cases fulfilling the Singapore Ministry of Health criteria for MIS-C from January 2020 to December 2021 in KKH. Medical records were reviewed to obtain information on clinical presentation, disease course, treatment received and outcomes.
Results: In the 12 cases detected, the median age was 7.50 years (interquartile range 4.00–9.25); 8 were male. All patients had mucocutaneous symptoms similar to Kawasaki disease. Other commonly involved systems were: haematological (coagulopathy 100%, lymphopaenia 91.70% and thrombocytopaenia 75.00%), gastrointestinal (75.00%) and cardiovascular (83.30%). Six patients (50.00%) had shock and were admitted to the intensive care unit. The majority of patients received treatment within 2 days of hospitalisation with intravenous immunoglobulin (IVIg) and steroids. All survived; the majority had normal echocardiograms and no long-term organ sequelae at 6 months post-discharge.
Conclusion: MIS-C emerged in Singapore as the incidence of COVID-19 in the community increased in 2021. The clinical presentation of our patients is similar to earlier reports, with some significant differences from Kawasaki disease. Multidisciplinary management, timely diagnosis, and early initiation of treatment with IVIg and steroids likely contributed to comparatively good outcomes. Our cases highlight the need for continued awareness of MIS-C among physicians, and surveillance of its incidence, short- and long-term outcomes.
Keywords: COVID-19, children, MIS-C, inflammation, paediatrics
Collapse
Affiliation(s)
| | | | | | - Yee Hui Mok
- KK Women’s and Children’s Hospital, Singapore
| | | | | | - Jiahui Li
- KK Women’s and Children’s Hospital, Singapore
| | | | | | | | | | - Lena Das
- KK Women’s and Children’s Hospital, Singapore
| | | | | |
Collapse
|
11
|
Abrams CM, Jaffray J, Stillings A, Branchford B, Young G, Goldenberg NA, Abajas YL. Current practices in pediatric hospital-acquired thromboembolism: Survey of the Children's Hospital Acquired Thrombosis (CHAT) Consortium. Res Pract Thromb Haemost 2022; 6:e12793. [PMID: 38024326 PMCID: PMC10656282 DOI: 10.1002/rth2.12793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 08/03/2022] [Indexed: 11/05/2022] Open
Abstract
Background A rise in hospital-acquired venous thromboembolism (HA-VTE) in children has led to increased awareness regarding VTE prophylaxis and risk assessment. Despite no consensus exists regarding these practices in pediatrics. Objective To describe common practices in VTE prophylaxis, VTE risk assessment models, and anticoagulation dosing strategies in pediatric hospitals that are members of the Children's Hospital Acquired Thrombosis (CHAT) Consortium. Methods An electronic survey of 44 questions evaluating practices surrounding pediatric HA-VTE risk assessment and prevention was distributed between August 9, 2021, and August 30, 2021, to the primary investigators from the 32 institutions within the CHAT Consortium. Results The survey response rate was 100% (n = 32). In total, 85% (n = 27) of the institutions assess HA-VTE, but only 63% (n = 20) have formal hospital guidelines. Within the institutions with formal guidelines, 100% (n = 20) include acute systemic inflammation or infection and presence of a central venous catheter (CVC) as risk factors for VTE. Pharmacologic prophylaxis is prescribed at 87% (28) of institutions, with enoxaparin being the most frequent (96%, n = 27). Variability in responses persisted regarding risk factors, risk assessment, thromboprophylaxis, dosing of prophylactic anticoagulation or anticoagulant drug monitoring. A majority of providers were comfortable providing thromboprophylaxis across all age groups. In addition, the global coronavirus disease 2019 increased the providers' use of prophylactic anticoagulation 78% (n = 25). Conclusion Practices among institutions are variable in regard to use of HA-VTE prophylaxis, risk assessment, or guideline implementation, highlighting the need for further research and a validated risk assessment model through groups like the CHAT Consortium.
Collapse
Affiliation(s)
- Christina M. Abrams
- Division of Hematology/Oncology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Julie Jaffray
- Division of Hematology, Oncology, and Bone Marrow Transplant, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Amy Stillings
- Division of Hematology, Oncology, and Bone Marrow Transplant, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Brian R. Branchford
- Versiti Medical Sciences Institute, Milwaukee, Wisconsin, USA
- Children's Wisconsin Hospital, Wauwatosa, Wisconsin, USA
| | - Guy Young
- Division of Hematology, Oncology, and Bone Marrow Transplant, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Neil A. Goldenberg
- Johns Hopkins University School of Medicine, Departments of Pediatrics and Medicine, Baltimore, Maryland, USA
| | - Yasmina L. Abajas
- Hemophilia and Thrombosis Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - for the CHAT Consortium Investigators
- Division of Hematology/Oncology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Division of Hematology, Oncology, and Bone Marrow Transplant, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Versiti Medical Sciences Institute, Milwaukee, Wisconsin, USA
- Children's Wisconsin Hospital, Wauwatosa, Wisconsin, USA
- Johns Hopkins University School of Medicine, Departments of Pediatrics and Medicine, Baltimore, Maryland, USA
- Hemophilia and Thrombosis Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - the VTE Risk Factors and Thromboprophylaxis Working Group of the Pediatric and Neonatal Thrombosis and Hemostasis Subcommittee of the ISTH SSC
- Division of Hematology/Oncology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Division of Hematology, Oncology, and Bone Marrow Transplant, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California, USA
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Versiti Medical Sciences Institute, Milwaukee, Wisconsin, USA
- Children's Wisconsin Hospital, Wauwatosa, Wisconsin, USA
- Johns Hopkins University School of Medicine, Departments of Pediatrics and Medicine, Baltimore, Maryland, USA
- Hemophilia and Thrombosis Center, University of North Carolina, Chapel Hill, North Carolina, USA
| |
Collapse
|
12
|
Tehseen S, Williams S, Robinson J, Morris SK, Bitnun A, Gill P, Tal TE, Yeh A, Yea C, Ulloa‐Gutierrez R, Brenes‐Chacon H, Yock‐Corrales A, Ivankovich‐Escoto G, Soriano‐Fallas A, Papenburg J, Lefebvre M, Scuccimarri R, Nateghian A, Aski BH, Dwilow R, Bullard J, Cooke S, Restivo L, Lopez A, Sadarangani M, Roberts A, Forbes M, Saux NL, Bowes J, Purewal R, Lautermilch J, Bayliss A, Wong JK, Leifso K, Foo C, Panetta L, Kakkar F, Piche D, Viel‐Theriault I, Merckx J, Lieberman L. Thrombosis and hemorrhage experienced by hospitalized children with SARS-CoV-2 infection or MIS-C: Results of the PICNIC registry. Pediatr Blood Cancer 2022; 69:e29793. [PMID: 35689507 PMCID: PMC9350140 DOI: 10.1002/pbc.29793] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 04/06/2022] [Accepted: 04/26/2022] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Coagulopathy and thrombosis associated with SARS-CoV-2 infection are well defined in hospitalized adults and leads to adverse outcomes. Pediatric studies are limited. METHODS An international multicentered (n = 15) retrospective registry collected information on the clinical manifestations of SARS-CoV-2 and multisystem inflammatory syndrome (MIS-C) in hospitalized children from February 1, 2020 through May 31, 2021. This sub-study focused on coagulopathy. Study variables included patient demographics, comorbidities, clinical presentation, hospital course, laboratory parameters, management, and outcomes. RESULTS Nine hundred eighty-five children were enrolled, of which 915 (93%) had clinical information available; 385 (42%) had symptomatic SARS-CoV-2 infection, 288 had MIS-C (31.4%), and 242 (26.4%) had SARS-CoV-2 identified incidentally. Ten children (1%) experienced thrombosis, 16 (1.7%) experienced hemorrhage, and two (0.2%) experienced both thrombosis and hemorrhage. Significantly prevalent prothrombotic comorbidities included congenital heart disease (p-value .007), respiratory support (p-value .006), central venous catheter (CVC) (p = .04) in children with primary SARS-CoV-2 and in those with MIS-C included respiratory support (p-value .03), obesity (p-value .002), and cytokine storm (p = .012). Comorbidities prevalent in children with hemorrhage included age >10 years (p = .04), CVC (p = .03) in children with primary SARS-CoV-2 infection and in those with MIS-C encompassed thrombocytopenia (p = .001) and cytokine storm (p = .02). Eleven patients died (1.2%), with no deaths attributed to thrombosis or hemorrhage. CONCLUSION Thrombosis and hemorrhage are uncommon events in children with SARS-CoV-2; largely experienced by those with pre-existing comorbidities. Understanding the complete spectrum of coagulopathy in children with SARS-CoV-2 infection requires ongoing research.
Collapse
Affiliation(s)
- Sarah Tehseen
- Department of Laboratory medicine and PediatricsUniversity of Saskatchewan, SHASaskatoonSaskatchewanCanada
| | - Suzan Williams
- Division of Hematology OncologyHospital for Sick ChildrenTorontoOntarioCanada
| | - Joan Robinson
- Department of PediatricsUniversity of AlbertaEdmontonAlbertaCanada
| | - Shaun K. Morris
- Department of Pediatrics, Division of Infectious DiseasesUniversity of TorontoTorontoOntarioCanada
| | - Ari Bitnun
- Department of Pediatrics, Division of Infectious DiseasesUniversity of TorontoTorontoOntarioCanada
| | - Peter Gill
- Department of Pediatrics, Division of Infectious DiseasesUniversity of TorontoTorontoOntarioCanada
| | - Tala El Tal
- Department of Pediatrics, Division of Infectious DiseasesUniversity of TorontoTorontoOntarioCanada
| | - Ann Yeh
- Department of Pediatrics, Division of Infectious DiseasesUniversity of TorontoTorontoOntarioCanada
| | - Carmen Yea
- Department of Pediatrics, Division of Infectious DiseasesUniversity of TorontoTorontoOntarioCanada
| | - Rolando Ulloa‐Gutierrez
- Department of PediatricsHospital Nacional de Niños “Dr. Carlos Sáenz Herrera,” Caja Costarricense de Seguro Social (CCSS)San JoséCosta Rica
| | - Helena Brenes‐Chacon
- Department of PediatricsHospital Nacional de Niños “Dr. Carlos Sáenz Herrera,” Caja Costarricense de Seguro Social (CCSS)San JoséCosta Rica
| | - Adriana Yock‐Corrales
- Department of PediatricsHospital Nacional de Niños “Dr. Carlos Sáenz Herrera,” Caja Costarricense de Seguro Social (CCSS)San JoséCosta Rica
| | - Gabriela Ivankovich‐Escoto
- Department of PediatricsHospital Nacional de Niños “Dr. Carlos Sáenz Herrera,” Caja Costarricense de Seguro Social (CCSS)San JoséCosta Rica
| | - Alejandra Soriano‐Fallas
- Department of PediatricsHospital Nacional de Niños “Dr. Carlos Sáenz Herrera,” Caja Costarricense de Seguro Social (CCSS)San JoséCosta Rica
| | - Jesse Papenburg
- Department of PediatricsMcGill UniversityMontrealQuebecCanada
| | | | | | - Alireza Nateghian
- Department of PediatricsIran University of Medical SciencesTehranIran
| | | | - Rachel Dwilow
- Department of PediatricsUniversity of ManitobaWinnipegManitobaCanada
| | - Jared Bullard
- Department of PediatricsUniversity of ManitobaWinnipegManitobaCanada
| | - Suzette Cooke
- Department of PediatricsUniversity of CalgaryCalgaryAlbertaCanada
| | - Lea Restivo
- Department of PediatricsUniversity of CalgaryCalgaryAlbertaCanada
| | - Alison Lopez
- Department of PediatricsUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Manish Sadarangani
- Department of PediatricsUniversity of British ColumbiaVancouverBritish ColumbiaCanada,Vaccine Evaluation CenterBC Children's Hospital Research InstituteVancouverBritish ColumbiaCanada
| | - Ashley Roberts
- Department of PediatricsUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Michelle Forbes
- Department of PediatricsWestern UniversityLondonOntarioCanada
| | - Nicole Le Saux
- Department of PediatricsUniversity of OttawaOttawaOntarioCanada
| | - Jennifer Bowes
- Department of PediatricsUniversity of OttawaOttawaOntarioCanada
| | - Rupeena Purewal
- Department of PediatricsUniversity of SaskatchewanSaskatoonSaskatchewanCanada
| | - Janell Lautermilch
- Department of PediatricsUniversity of SaskatchewanSaskatoonSaskatchewanCanada
| | - Ann Bayliss
- Department of PediatricsTrillium Health PartnersMississaugaOntarioCanada
| | | | - Kirk Leifso
- Department of PediatricsQueen's UniversityKingstonOntarioCanada
| | - Cheryl Foo
- Department of PediatricsMemorial UniversitySt John'sNewfoundland and LabradorCanada
| | - Luc Panetta
- Department of PediatricsUniversitie du MontrealMontrealQuebecCanada
| | - Fatima Kakkar
- Department of PediatricsUniversitie du MontrealMontrealQuebecCanada
| | - Dominique Piche
- Department of PediatricsDalhousie UniversityHalifaxNova ScotiaCanada
| | | | - Joanna Merckx
- Department of Epidemiology, Biostatistics and Occupational HealthMcGill UniversityMontrealQuebecCanada
| | - Lani Lieberman
- Department of Laboratory Medicine and PathobiologyUniversity Health NetworkTorontoOntarioCanada
| |
Collapse
|
13
|
McDaniel CG, Commander SJ, DeLaura I, Cantrell S, Leraas HJ, Moore CB, Reed CR, Pahl KS, Tracy ET. Coagulation Abnormalities and Clinical Complications in Children With SARS-CoV-2: A Systematic Review of 48,322 Patients. J Pediatr Hematol Oncol 2022; 44:323-335. [PMID: 34862349 DOI: 10.1097/mph.0000000000002321] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/07/2021] [Indexed: 02/03/2023]
Abstract
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.
Collapse
Affiliation(s)
| | | | | | - Sarah Cantrell
- Duke University School of Medicine
- Duke University Medical Center Library and Archives, Durham, NC
| | | | | | | | - Kristy S Pahl
- Division of Pediatric Hematology-Oncology
- Department of Pediatrics
| | - Elisabeth T Tracy
- Department of Surgery
- Division of Pediatric Surgery, Duke University Medical Center
| |
Collapse
|
14
|
Schmitz AH, Wood KE, Burghardt EL, Koestner BP, Wendt LH, Badheka AV, Sharathkumar AA. Thromboprophylaxis for children hospitalized with COVID-19 and MIS-C. Res Pract Thromb Haemost 2022; 6:e12780. [PMID: 35949885 PMCID: PMC9357887 DOI: 10.1002/rth2.12780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 05/22/2022] [Accepted: 06/28/2022] [Indexed: 11/26/2022] Open
Abstract
Background Limited data exist about effective regimens for pharmacological thromboprophylaxis in children with acute coronavirus disease 2019 (COVID‐19) and multisystem inflammatory syndrome in children (MIS‐C). Objectives Study the outcomes of institutional thromboprophylaxis protocol for primary venous thromboembolism (VTE) prevention in children hospitalized with acute COVID‐19/MIS‐C. Methods This single‐center retrospective cohort study included consecutive children (aged less than 21 years) with COVID‐19/MIS‐C who received tailored intensity thromboprophylaxis, primarily with low‐molecular‐weight heparin, from April 2020 through October 2021. Thromboprophylaxis was given to those with moderate to severe disease based on the World Health Organization scale and exposure to two or more VTE risk factors. Therapeutic intensity was considered for severe illness. Clinical recovery along with D‐dimer improvement determined thromboprophylaxis duration. Outcomes were incident VTEs, bleeding, and mortality. Results Among 211 hospitalizations, 45 (21.3%) received thromboprophylaxis (COVID‐19, 16; MIS‐C, 29). Median age was 14.8 years (interquartile range [IQR], 8.9–16.1). Among 35 (77.8%) with severe illness, 27 (60.0%) required respiratory support, and 19 (42.2%) required an intensive care unit stay. Median hospitalization was 6 days (IQR, 5.0–10.5). Median thromboprophylaxis duration was 19 days (IQR, 6.0–31.0) with therapeutic intensity in 24 (53.3%) and prophylactic in 21 (46.7%). Outcomes were as follows: VTE, 1 (2.2%); death, 1 (2.2%, unrelated to bleeding/thrombosis); major/clinically relevant nonmajor bleeding, 0; and minor bleeding, 7 (15.5%). D‐dimer was elevated in a majority at diagnosis (median, 2.3; IQR, 1.2–3.3 mg/ml fibrinogen‐equivalent units) and was noninformative in assessing disease severity. D‐dimer normalized at thromboprophylaxis discontinuation. Conclusions Our experience of using clinically directed thromboprophylaxis with tailored intensity approach for children hospitalized with COVID‐19 and MIS‐C favors its inclusion in current standard of care. The role of D‐dimer in directing thromboprophylaxis management deserves further evaluation.
Collapse
Affiliation(s)
- Anna H Schmitz
- Stead Family Department of Pediatrics University of Iowa Iowa City Iowa USA.,Carver College of Medicine University of Iowa Iowa City Iowa USA
| | - Kelly E Wood
- Stead Family Department of Pediatrics University of Iowa Iowa City Iowa USA.,Carver College of Medicine University of Iowa Iowa City Iowa USA
| | - Elliot L Burghardt
- Carver College of Medicine University of Iowa Iowa City Iowa USA.,Department of Biostatistics, College of Public Health University of Iowa Iowa City Iowa USA
| | - Bryan P Koestner
- Stead Family Department of Pediatrics University of Iowa Iowa City Iowa USA.,Carver College of Medicine University of Iowa Iowa City Iowa USA
| | - Linder H Wendt
- Institute for Clinical and Translational Science University of Iowa Iowa City Iowa USA
| | - Aditya V Badheka
- Stead Family Department of Pediatrics University of Iowa Iowa City Iowa USA.,Carver College of Medicine University of Iowa Iowa City Iowa USA
| | - Anjali A Sharathkumar
- Stead Family Department of Pediatrics University of Iowa Iowa City Iowa USA.,Carver College of Medicine University of Iowa Iowa City Iowa USA
| |
Collapse
|
15
|
Noni M, Koukou DM, Tritzali M, Kanaka-Gantenbein C, Michos A, Spoulou V. Coagulation Abnormalities and Management in Hospitalized Pediatric Patients With COVID-19. Pediatr Infect Dis J 2022; 41:570-574. [PMID: 35389967 PMCID: PMC9177125 DOI: 10.1097/inf.0000000000003545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/22/2022] [Indexed: 11/26/2022]
Abstract
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.
Collapse
Affiliation(s)
- Maria Noni
- From the First Department of Pediatrics, National and Kapodistrian University of Athens, ‘Aghia Sophia’ Children’s Hospital, Athens, Greece
| | - Dimitra-Maria Koukou
- From the First Department of Pediatrics, National and Kapodistrian University of Athens, ‘Aghia Sophia’ Children’s Hospital, Athens, Greece
| | - Maroula Tritzali
- From the First Department of Pediatrics, National and Kapodistrian University of Athens, ‘Aghia Sophia’ Children’s Hospital, Athens, Greece
| | - Christina Kanaka-Gantenbein
- From the First Department of Pediatrics, National and Kapodistrian University of Athens, ‘Aghia Sophia’ Children’s Hospital, Athens, Greece
| | - Athanasios Michos
- From the First Department of Pediatrics, National and Kapodistrian University of Athens, ‘Aghia Sophia’ Children’s Hospital, Athens, Greece
| | - Vana Spoulou
- From the First Department of Pediatrics, National and Kapodistrian University of Athens, ‘Aghia Sophia’ Children’s Hospital, Athens, Greece
| |
Collapse
|
16
|
Vitaliti G, Giacchi V, Sciacca M, Ruggieri M, Falsaperla R. Thrombotic events in children and adolescent patients with SARS-Cov-2 infection: a systematic review with meta-analysis on incidence and management. Expert Rev Hematol 2022; 15:635-643. [PMID: 35757861 DOI: 10.1080/17474086.2022.2094758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES the present paper aimed to study available literature on the hypercoagulability state of pediatric patients affected by COVID-19, and the current management of thrombosis in these patients, considering that no guidelines have been published since now in this age group. METHODS N 244 titles were screened using the selected MESH words, 180 abstracts and 120 full texts were read, 12 articles were included, and four were analysed by meta-analysis. RESULTS Over 1128 COVID-19 positive patients, nearly half of them developed inflammatory sequelae, and 7.35% (40 patients over 544 who developed MIS-C) had thrombotic events. Less than 50% of patients with inflammatory disease were under anticoagulant prophylactic treatment, and doses of anticoagulant protocols vary from different centres. Thrombotic events prevented after the start of unfractioned heparin (UFH) therapy, even if 1.06% (4 patients) died. Only two patients presented complications after anticoagulant treatment, with non-fatal bleeding after UFH treatment. No other complications were reported. No difference in the incidence of thrombotic events between patients under prophylactic low molecular weight heparin (LMWH) and without was found in meta-analysis (p=0.32). CONCLUSIONS Little is known on the incidence and management of hyper coagulopathy in pediatric COVID-19 infection. Further studies have to clarify this topic.
Collapse
Affiliation(s)
- Giovanna Vitaliti
- Unit of Pediatrics and Pediatric Emergency, Azienda Ospedaliero Universitaria Policlinico "G.Rodolico - San Marco, San Marco Hospital, Via Azeglio Ciampi, 95100, Catania, Italy
| | - Valentina Giacchi
- Neonatal Intensive Care Unit, Azienda Ospedaliero Universitaria Policlinico "G.Rodolico - San Marco, San Marco Hospital, San Marco Hospital, Via Azeglio Ciampi, 95100, Catania, Italy
| | - Monica Sciacca
- Post graduate program in Pediatric, Department of Clinical and Experimental Medicine, University of Catania, Italy
| | - Martino Ruggieri
- Unit of Rare Diseases of the Nervous System in Childhood, Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, 95124, Catania, Italy
| | - Raffaele Falsaperla
- Unit of Pediatrics and Pediatric Emergency, Azienda Ospedaliero Universitaria Policlinico "G.Rodolico - San Marco, San Marco Hospital, Via Azeglio Ciampi, 95100, Catania, Italy.,Neonatal Intensive Care Unit, Azienda Ospedaliero Universitaria Policlinico "G.Rodolico - San Marco, San Marco Hospital, San Marco Hospital, Via Azeglio Ciampi, 95100, Catania, Italy
| |
Collapse
|
17
|
Dain AS, Raffini L, Whitworth H. Thrombotic events in critically ill children with coronavirus disease 2019 or multisystem inflammatory syndrome in children. Curr Opin Pediatr 2022; 34:261-267. [PMID: 35634699 PMCID: PMC9197313 DOI: 10.1097/mop.0000000000001130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW To provide an update regarding what is known about thrombotic events and thromboprophylaxis in critically ill children with SARS-CoV-2 infection. RECENT FINDINGS Pediatric patients with SARS-CoV-2 generally have mild illness; however, intensive care is required in about 20-30% of hospitalized children with COVID-19 and an even higher proportion in those with MIS-C. Increased rates of thrombosis have been observed in adults hospitalized with COVID-19, and clinical trials have attempted to optimize thromboprophylaxis. There is significant variability in the estimated incidence of thrombosis in pediatric patients (0-27%) because of variation in patient populations and study design. Multiple studies demonstrate an increased rate of thrombosis compared with baseline in hospitalized pediatric patients. Few studies have evaluated risk factors for thrombosis, but critical illness, older age, and other known thrombosis risk factors appear to increase the risk. Thromboprophylaxis strategies are inconsistent, with little evidence of efficacy but few reports of major bleeding. SUMMARY Critically ill children with SARS-CoV-2-related illnesses are at increased risk of thrombosis. Thromboprophylaxis should be considered in select patients with COVID-19 or MIS-C, though the optimal strategy is not yet known. More data is required to guide practice to prevent thrombosis in this population.
Collapse
Affiliation(s)
| | - Leslie Raffini
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Hilary Whitworth
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| |
Collapse
|
18
|
McCafferty C, Lee L, Cai T, Praporski S, Stolper J, Karlaftis V, Attard C, Myint D, Carey LM, Howells DW, Donnan GA, Davis S, Ma H, Crewther S, Nguyen VA, Van Den Helm S, Letunica N, Swaney E, Elliott D, Subbarao K, Ignjatovic V, Monagle P. Fibrin clot characteristics and anticoagulant response in a SARS‐CoV‐2‐infected endothelial model. EJHAEM 2022; 3:326-334. [PMID: 35602246 PMCID: PMC9110985 DOI: 10.1002/jha2.407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/16/2022] [Accepted: 02/18/2022] [Indexed: 11/17/2022]
Abstract
Coronavirus disease 2019 (COVID‐19) patients have increased thrombosis risk. With increasing age, there is an increase in COVID‐19 severity. Additionally, adults with a history of vasculopathy have the highest thrombotic risk in COVID‐19. The mechanisms of these clinical differences in risk remain unclear. Human umbilical vein endothelial cells (HUVECs) were infected with SARS‐CoV‐2, influenza A/Singapore/6/86 (H1N1) or mock‐infected prior to incubation with plasma from healthy children, healthy adults or vasculopathic adults. Fibrin on surface of cells was observed using scanning electron microscopy, and fibrin characteristics were quantified. This experiment was repeated in the presence of bivalirudin, defibrotide, low‐molecular‐weight‐heparin (LMWH) and unfractionated heparin (UFH). Fibrin formed on SARS‐CoV‐2 infected HUVECs was densely packed and contained more fibrin compared to mock‐infected cells. Fibrin generated from child plasma was the thicker than fibrin generated in vasculopathic adult plasma (p = 0.0165). Clot formation was inhibited by LMWH (0.5 U/ml) and UFH (0.1–0.7 U/ml). We show that in the context of the SARS‐CoV‐2 infection on an endothelial culture, plasma from vasculopathic adults produces fibrin clots with thinner fibrin, indicating that the plasma coagulation system may play a role in determining the thrombotic outcome of SARS‐CoV‐2 infection. Heparinoid anticoagulants were most effective at preventing clot formation.
Collapse
Affiliation(s)
- Conor McCafferty
- Department of Paediatrics The University of Melbourne Melbourne Victoria Australia
- Haematology Murdoch Children's Research Institute Melbourne Victoria Australia
| | - Leo Lee
- Department of Microbiology and Immunology The Peter Doherty Institute for Infection and Immunity The University of Melbourne Melbourne Victoria Australia
| | - Tengyi Cai
- Department of Paediatrics The University of Melbourne Melbourne Victoria Australia
- Haematology Murdoch Children's Research Institute Melbourne Victoria Australia
| | - Slavica Praporski
- Haematology Murdoch Children's Research Institute Melbourne Victoria Australia
| | - Julian Stolper
- Heart Regeneration Murdoch Children's Research Institute Melbourne Victoria Australia
| | - Vasiliki Karlaftis
- Haematology Murdoch Children's Research Institute Melbourne Victoria Australia
| | - Chantal Attard
- Department of Paediatrics The University of Melbourne Melbourne Victoria Australia
- Haematology Murdoch Children's Research Institute Melbourne Victoria Australia
| | - David Myint
- TA Scientific Pty. Ltd. Taren Point Sydney New South Wales Australia
| | - Leeanne M. Carey
- Department of Occupational Therapy Social Work and Social Policy La Trobe University Melbourne Victoria Australia
- Neurorehabilitation and Recovery Florey Institute of Neuroscience and Mental Health University of Melbourne Melbourne Victoria Australia
| | - David W. Howells
- Tasmanian School of Medicine University of Tasmania Hobart Tasmania Australia
| | - Geoffrey A. Donnan
- Melbourne Brain Centre Royal Melbourne Hospital and University of Melbourne Melbourne Victoria Australia
| | - Stephen Davis
- Melbourne Brain Centre Royal Melbourne Hospital and University of Melbourne Melbourne Victoria Australia
| | - Henry Ma
- Department of Neurology and Stroke Monash Health Hospital Melbourne Victoria Australia
| | - Sheila Crewther
- Department of Psychology and Counselling La Trobe University Melbourne Victoria Australia
| | - Vinh A. Nguyen
- Department of Psychology and Counselling La Trobe University Melbourne Victoria Australia
| | - Suelyn Van Den Helm
- Haematology Murdoch Children's Research Institute Melbourne Victoria Australia
| | - Natasha Letunica
- Haematology Murdoch Children's Research Institute Melbourne Victoria Australia
| | - Ella Swaney
- Department of Paediatrics The University of Melbourne Melbourne Victoria Australia
- Haematology Murdoch Children's Research Institute Melbourne Victoria Australia
| | - David Elliott
- Heart Regeneration Murdoch Children's Research Institute Melbourne Victoria Australia
| | - Kanta Subbarao
- Department of Microbiology and Immunology The Peter Doherty Institute for Infection and Immunity The University of Melbourne Melbourne Victoria Australia
- WHO Collaborating Centre for Reference and Research on Influenza The Peter Doherty Institute for Infection and Immunity Melbourne Victoria Australia
| | - Vera Ignjatovic
- Department of Paediatrics The University of Melbourne Melbourne Victoria Australia
- Haematology Murdoch Children's Research Institute Melbourne Victoria Australia
| | - Paul Monagle
- Department of Paediatrics The University of Melbourne Melbourne Victoria Australia
- Haematology Murdoch Children's Research Institute Melbourne Victoria Australia
- Department of Clinical Haematology The Royal Children's Hospital Melbourne Victoria Australia
- Kids Cancer Centre Sydney Children's Hospital Randwick New South Wales Australia
| |
Collapse
|
19
|
Morparia K, Spinella PC, McQueen D, Kalyanaraman M, Bergel M, Lin J, Narang S, Saini A. Thromboelastography profiles in critically ill children with multisystem inflammatory syndrome. Pediatr Blood Cancer 2022; 69:e29426. [PMID: 34941014 DOI: 10.1002/pbc.29426] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 10/01/2021] [Accepted: 10/11/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To describe critically ill children's coagulation profile with the multisystem inflammatory syndrome (MIS-C) related to coronavirus. STUDY DESIGN Single-center, observational study at a tertiary, pediatric intensive care unit (PICU) in children aged 1 month to 18 years. MEASUREMENTS AND MAIN RESULTS Sixteen children, with a median age of 5.4 years (interquartile range [IQR] 2.1, 11.75), 56% female, admission Pediatric Logistic Organ Dysfunction-2 (PELOD-2) score of 3.5 (IQR 2, 5), and median PICU length of stay 3 days (IQR 1.5, 4), met criteria of MIS-C. All patients received acetylsalicylic acid (80-100 mg/kg) and none received anticoagulation. Sixty-three percent (10/16) of children had out-of-normal range values on thromboelastography (TEG) (44% [7/16] with hypercoagulability and 19% [3/16] with hypocoagulability). Of those with hypercoagulability, 19% (3/16) had rapid clot formation, and 25% (4/16) had increased clot strength. In 69% (11/16) of children, there was impaired fibrinolysis (0% lysis at 30 minutes) on TEG. Seventy-five percent (12/16) of children had out-of-normal range value on standard coagulation assays (37.5% [6/16] with hypocoagulability and 37.5% [6/16] with hypercoagulability). TEG-G (clot strength as measured by TEG) value (ρ -.553, p = .033) and platelet count (ρ -.840, p < .0001) were correlated with admission PELOD-2 score. TEG-G value (ρ -.506, p = .04) and platelet count (ρ -.539, p = .03) were correlated with the duration of intensive care unit stay. CONCLUSIONS Coagulation abnormalities are frequent in children with MIS-C. TEG parameter and platelet count are correlated with the severity of multiorgan dysfunction and the duration of intensive care stay. Multicenter studies are needed to confirm the clinical implications of these coagulation abnormalities.
Collapse
Affiliation(s)
- Kavita Morparia
- Pediatric Critical Care Medicine, Children's Hospital of New Jersey, Newark Beth Israel Medical Center, Newark, New Jersey, USA
| | - Philip C Spinella
- Pediatric Critical Care Medicine, Department of Pediatrics, Washington School of Medicine in St. Louis, St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Derrick McQueen
- Pediatric Critical Care Medicine, Children's Hospital of New Jersey, Newark Beth Israel Medical Center, Newark, New Jersey, USA
| | - Meena Kalyanaraman
- Pediatric Critical Care Medicine, Children's Hospital of New Jersey, Newark Beth Israel Medical Center, Newark, New Jersey, USA
| | - Maria Bergel
- Pediatric Critical Care Medicine, Children's Hospital of New Jersey, Newark Beth Israel Medical Center, Newark, New Jersey, USA
| | - John Lin
- Pediatric Critical Care Medicine, Department of Pediatrics, Washington School of Medicine in St. Louis, St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Shalu Narang
- Pediatric Hematology and Oncology, Children's Hospital of New Jersey, Newark Beth Israel Medical Center, Newark, New Jersey, USA
| | - Arun Saini
- Pediatric Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| |
Collapse
|
20
|
Gatti E, Piotto M, Lelii M, Pensabene M, Madini B, Cerrato L, Hassan V, Aliberti S, Bosis S, Marchisio P, Patria MF. Therapeutic Strategies for COVID-19 Lung Disease in Children. Front Pediatr 2022; 10:829521. [PMID: 35321012 PMCID: PMC8936419 DOI: 10.3389/fped.2022.829521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 01/20/2022] [Indexed: 12/15/2022] Open
Abstract
The novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection has milder presentation in children than in adults, mostly requiring only supportive therapy. The immunopathogenic course of COVID-19 can be divided in two distinct but overlapping phases: the first triggered by the virus itself and the second one by the host immune response (cytokine storm). Respiratory failure or systemic involvement as Multisystem Inflammatory Syndrome in Children (MIS-C) requiring intensive care are described only in a small portion of infected children. Less severe lung injury in children could be explained by qualitative and quantitative differences in age-related immune response. Evidence on the best therapeutic approach for COVID-19 lung disease in children is lacking. Currently, the approach is mainly conservative and based on supportive therapy. However, in hospitalized children with critical illness and worsening lung function, antiviral therapy with remdesivir and immunomodulant treatment could be considered the "therapeutic pillars."
Collapse
Affiliation(s)
| | | | - Mara Lelii
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | | | | | | | - Stefano Aliberti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, Milan, Italy.,Respiratory Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Milan, Italy
| | - Samantha Bosis
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paola Marchisio
- Università Degli Studi di Milano, Milan, Italy.,Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | |
Collapse
|
21
|
Imaging findings in acute pediatric coronavirus disease 2019 (COVID-19) pneumonia and multisystem inflammatory syndrome in children (MIS-C). Pediatr Radiol 2022; 52:1985-1997. [PMID: 35616701 PMCID: PMC9132751 DOI: 10.1007/s00247-022-05393-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 04/06/2022] [Accepted: 05/03/2022] [Indexed: 12/04/2022]
Abstract
The two primary manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in children are acute coronavirus disease 2019 (COVID-19) pneumonia and multisystem inflammatory syndrome (MIS-C). While most pediatric cases of acute COVID-19 disease are mild or asymptomatic, some children are at risk for developing severe pneumonia. In MIS-C, children present a few weeks after SARS-CoV-2 exposure with a febrile illness that can rapidly progress to shock and multiorgan dysfunction. In both diseases, the clinical and laboratory findings can be nonspecific and present a diagnostic challenge. Thoracic imaging is commonly obtained to assist with initial workup, assessment of disease progression, and guidance of therapy. This paper reviews the radiologic findings of acute COVID-19 pneumonia and MIS-C, highlights the key distinctions between the entities, and summarizes our understanding of the role of imaging in managing SARS-CoV-2-related illness in children.
Collapse
|
22
|
Menon NM, Srivaths LV. Thromboembolism in children with multisystem inflammatory syndrome: a literature review. Pediatr Res 2022; 92:946-950. [PMID: 35031708 PMCID: PMC8758928 DOI: 10.1038/s41390-021-01873-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 09/13/2021] [Accepted: 11/13/2021] [Indexed: 12/22/2022]
Abstract
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.
Collapse
Affiliation(s)
- Neethu M. Menon
- grid.267308.80000 0000 9206 2401Division of Hematology, Department of Pediatrics, University of Texas Health Science Center at Houston, 7000 Fannin Street, Houston, TX 77030 USA
| | - Lakshmi V. Srivaths
- grid.267308.80000 0000 9206 2401Division of Hematology, Department of Pediatrics, University of Texas Health Science Center at Houston, 7000 Fannin Street, Houston, TX 77030 USA
| |
Collapse
|
23
|
Trapani S, Rubino C, Lasagni D, Pegoraro F, Resti M, Simonini G, Indolfi G. Thromboembolic complications in children with COVID-19 and MIS-C: A narrative review. Front Pediatr 2022; 10:944743. [PMID: 36034557 PMCID: PMC9402981 DOI: 10.3389/fped.2022.944743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
COVID-19 and multisystem inflammatory syndrome in children (MIS-C) have been associated with a higher incidence of hypercoagulability and thromboembolic events (TEs), even in children, leading to relevant morbidity, and mortality. However, our understanding of such complications in childhood is limited. To better understand the incidence, clinical manifestations, risk factors, and management of COVID-19 and MIS-C-related TEs in children, a review of the current literature and a brief update on pathophysiology are given. Sixty-two studies, describing 138 patients with TEs associated with COVID-19 or MIS-C, were included. The overall number of TEs was 157, as 16 patients developed multiple TEs: venous TEs represented the majority (54%), followed by arterial thrombosis (38%, mainly represented by arterial ischemic stroke-AIS), and intracardiac thrombosis (ICT) (8%). Within the venous TEs group, pulmonary embolism (PE) was the most frequent, followed by deep venous thrombosis, central venous sinus thrombosis, and splanchnic venous thrombosis. Notably, 10 patients had multiple types of venous TEs, and four had both venous and arterial thrombosis including a newborn. Most of them (79 cases,57%) had at least one predisposing condition, being obesity the most frequent (21%), especially in patients with PE, followed by malignancy (9%). In 35% of cases, no data about the outcome were available About one-third of cases recovered, 12% improved at discharge or follow-up, and 6% had persistent neurological sequelae. The mortality rate was 12%, with death due to comorbidities in most cases. Most fatalities occurred in patients with arterial thrombosis. Pediatricians should be aware of this life-threatening possibility facing children with SARS-CoV-2 infection or its multisystemic inflammatory complication, who abruptly develop neurological or respiratory impairment. A prompt intensive care is essential to avoid severe sequelae or even exitus.
Collapse
Affiliation(s)
- Sandra Trapani
- Department of Health Sciences, Meyer Children's University Hospital, University of Florence, Florence, Italy.,Pediatric Unit, Meyer Children's University Hospital, Florence, Italy
| | - Chiara Rubino
- Pediatric Unit, Meyer Children's University Hospital, Florence, Italy
| | - Donatella Lasagni
- Pediatric Unit, Meyer Children's University Hospital, Florence, Italy
| | - Francesco Pegoraro
- Department of Health Sciences, Meyer Children's University Hospital, University of Florence, Florence, Italy
| | - Massimo Resti
- Pediatric Unit, Meyer Children's University Hospital, Florence, Italy
| | - Gabriele Simonini
- Rheumatology Unit, Meyer Children's University Hospital, University of Florence, Florence, Italy.,Department of NEUROFARBA, Meyer Children's University Hospital, University of Florence, Florence, Italy
| | - Giuseppe Indolfi
- Pediatric Unit, Meyer Children's University Hospital, Florence, Italy.,Department of NEUROFARBA, Meyer Children's University Hospital, University of Florence, Florence, Italy
| |
Collapse
|
24
|
Wolf S, Rhoads A, Gomes W, Overby P, McGoldrick P. Aortic Thrombus Embolization in A Patient with Tuberous Sclerosis. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0041-1739261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AbstractTuberous sclerosis complex (TSC) is an autosomal dominant genetic disorder affecting many organ systems. Patients commonly develop a variety of benign tumors as well as neurological disease, including seizures, autism, and cognitive delay. We report here the case of an adolescent patient with TSC and a history of mild COVID-19 who presented with a 1-day history of altered mental status. The patient was found to have ischemic cerebral infarction of the right MCA and ACA territories. Initial angiography showed an occlusion of the right internal carotid artery without a demonstrable etiology, with follow-up echocardiography and angiography revealing a large aortic thrombus. The patient was not a candidate for thrombus removal due to her cerebral infarct and received medical anticoagulation. Thrombosis progressed to involve the left ICA, with left cerebral infarction and subsequent death. Aortic thrombus embolization as a cause of cerebrovascular accident (CVA) is a novel finding in the setting of TSC and should be considered for pediatric patients with CVA of unknown etiology. It is unclear whether this was related to the prior COVID-19 infection.
Collapse
Affiliation(s)
- Steven Wolf
- Department of Pediatrics, Division of Child Neurology, New York Medical College, Valhalla, New York, United States
| | - Andrew Rhoads
- Department of Pediatrics, Division of Child Neurology, New York Medical College, Valhalla, New York, United States
| | - William Gomes
- Department of Radiology, Division of Neuroradiology, Westchester Medical Center, Valhalla, New York, United States
| | - Philip Overby
- Department of Pediatrics, Division of Child Neurology, New York Medical College, Valhalla, New York, United States
| | - Patricia McGoldrick
- Department of Pediatrics, Division of Child Neurology, New York Medical College, Valhalla, New York, United States
| |
Collapse
|
25
|
Ankola AA, Bradford VR, Newburger JW, Emani S, Dionne A, Friedman K, Son MB, Henderson LA, Lee PY, Hellinger A, Hawkins B, Ventresco C, Esteso P, VanderPluym CJ. Coagulation profiles and viscoelastic testing in multisystem inflammatory syndrome in children. Pediatr Blood Cancer 2021; 68:e29355. [PMID: 34532964 DOI: 10.1002/pbc.29355] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 08/26/2021] [Accepted: 08/30/2021] [Indexed: 01/19/2023]
Abstract
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.
Collapse
Affiliation(s)
- Ashish A Ankola
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Victoria R Bradford
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Sirisha Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Audrey Dionne
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kevin Friedman
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mary Beth Son
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lauren A Henderson
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Pui Y Lee
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Amy Hellinger
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Beth Hawkins
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Courtney Ventresco
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Paul Esteso
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | | |
Collapse
|
26
|
Kanmaniraja D, Kurian J, Holder J, Gunther MS, Chernyak V, Hsu K, Lee J, Mcclelland A, Slasky SE, Le J, Ricci ZJ. Review of COVID-19, part 1: Abdominal manifestations in adults and multisystem inflammatory syndrome in children. Clin Imaging 2021; 80:88-110. [PMID: 34298343 PMCID: PMC8223038 DOI: 10.1016/j.clinimag.2021.06.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 05/23/2021] [Accepted: 06/17/2021] [Indexed: 02/07/2023]
Abstract
The coronavirus disease 2019 (COVID -19) pandemic caused by the novel severe acute respiratory syndrome coronavirus (SARS-CoV-2) has affected almost every country in the world, resulting in severe morbidity, mortality and economic hardship, and altering the landscape of healthcare forever. Although primarily a pulmonary illness, it can affect multiple organ systems throughout the body, sometimes with devastating complications and long-term sequelae. As we move into the second year of this pandemic, a better understanding of the pathophysiology of the virus and the varied imaging findings of COVID-19 in the involved organs is crucial to better manage this complex multi-organ disease and to help improve overall survival. This manuscript provides a comprehensive overview of the pathophysiology of the virus along with a detailed and systematic imaging review of the extra-thoracic manifestation of COVID-19 with the exception of unique cardiothoracic features associated with multisystem inflammatory syndrome in children (MIS-C). In Part I, extra-thoracic manifestations of COVID-19 in the abdomen in adults and features of MIS-C will be reviewed. In Part II, manifestations of COVID-19 in the musculoskeletal, central nervous and vascular systems will be reviewed.
Collapse
Affiliation(s)
- Devaraju Kanmaniraja
- Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, United States of America.
| | - Jessica Kurian
- Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, United States of America.
| | - Justin Holder
- Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, United States of America.
| | - Molly Somberg Gunther
- Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, United States of America.
| | - Victoria Chernyak
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
| | - Kevin Hsu
- Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, United States of America.
| | - Jimmy Lee
- Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, United States of America.
| | - Andrew Mcclelland
- Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, United States of America.
| | - Shira E Slasky
- Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, United States of America
| | - Jenna Le
- Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, United States of America.
| | - Zina J Ricci
- Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, United States of America.
| |
Collapse
|
27
|
Morsy HK, Tohamy NS, Abd El Ghaffar HM, Sayed R, Sabri NA. COVID-19 in children: an approach for multisystem inflammatory syndrome. EGYPTIAN PEDIATRIC ASSOCIATION GAZETTE 2021. [PMCID: PMC8547902 DOI: 10.1186/s43054-021-00082-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background and objectives Children suffering from coronavirus disease (COVID-19) usually present with mild symptoms and show lower mortality rates than adults. However, there have been several recent reports of more severe hyperinflammatory presentation in pediatric COVID-19 patients. This review article aims to summarize the current literature available on the main clinical features and management approaches of multisystem inflammatory syndrome in children (MIS-C). Methods The authors searched different indexing databases for observational and interventional studies using search terms including “Coronavirus, COVID-19, pediatric, MIS-C, Kawasaki, and inflammation.” The retrieved publications were further assessed for relevance to the topic. Only relevant articles were included in writing this review article. Main body Multisystem inflammatory syndrome in children (MIS-C) is a hyperinflammatory syndrome temporally related to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection in pediatrics. It is characterized by persistent fever, rash, elevated inflammatory markers, and multiorgan failure with increasing rates of cardiovascular and gastrointestinal involvement. The exact pathophysiologic mechanisms of MIS-C are still unknown, but it is postulated to be due to an exaggerated immune response to SARS-CoV-2 infection. Multisystem inflammatory syndrome in children is diagnosed by exclusion of other underlying causes of organ failure. There is a lack of clinical evidence on the management of MIS-C. The current guidelines depend mainly on expert opinion based on the management of other hyper-inflammatory syndromes in children. Patients suffering from MIS-C are treated with intravenous immunoglobulin (IVIg), corticosteroids, infliximab, tocilizumab, and anakinra. Conclusions Despite the growing reports on COVID-19 in children, there is still a lot to elucidate on the pathophysiology, diagnosis, and subsequent management of MIS-C. Further trials are needed to investigate new approaches to manage MIS-C. Specific evidence-based guideline for management of MIS-C should be tailored to the current available information on MIS-C.
Collapse
|
28
|
Slae M, Wilschanski M, Sanjines E, Abu-El-Haija M, Sellers ZM. International Survey on Severe Acute Respiratory Syndrome Coronavirus 2 and Acute Pancreatitis Co-occurrence in Children. Pancreas 2021; 50:1305-1309. [PMID: 34860816 PMCID: PMC8647781 DOI: 10.1097/mpa.0000000000001923] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES It is unknown to what extent coronavirus 2019 (COVID-19) may co-occur with acute pancreatitis (AP) in children and how their clinical course may differ from children with AP alone. METHODS An online survey was sent to pediatric gastroenterologists to report on COVID-19 and AP cases from December 11, 2020, to February 26, 2021. RESULTS From 72 respondents (20 countries, 5 continents), 22 cases of positive COVID-19 infection and AP were reported. Patients were predominantly White or Hispanic/Latinx (73%), female (68%), and adolescents (68%). For 86% of patients, this was their first episode of AP. Sixty-eight percent of positive COVID-19 tests were polymerase chain reaction based. There was significant morbidity; 60% required intensive care, 45% had multiorgan involvement, and 24% developed shock. Eleven percent had pancreatic necrosis. Abnormal clotting and systemic inflammatory laboratories were common (31%-92% and 93%, respectively). Median length of symptomatic pancreatitis recovery was 1.8× longer than AP without COVID-19. CONCLUSIONS Coronavirus 2019 infection and AP co-occur primarily in children without a prior history of pancreatitis. Given the increased need for intensive care, multiorgan involvement, and potentially higher risk for pancreatic necrosis, pediatric providers should have a high level of suspicion for AP in children with COVID-19 infection.
Collapse
Affiliation(s)
- Mordechai Slae
- From the Division of Pediatric Gastroenterology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Michael Wilschanski
- From the Division of Pediatric Gastroenterology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Elvi Sanjines
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, CA
| | | | - Zachary M Sellers
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, CA
| |
Collapse
|
29
|
Saleh M, Alkofide A, Alshammari A, Siddiqui K, Owaidah T. Changes in Hematological, Clinical and Laboratory Parameters for Children with COVID-19: Single-Center Experience. J Blood Med 2021; 12:819-826. [PMID: 34512062 PMCID: PMC8427837 DOI: 10.2147/jbm.s321372] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 08/06/2021] [Indexed: 12/23/2022] Open
Abstract
Background COVID-19 wreaked havoc on the healthcare system, with more than 36 million cases reported globally. Although the pediatric population makes up a lesser proportion of total COVID-19 patients than adults, the clinical status, age and comorbidities warrant identifying possible prognostic factors associated with disease severity in this group. The current study aimed to explore the incidence of thrombosis, overall outcome, and different hematological and coagulation markers in children with COVID-19. Methods This is a single-center prospective study of 43 patients (age < 14 years) with confirmed COVID-19 diagnosis recruited from April to August 2020. Data for clinical presentation were collected and analyzed. The samples were tested for different hematological and coagulation markers. Results Twenty-nine (67.4%) were symptomatic at presentation, with fever being the most common symptom (n = 23, 53.5%), followed by respiratory (n = 5, 11.6%) and gastrointestinal symptoms (n = 3, 7%). Co-morbid conditions were recorded in 26 (60.5%) patients, with malignancy being the commonest (n = 9, 20.9%). In this cohort of patients with age <14 years, hypertension, respiratory symptoms and ABO group-A were significantly associated with pediatric intensive care unit (PICU) admission during the course of treatment. Patients with elevated FVIII and fibrinogen levels at presentation were more likely to have an extended length of hospital stay (LOS) (P-value =0.036 and 0.032 respectively). No thrombotic event was observed in our cohort. D-dimer values were higher (above 0.5 µg/mL) in 24 (55.8%) patients at admission. We found an association between high D-dimer and PICU admission and LOS. Conclusion Although we did not observe thrombosis in our cohort, serial measurements of D-dimer and elevated FVIII bear a prognostic value in predicting the need for critical care in children with COVID-19. Further studies with larger sample size can aid in the establishment of prognostic factors for the pediatric COVID-19 population.
Collapse
Affiliation(s)
- Mahasen Saleh
- Department of Pediatric Hematology Oncology, King Faisal Specialist Hospital and Research Center, Riyadh, 11533, Kingdom of Saudi Arabia
| | - Amani Alkofide
- Department of Pediatric Hematology Oncology, King Faisal Specialist Hospital and Research Center, Riyadh, 11533, Kingdom of Saudi Arabia
| | - Anfal Alshammari
- Department of Pediatric Hematology Oncology, King Faisal Specialist Hospital and Research Center, Riyadh, 11533, Kingdom of Saudi Arabia
| | - Khawar Siddiqui
- Department of Pediatric Hematology Oncology, King Faisal Specialist Hospital and Research Center, Riyadh, 11533, Kingdom of Saudi Arabia
| | - Tarek Owaidah
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, 11211, Kingdom of Saudi Arabia.,Department of Pathology, Alfaisal University, Riyadh, 11533, Kingdom of Saudi Arabia
| |
Collapse
|
30
|
Abstract
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.
Collapse
Affiliation(s)
- Jordan E Roberts
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | |
Collapse
|
31
|
Avila L, Amiri N, Pullenayegum E, Sealey VA, De R, Williams S, Vincelli J, Brandão LR. Diagnostic value of D-dimers for limb deep vein thrombosis in children: A prospective study. Am J Hematol 2021; 96:954-960. [PMID: 33930198 DOI: 10.1002/ajh.26212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 04/24/2021] [Accepted: 04/28/2021] [Indexed: 01/01/2023]
Abstract
The present study sought to evaluate the discriminative and predictive ability of D-dimer for pediatric limb DVT. Children aged 28 days-18 years requiring imaging to rule out limb DVT, as per the treating clinical team, were enrolled in the study. The outcome was ultrasound proven DVT. The D-dimer levels were obtained around the time of imaging. Receiver operating characteristic (ROC) curves and logistic regression models were used for data analyses. In total, 296 patients were enrolled between 2017-2020; 204 patients were diagnosed with DVT (DVT[+]). Median D-dimer levels were 2.3 μg/ml FEU (25th-75th percentile 0.9-3.9) among DVT(+) and 1.9 μg/ml FEU (25th-75th percentile 0.8-4.0) among DVT(-) patients (p = 0.60). The area under the ROC curve (AUC) was 0.52 (95% confidence interval [CI] 0.45-0.59). The odds ratio for D-dimer levels was 1.00 (95% CI 0.99-1.01), holding confounders constant. In a sub-group exploratory analysis including 23 patients with no underlying conditions or co-morbidities, the AUC curve was 0.90 (95% CI 0.76-1.00). In conclusion, in this prospective cohort study of consecutive children with suspected limb DVT, D-dimer levels had poor discriminative and predictive ability for DVT. However, D-dimer levels showed better discriminative and predictive ability for DVT in an exploratory sample of patients with no underlying conditions or co-morbidities at the time of diagnosis.
Collapse
Affiliation(s)
- Laura Avila
- The Hospital for Sick Children Toronto Ontario Canada
| | - Nour Amiri
- The Hospital for Sick Children Toronto Ontario Canada
| | | | | | - Riddhita De
- The Hospital for Sick Children Toronto Ontario Canada
| | | | | | | |
Collapse
|
32
|
Whitworth H, Sartain SE, Kumar R, Armstrong K, Ballester L, Betensky M, Cohen CT, Diaz R, Diorio C, Goldenberg NA, Jaffray J, Keegan J, Malone K, Randolph AG, Rifkin-Zenenberg S, Leung WS, Sochet A, Srivaths L, Zia A, Raffini L. Rate of thrombosis in children and adolescents hospitalized with COVID-19 or MIS-C. Blood 2021; 138:190-198. [PMID: 33895804 PMCID: PMC8079262 DOI: 10.1182/blood.2020010218] [Citation(s) in RCA: 130] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 01/30/2021] [Indexed: 01/06/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is associated with thrombotic complications in adults, but the incidence of COVID-19-related thrombosis in children and adolescents is unclear. Most children with acute COVID-19 have mild disease, but coagulopathy has been associated with multisystem inflammatory syndrome in children (MIS-C), a postinfectious complication. We conducted a multicenter retrospective cohort study to determine the incidence of thrombosis in children hospitalized with COVID-19 or MIS-C and evaluate associated risk factors. We classified patients into 1 of 3 groups for analysis: COVID-19, MIS-C, or asymptomatic SARS-CoV-2. Among a total of 853 admissions (COVID-19, n = 426; MIS-C, n = 138; and asymptomatic SARS-CoV-2, n = 289) in 814 patients, there were 20 patients with thrombotic events (TEs; including 1 stroke). Patients with MIS-C had the highest incidence (9 [6.5%] of 138) vs COVID-19 (9 [2.1%] of 426) or asymptomatic SARS-CoV-2 (2 [0.7%] of 289). In patients with COVID-19 or MIS-C, a majority of TEs (89%) occurred in patients age ≥12 years. Patients age ≥12 years with MIS-C had the highest rate of thrombosis at 19% (9 of 48). Notably, 71% of TEs that were not present on admission occurred despite thromboprophylaxis. Multivariable analysis identified the following as significantly associated with thrombosis: age ≥12 years, cancer, presence of a central venous catheter, and MIS-C. In patients with COVID-19 or MIS-C, hospital mortality was 2.3% (13 of 564), but it was 28% (5 of 18) in patients with TEs. Our findings may help inform pediatric thromboprophylaxis strategies.
Collapse
Affiliation(s)
- Hilary Whitworth
- Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Sarah E Sartain
- Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Riten Kumar
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Katherine Armstrong
- Department of Pediatrics, Joseph M. Sanzari Children's Hospital, Hackensack University Medical Center, Hackensack, NJ
| | - Lance Ballester
- Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Marisol Betensky
- Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
- Thrombosis Program and Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St Petersburg, FL
| | - Clay T Cohen
- Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Rosa Diaz
- Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Caroline Diorio
- Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Neil A Goldenberg
- Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
- Thrombosis Program and Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St Petersburg, FL
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Julie Jaffray
- Department of Pediatrics, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Jacquelyn Keegan
- Department of Pediatrics, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Kendra Malone
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Stacey Rifkin-Zenenberg
- Department of Pediatrics, Joseph M. Sanzari Children's Hospital, Hackensack University Medical Center, Hackensack, NJ
| | - Wendy Seto Leung
- Department of Pediatrics, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Anthony Sochet
- Division of Pediatric Critical Care Medicine, Department of Anesthesia and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; and
| | - Lakshmi Srivaths
- Department of Pediatrics, University of Texas Houston, Houston, TX
| | - Ayesha Zia
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Leslie Raffini
- Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
33
|
Al-Ghafry M, Vagrecha A, Malik M, Levine C, Uster E, Aygun B, Appiah-Kubi A, Vlachos A, Capone CA, Rajan S, Palumbo N, Misra N, Mitchell EC, Wolfe LC, Lipton JM, Shore-Lesserson L, Acharya SS. Multisystem inflammatory syndrome in children (MIS-C) and the prothrombotic state: Coagulation profiles and rotational thromboelastometry in a MIS-C cohort. J Thromb Haemost 2021; 19:1764-1770. [PMID: 33872443 PMCID: PMC9906141 DOI: 10.1111/jth.15340] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/31/2021] [Accepted: 04/09/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Adults infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have had high rates of thrombosis. A novel condition in children infected with SARS-CoV-2, multisystem inflammatory syndrome in children (MIS-C), has limited data on their prothrombotic state or need for thromboprophylaxis. OBJECTIVES We aimed to analyze the prothrombotic state using coagulation profiles, rotational thromboelastometry (ROTEM) parameters and clinical outcomes, to determine if this could aid in risk stratification for thromboprophylaxis. METHODS This analysis included patients (<21 years of age) with a diagnosis of MIS-C (n = 40) and controls (presenting with suspicion of MIS-C but later ruled out; n = 26). RESULTS MIS-C patients had higher levels of inflammatory markers including D-dimer (p < .0001), compared with controls, along with evidence of hypercoagulability on ROTEM with elevated evaluation of fibrinogen activity (FIBTEM) maximum clot firmness (MCF) (p < .05). For MIS-C patients with D-dimers >1000 ng/ml, there was a significant correlation of FIBTEM MCF (p < .0001) with a mean value of 37.4 (standard deviation 5.1). D-dimer >2144 ng/ml was predictive of intensive care unit admission (area under the curve [AUC] 0.80; 95% confidence interval, 0.60-0.99; p < .01; sensitivity: 82%, specificity: 75%), and elevated FIBTEM MCF (AUC 1 for >2500 ng/ml). MIS-C patients (50%) received enoxaparin thromboprophylaxis (in addition to aspirin) with significant improvement in their inflammatory and ROTEM parameters upon outpatient follow-up; none developed symptomatic thrombosis. CONCLUSIONS Despite an observed prothrombotic state, none of the MIS-C patients (on aspirin alone or in combination with enoxaparin) developed symptomatic thrombosis. ROTEM, in addition to coagulation profiles, may be helpful to tailor thromboprophylaxis in critically ill MIS-C patients.
Collapse
Affiliation(s)
- Maha Al-Ghafry
- Division of Pediatric Hematology/Oncology and Cellular Therapy, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Anshul Vagrecha
- Division of Pediatric Hematology/Oncology and Cellular Therapy, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Marium Malik
- Division of Pediatric Hematology/Oncology and Cellular Therapy, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Chana Levine
- Division of Pediatric Hematology/Oncology and Cellular Therapy, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Eliza Uster
- Division of Pediatrics, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Banu Aygun
- Division of Pediatric Hematology/Oncology and Cellular Therapy, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Abena Appiah-Kubi
- Division of Pediatric Hematology/Oncology and Cellular Therapy, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Adrianna Vlachos
- Division of Pediatric Hematology/Oncology and Cellular Therapy, Cohen Children's Medical Center, New Hyde Park, NY, USA
- Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Christine A Capone
- Feinstein Institutes for Medical Research, Manhasset, NY, USA
- Division of Pediatric Critical Care Medicine, Cohen Children's Medical Center, New Hyde Park, NY, USA
- Division of Pediatric Cardiology, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Sujatha Rajan
- Division of Pediatric Infectious Disease, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Nancy Palumbo
- Division of Pediatric Hospital Medicine, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Nilanjana Misra
- Division of Pediatric Cardiology, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Elizabeth C Mitchell
- Division of Pediatric Cardiology, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Lawrence C Wolfe
- Division of Pediatric Hematology/Oncology and Cellular Therapy, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Jeffrey M Lipton
- Division of Pediatric Hematology/Oncology and Cellular Therapy, Cohen Children's Medical Center, New Hyde Park, NY, USA
- Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | | | - Suchitra S Acharya
- Division of Pediatric Hematology/Oncology and Cellular Therapy, Cohen Children's Medical Center, New Hyde Park, NY, USA
| |
Collapse
|
34
|
Sharathkumar AA, Faustino EVS, Takemoto CM. How we approach thrombosis risk in children with COVID-19 infection and MIS-C. Pediatr Blood Cancer 2021; 68:e29049. [PMID: 33955167 PMCID: PMC8206673 DOI: 10.1002/pbc.29049] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 03/04/2021] [Accepted: 03/22/2021] [Indexed: 01/08/2023]
Abstract
Thrombosis within the microvasculature and medium to large vessels is a serious and common complication among critically ill individuals with coronavirus disease 2019 (COVID-19). While children are markedly less likely to develop severe disease than adults, they remain at risk for thrombosis during acute infection and with the post-acute inflammatory illness termed multisystem inflammatory syndrome in children. Significant knowledge deficits in understanding COVID-19-associated coagulopathy and thrombotic risk pose clinical challenges for pediatric providers who must incorporate expert opinion and personal experience to manage individual patients. We discuss clinical scenarios to provide framework for characterizing thrombosis risk and thromboprophylaxis in children with COVID-19.
Collapse
Affiliation(s)
- Anjali A. Sharathkumar
- Stead Family Department of Pediatrics, Carver College of MedicineUniversity of IowaIowa CityIowaUSA
| | - E. Vincent S. Faustino
- Section of Pediatric Critical Care Medicine, Department of PediatricsYale School of MedicineNew HavenConnecticutUSA
| | - Clifford M. Takemoto
- Division of Clinical HematologySt. Jude Children's Research HospitalMemphisTennesseeUSA
| |
Collapse
|
35
|
Mansory EM, Srigunapalan S, Lazo-Langner A. Venous Thromboembolism in Hospitalized Critical and Noncritical COVID-19 Patients: A Systematic Review and Meta-analysis. TH OPEN 2021; 5:e286-e294. [PMID: 34240001 PMCID: PMC8260281 DOI: 10.1055/s-0041-1730967] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/06/2021] [Indexed: 12/11/2022] Open
Abstract
Introduction Venous thromboembolism (VTE) has been observed as a frequent complication in patients with severe novel coronavirus disease 2019 (COVID-19) infection requiring hospital admission. Aim This study was aimed to evaluate the epidemiology of VTE in hospitalized intensive care unit (ICU) and non-ICU patients. Materials and Methods PubMed was searched up to November 13, 2020, and updated in December 12, 2020. We included studies that evaluated the epidemiology of VTE, including pulmonary embolism (PE) and/or deep vein thrombosis (DVT), in patients with COVID-19. Results A total of 91 studies reporting on 35,017 patients with COVID-19 was included. The overall frequency of VTE in all patients, ICU and non-ICU, was 12.8% (95% confidence interval [CI]: 11.103-14.605), 24.1% (95% CI: 20.070-28.280), and 7.7% (95% CI: 5.956-9.700), respectively. PE occurred in 8.5% (95% CI: 6.911-10.208), and proximal DVT occurred in 8.2% (95% CI: 6.675-9.874) of all hospitalized patients. The relative risk for VTE associated with ICU admission was 2.99 (95% CI: 2.301-3.887, p <0.001). DVT and PE estimated in studies that adopted some form of systematic screening were higher compared with studies with symptom-triggered screening. Analysis restricted to studies in the 5th quintile of sample size reported significantly lower VTE estimates. Conclusion This study confirmed a high risk of VTE in hospitalized COVID-19 patients, especially those admitted to the ICU. Nevertheless, sensitivity analysis suggests that previously reported frequencies of VTE in COVID-19 might have been overestimated.
Collapse
Affiliation(s)
- Eman M Mansory
- Division of Hematology, Department of Medicine, Western University, London, Ontario, Canada
- Department of Hematology, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Suthan Srigunapalan
- Division of Hematology, Department of Medicine, Western University, London, Ontario, Canada
| | - Alejandro Lazo-Langner
- Division of Hematology, Department of Medicine, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| |
Collapse
|
36
|
Patel R, Patel KJ, Rocker J. Testing for and identification of Multisystem Inflammatory Syndrome in children in the pediatric emergency department. Curr Opin Pediatr 2021; 33:275-280. [PMID: 33928912 DOI: 10.1097/mop.0000000000001020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The current article summarizes updates on multisystem inflammatory syndrome in children (MIS-C) research and focuses on strategies to diagnose and manage these patients in the emergency department. RECENT FINDINGS MIS-C is an inflammatory syndrome that occurs approximately 4-5 weeks after severe acute respiratory syndrome coronavirus 2 infection. It is associated with symptoms such as fever, shock, abdominal pain, rash, and conjunctivitis along with laboratory abnormalities such as elevated inflammatory markers, coagulation factors, and cytokines. Patients fall into the following three subcategories: first, classic or incomplete Kawasaki; second, cardiogenic or distributive shock; or third, an inflammatory response that does not initially meet criteria of the other subcategories. Immediate treatment largely focuses on supportive care through fluid resuscitation and pressor support; however, inpatient management may also include intravenous immunoglobulin, steroids, anticoagulation and at times anti-inflammatory biologics. SUMMARY Overall fatality rate remains low and short-term research has demonstrated self-limited sequelae. Pediatricians should focus on the timely diagnosis and identification of this inflammatory disease via clinical findings and laboratory evidence to best treat these patients.
Collapse
Affiliation(s)
- Roshni Patel
- Cohen Children's Medical Center, New Hyde Park, New York, USA
| | | | | |
Collapse
|
37
|
Auriti C, De Rose DU, Mondì V, Stolfi I, Tzialla C. Neonatal SARS-CoV-2 Infection: Practical Tips. Pathogens 2021; 10:pathogens10050611. [PMID: 34067588 PMCID: PMC8157198 DOI: 10.3390/pathogens10050611] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/02/2021] [Accepted: 05/13/2021] [Indexed: 02/05/2023] Open
Abstract
The recent viral pandemic in Wuhan, Hubei, China has led to the identification of a new species of beta-coronavirus, able to infect humans, the 2019-nCoV, later named SARS-CoV-2. SARS-CoV-2 causes a clinical syndrome named COVID-19, which presents with a spectrum of symptoms ranging from mild upper respiratory tract infection to severe pneumonia, with acute respiratory distress syndrome and frequent death. All age groups are susceptible to the infection, but children, especially infants, seem to be partially spared, having a more favorable clinical course than other age groups. There is currently no clear evidence showing vertical transmission and intrauterine SARS-CoV-2 infection in fetuses of women developing COVID-19 pneumonia in late pregnancy, and even if transmission is possible, the SARS-CoV2 positivity of the mother does not require delivery by caesarean section, does not contraindicate the management of the infant in rooming-in and allows breastfeeding. This review provides an overview on the biology of the virus, on the pathogenesis of the infection, with particular attention to pregnancy and neonatal age, on the clinical presentation of infection in newborns and young infants and summarizes the international recommendations currently available on the clinical care of neonates with SARS-CoV2 infection or at risk of catching the virus. The main objective of the review is to provide an update especially focused to the clinical management of COVID-19 infection in the perinatal and neonatal age.
Collapse
Affiliation(s)
- Cinzia Auriti
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus, Newborn and Infant—“Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy;
| | - Domenico Umberto De Rose
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus, Newborn and Infant—“Bambino Gesù” Children’s Hospital IRCCS, 00165 Rome, Italy;
- Correspondence: or ; Tel.: +39-06-6859-2427; Fax: +39-06-6859-3916
| | - Vito Mondì
- Neonatology and Neonatal Intensive Care Unit, Policlinico Casilino Hospital, 00169 Rome, Italy;
| | - Ilaria Stolfi
- Department of Neonatology, Policlinico Umberto I, “Sapienza” University, 00161 Rome, Italy;
| | - Chryssoula Tzialla
- Neonatal Intensive Care Unit and Neonatal pathology Unit, Policlinico San Matteo IRCCS Foundation, 27100 Pavia, Italy;
| | | |
Collapse
|
38
|
Opoka-Winiarska V, Grywalska E, Roliński J. PIMS-TS, the New Paediatric Systemic Inflammatory Disease Related to Previous Exposure to SARS-CoV-2 Infection-"Rheumatic Fever" of the 21st Century? Int J Mol Sci 2021; 22:ijms22094488. [PMID: 33925779 PMCID: PMC8123467 DOI: 10.3390/ijms22094488] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/22/2021] [Accepted: 04/23/2021] [Indexed: 11/17/2022] Open
Abstract
Paediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (PIMS-TS) is a new systemic inflammatory disease that mainly affects children. Its course in many features resembles that of acute rheumatic fever (ARF). Therefore, it is interesting that the experiences with ARF can be used in the management of patients with PIMS-TS. The aim of the article is to analyse the current data on PIMS-TS in relation to ARF. PIMS-TS and ARF are associated with an abnormal immune response to specific pathogens (SARS-CoV-2 and group A streptococcus, respectively). The main symptoms of both diseases are fever and cardiac involvement. Current therapy for PIMS-TS is based on anti-inflammatory treatment: intravenous immunoglobulin (first-line), intravenous glucocorticoids (second-line), or biological therapy (third-line; including interleukin [IL]-1 antagonists, IL-6 receptor blockers, and anti-tumour necrosis factor agents). Vaccination might be good prophylaxis, but the efficacy and safety of the vaccines against SARS-CoV-2 have not yet been established in children. Interesting insights may be gained by considering PIMS-TS in light of what is known of ARF due to their similar courses, but there are still many unanswered questions surrounding this disease and its pathogenesis.
Collapse
Affiliation(s)
- Violetta Opoka-Winiarska
- Department of Paediatric Pulmonology and Rheumatology, Medical University of Lublin, Gębali 6, 20-093 Lublin, Poland
- Correspondence: ; Tel.: +48-81-743-0141
| | - Ewelina Grywalska
- Department of Clinical Immunology and Immunotherapy, Medical University of Lublin, Chodzki 4a Street, 20-093 Lublin, Poland; (E.G.); (J.R.)
| | - Jacek Roliński
- Department of Clinical Immunology and Immunotherapy, Medical University of Lublin, Chodzki 4a Street, 20-093 Lublin, Poland; (E.G.); (J.R.)
| |
Collapse
|
39
|
Iba T, Levy JH, Connors JM, Warkentin TE, Thachil J, Levi M. Managing thrombosis and cardiovascular complications of COVID-19: answering the questions in COVID-19-associated coagulopathy. Expert Rev Respir Med 2021; 15:1003-1011. [PMID: 33667146 DOI: 10.1080/17476348.2021.1899815] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The first patients with Coronavirus disease 2019 (COVID-19) emerged at the end of 2019. This novel viral infection demonstrated unique features that include prothrombotic clinical presentations. However, one year after the first occurrence, there remain many unanswered questions. We tried to address some of the important queries in this review. AREAS COVERED We raised the following critical questions. 'Why is COVID-19 so hypercoagulable?', 'Why are most coagulation test results relatively normal?', 'Why is COVID-19-associated coagulopathy more thrombotic than most other infectious diseases?', 'Why is arterial thrombus formed frequently?', 'Is anticoagulant therapy for COVID-19 effective?', and 'Are there racial disparities in thrombosis in COVID-19?' EXPERT OPINION There are commonalities and differences in the pathogeneses and clinical features between COVID-19 and other infectious diseases. Correct understanding will help discussing appropriate anticoagulation prophylaxis or treatment for thromboembolism.
Collapse
Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Jean Marie Connors
- Hematology Division Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Theodore E Warkentin
- Department of Pathology and Molecular Medicine, and Department of Medicine, McMaster University, Hamilton, Canada
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
| | - Marcel Levi
- Department of Medicine, University College London Hospitals NHS Foundation Trust, and Cardio-metabolic Programme-NIHR UCLH/UCL BRC London, UK
| |
Collapse
|
40
|
Faganel Kotnik B, Zajc Avramovič M, Kitanovski L, Avčin T. Prophylactic Anticoagulation Therapy: Comment on the Article by Henderson et al. Arthritis Rheumatol 2021; 73:1341-1342. [PMID: 33586369 DOI: 10.1002/art.41690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 02/01/2021] [Indexed: 11/11/2022]
Affiliation(s)
| | | | | | - Tadej Avčin
- University Children's Hospital Ljubljana and University of Ljubljana, Ljubljana, Slovenia
| |
Collapse
|
41
|
Licciardi F, Baldini L, Dellepiane M, Covizzi C, Mogni R, Pruccoli G, Orsi C, Rabbone I, Parodi E, Mignone F, Montin D. MIS-C Treatment: Is IVIG Always Necessary? Front Pediatr 2021; 9:753123. [PMID: 34805048 PMCID: PMC8595395 DOI: 10.3389/fped.2021.753123] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 10/04/2021] [Indexed: 12/19/2022] Open
Abstract
Background: MIS-C is a potentially severe inflammatory syndrome associated with SARS-CoV-2 exposure. Intravenous immunoglobulin (IVIG) is considered the first-tier therapy, but it implies infusion of large fluid volumes that may worsen cardiac function. Patients and Methods: Since April 2020, we have developed a treatment protocol that avoids the infusion of IVIG as first-line therapy in the early phase of MIS-C. In this study, we retrospectively analyzed a cohort of consecutive patients treated according to this protocol between 01/04/2020 and 01/04/2021. Results: In the last year, 31 patients have been treated according to the protocol: 25 with high-dose pulse MP (10 mg/kg) and 6 with 2 mg/kg. 67.7% of the patients responded to the initial treatment, while the others needed a step-up, either with Anakinra (25.8%) or with MP dose increase (6.5%). IVIG was administered in four patients. Overall, only one patient (3.2%) needed ICU admission and inotropic support; one patient developed a small coronary artery aneurysm. Conclusions: Timely start of MP therapy and careful fluid management might improve the outcomes of MIS-C patients.
Collapse
Affiliation(s)
- Francesco Licciardi
- Department of Pediatrics and Public Health, Università degli Studi di Torino, Turin, Italy.,Ospedale Infantile Regina Margherita, Città della Salute e della Scienza, Turin, Italy
| | - Letizia Baldini
- Postgraduate School of Pediatrics, Università degli Studi di Torino, Turin, Italy
| | - Marta Dellepiane
- Department of Pediatrics and Public Health, Università degli Studi di Torino, Turin, Italy
| | - Carlotta Covizzi
- Postgraduate School of Pediatrics, Università degli Studi di Torino, Turin, Italy
| | - Roberta Mogni
- Postgraduate School of Pediatrics, Università degli Studi di Torino, Turin, Italy
| | - Giulia Pruccoli
- Department of Pediatrics and Public Health, Università degli Studi di Torino, Turin, Italy
| | - Cecilia Orsi
- Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
| | - Ivana Rabbone
- Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
| | - Emilia Parodi
- Department of Pediatrics and Public Health, Università degli Studi di Torino, Turin, Italy.,Ospedale Infantile Regina Margherita, Città della Salute e della Scienza, Turin, Italy
| | - Federica Mignone
- Department of Pediatrics and Public Health, Università degli Studi di Torino, Turin, Italy.,Ospedale Infantile Regina Margherita, Città della Salute e della Scienza, Turin, Italy
| | - Davide Montin
- Department of Pediatrics and Public Health, Università degli Studi di Torino, Turin, Italy.,Ospedale Infantile Regina Margherita, Città della Salute e della Scienza, Turin, Italy
| |
Collapse
|