Coronavirus Disease 2019-Related Multisystem Inflammatory Syndrome in Children: A Systematic Review and Meta-Analysis

Evidence linking COVID-19 and the health/well-being of children and adolescents: an umbrella review

BACKGROUND

Experiences during childhood and adolescence have enduring impacts on physical and mental well-being, overall quality of life, and socioeconomic status throughout one's lifetime. This underscores the importance of prioritizing the health of children and adolescents to establish an impactful healthcare system that benefits both individuals and society. It is crucial for healthcare providers and policymakers to examine the relationship between COVID-19 and the health of children and adolescents, as this understanding will guide the creation of interventions and policies for the long-term management of the virus.

METHODS

In this umbrella review (PROSPERO ID: CRD42023401106), systematic reviews were identified from the Cochrane Database of Systematic Reviews; EMBASE (OvidSP); and MEDLINE (OvidSP) from December 2019 to February 2023. Pairwise and single-arm meta-analyses were extracted from the included systematic reviews. The methodological quality appraisal was completed using the AMSTAR-2 tool. Single-arm meta-analyses were re-presented under six domains associated with COVID-19 condition. Pairwise meta-analyses were classified into five domains according to the evidence classification criteria. Rosenberg's FSN was calculated for both binary and continuous measures.

RESULTS

We identified 1551 single-arm and 301 pairwise meta-analyses from 124 systematic reviews that met our predefined criteria for inclusion. The focus of the meta-analytical evidence was predominantly on the physical outcomes of COVID-19, encompassing both single-arm and pairwise study designs. However, the quality of evidence and methodological rigor were suboptimal. Based on the evidence gathered from single-arm meta-analyses, we constructed an illustrative representation of the disease severity, clinical manifestations, laboratory and radiological findings, treatments, and outcomes from 2020 to 2022. Additionally, we discovered 17 instances of strong or highly suggestive pairwise meta-analytical evidence concerning long-COVID, pediatric comorbidity, COVID-19 vaccines, mental health, and depression.

CONCLUSIONS

The findings of our study advocate for the implementation of surveillance systems to track health consequences associated with COVID-19 and the establishment of multidisciplinary collaborative rehabilitation programs for affected younger populations. In future research endeavors, it is important to prioritize the investigation of non-physical outcomes to bridge the gap between research findings and clinical application in this field.

COVID-19 and the eye

There is growing literature describing the ocular manifestations of COVID-19. We have assessed published reviews, cross-sectional analyses, and clinical reports to summarize the ocular manifestations of the disease and available vaccines, identify the potential role of ocular transmission, and offer basic clinical guidance to health care providers. Ultimately, self-limiting conjunctivitis and conjunctival hyperemia are the most frequently reported ocular findings; several rarer entities may warrant targeted topical therapies. COVID-19 vaccines have been infrequently associated with the development of rare but significant side effects that may warrant ophthalmologist referral as well as specific treatments. Despite the overall low risk of ocular transmission, eye protection is advisable for health care providers in high-risk scenarios. This review should help to guide the assessment of patients with eye complaints in the setting of COVID-19 to promote appropriate diagnosis, treatment, monitoring, and referral.

COVID-19 Biomarkers Comparison: Children, Adults and Elders

Background and Objectives: this study aimed to research links between C-reactive protein (CRP), lactate dehydrogenase (LDH), creatinekinase (CK), 25-OH vitamin D (25-OHD), ferritin (FER), high-density lipoprotein cholesterol (HDL)cholesterol and clinical severity in patients from the western part of Romania, and compare their potential use as biomarkers for intensive care units (ICU) admission and death in children, adults and elders. Materials and Methods: this study is a retrospective cohort study, performed on patients positively diagnosed with COVID-19. Available CRP, LDH, CK 25-OH vitamin D, ferritin, HDL cholesterol and clinical severity were recorded. The following were assessed: median group differences, association, correlation and receiver operating characteristic. Results: 381 children, 614 adults and 381 elders were studied between 1 March 2021 and 1 March 2022. Most children and adults presented mild symptomatology (53.28%, 35.02%, respectively), while most elders presented severe symptomatology (30.04%). ICU admission was 3.67% for children, 13.19% for adults and 46.09% for elders, while mortality was 0.79% for children, 8.63% for adults and 25.1% for elders. With the exception of CK, all other biomarkers showed some significant associations with clinical severity, ICU admission and death. Conclusions: CRP, LDH, 25-OH vitamin D, ferritin and HDL are important biomarkers for COVID-19 positive patients, especially in the pediatric population, while CK was mostly within normal ranges.

COVID-19 Inflammatory Markers and Vitamin D Relationship in Pediatric Patients

BACKGROUND

Biomarkers play an important role in COVID-19, and more research in this regard is needed, especially in the case of children. This study aimed to look for a link between the C reactive protein (CRP), lactate dehydrogenase (LDH), creatine kinase (CK), vitamin D and COVID-19 in pediatric patients.

METHODS

This is a retrospective cohort study, performed on children diagnosed positively with COVID-19 at a children's hospital in western Romania. Available CRP, LDH, CK vitamin D and clinical severity were recorded. For each biomarker, groups were formed by patients' age. Mean/median group differences were assessed using Student's t test or Mann-Whitney and Kruskal-Wallis with Dunn's post hoc tests. Association was assessed using the chi2 test, while correlation was assessed using Spearman's rank correlation.

RESULTS

181 positive children were studied between 1 August 2021 and 1 February 2022. Average age was 8.76 years (SD = 3.93). There were 94 (51.93%) males and 87 (48.07%) females. The cases were: 62 asymptomatic (34.25%), 107 mild (59.12%), 9 moderate (4.97%), 3 severe (1.66%). Regarding CRP, a significant difference between older and younger patients was observed (p = 0.0034). Clinical severity was associated with CRP (p = 0.0281), LDH (p = 0.0410) and vitamin D (p = 0.0444). Regarding CK, no differences or associations proved significant. Correlation testing was conducted for CRP, LDH, vitamin D and clinical signs. With the exception of LDH-CRP and LDH-vitamin D, all relationships proved statistically significant.

CONCLUSIONS

CRP, LDH and vitamin D levels are important biomarkers for COVID-19-positive pediatric patients, while CK was mostly within normal ranges.

Giant Partially Thrombosed Coronary Aneurysm in Multisystem Inflammatory Syndrome Associated with SARS-CoV-2 in Children

Multisystem inflammatory syndrome in children (MIS-C) is a postinfectious condition which usually develops 4 to 6 weeks after SARS-CoV-2 infection in a genetically predisposed individual. Clinical features are heterogeneous and include fever, respiratory compromise, mucocutaneous involvement with conjunctival abnormalities and erythematous exanthem, abdominal pain, and diarrhea. Neurologic and cardiovascular symptoms can also develop, including coronary artery dilatation. Some cases involve 2 or more organs and require critical admission. Echocardiography is the mainstay of cardiac evaluation in the acute setting as well as on outpatient follow-up. We present the case of a 4-month-old female with no past medical or surgical history who presented with a prolonged febrile syndrome associated with severe respiratory illness, gastrointestinal symptoms, and mucocutaneous abnormalities. Diagnosis of MIS-C was established based on clinical findings, persistently elevated markers of systemic inflammation and positive SARS-CoV-2 molecular test and evidence of prior SARS-CoV-2 infection with SARS-CoV-2 IgG positive. Echocardiogram evidenced myopericarditis and coronary aneurysms and patient was deemed candidate for immunomodulatory therapy with intravenous immunoglobulin (IVIg), resulting in favorable clinical and paraclinical outcomes. Few cases of giant coronary aneurysms have been reported in children. There are no existing literature reports about coronary thrombosis or thrombus formation resulting from vascular aneurysmal dilations in this population. As such, the prognosis and natural history of coronary artery aneurysms in the setting of MIS-C remain largely unknown.

Role of Endomyocardial Biopsy in Diagnostics of Myocarditis

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

Neurological effects of COVID-19 in infants and children

Neurological manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in children are becoming increasingly apparent as the coronavirus disease (COVID-19) pandemic continues. While children manifest relatively milder features of the disease, accumulating evidence warrants concern that COVID-19 exacts both acute- and long-term effects on the developing central and peripheral nervous systems. This review focuses on the relatively underinvestigated topic of the effects of SARS-CoV-2 on the brain in infancy and childhood, concluding that clinicians should be attentive to both the acute effects and long-term consequences of COVID-19 from a neurological perspective.

Síndrome inflamatória multissistêmica (SIMS) pós-COVID-19

INTRODUÇÃO: A potencial associação da COVID-19 com fenômenos inflamatórios e autoimunes abre um novo capítulo na prática clínica. Entre várias condições inflamatórias descritas no pós-COVID-19, destacam-se a doença de Kawasaki e uma nova afecção denominada síndrome inflamatória multissistêmica.OBJETIVOS: Revisar, de forma prática e concisa, conceito e critérios diagnósticos da síndrome inflamatória multisistêmica, as sobreposições com a doença de Kawasaki, assim como a imunopatogênese e o tratamento desta nova e intrigante enfermidade.MÉTODOS: Revisão da literatura disponível na base de dados Pubmed, com ênfase em revisões sistemáticas com metaanálises.RESULTADOS: A síndrome inflamatória multisistêmica se configura como uma condição hiperinflamatória multiorgânica pós-viral. A condição é primordialmente pediátrica, e os primeiros casos foram descritos na Inglaterra em maio de 2020. Os critérios diagnósticos são ainda imprecisos, e incluem algumas manifestações doença de Kawasaki-símiles. A síndrome inflamatória multisistêmica difere da doença de Kawasaki, entretanto, por geralmente acometer crianças acima cinco anos e de raças negras ou hispânicas; em termos clínicos, se distingue pela alta frequência de gastroenteropatia, miocardiopatia e choque. O diagnóstico diferencial inclui sepse bacteriana, síndrome de ativação macrofágica e formas sistêmicas de artrite reumatoide. Uma hiperexpressão de interferons e de outras citocinas inflamatórias caracteriza patogenicamente a síndrome inflamatória mulsistêmica. A enfermidade é, via de regra, responsiva a cuidados de terapia intensiva, corticóides, imunoglobulina intravenosa e imunobiológicos.CONCLUSÕES: A síndrome inflamatória multisistêmica é uma nova e complexa afecção hiperinflamatória associada à exposição prévia ao SARS-CoV-2. Apresenta instigantes interfaces com a doença de Kawasaki. Apesar da descrição recente, a literatura já é quantitativamente robusta, e algumas pendências de imunopatogênese, critérios diagnósticos e terapêutica deverão ser esclarecidas em breve.

Neurological Aspects of the Sequelae of COVID-19 in Children

It has now been established that neurological and neuropsychiatric disorders persist for prolonged periods in a significant proportion of adult patients who have had COVID-19, though there is much less information about the manifestations of post-COVID syndrome (PCS) in children and adolescents. This review presents data on the features of the course of PCS in young patients, and considers the options for treating these patients. The results of studies on the use of Cortexin for correcting cognitive and emotional disorders are analyzed.

Factors of parental COVID-19 vaccine hesitancy: A cross sectional study in Japan

The eligibility of COVID-19 vaccines has been expanded to children aged 12 and above in several countries including Japan, and there is a plan to further lower the age. This study aimed to assess factors related to parental COVID-19 vaccine hesitancy. A nationwide internet-based cross-sectional study was conducted between May 25 and June 3, 2021 in Japan. The target population was parents of children aged 3–14 years who resided in Japan, and agreed to answer the online questionnaire. Parental COVID-19 vaccine hesitancy (their intention to vaccinate their child) and related factors were analyzed using logistic regression models. Interaction effects of gender of parents and their level of social relationship satisfaction related to parental vaccine hesitancy was tested using log likelihood ratio test (LRT). Social media as the most trusted information source increased parental vaccine hesitancy compared to those who trusted official information (Adjusted Odds Ratio: aOR 2.80, 95% CI 1.53–5.12). Being a mother and low perceived risk of infection also increased parental vaccine hesitancy compared to father (aOR 2.43, 95% CI 1.57–3.74) and those with higher perceived risk of infection (aOR 1.55, 95% CI 1.04–2.32) respectively. People with lower satisfaction to social relationships tended to be more hesitant to vaccinate their child among mothers in contrast to fathers who showed constant intention to vaccinate their child regardless of the level of satisfaction to social relationship (LRT p = 0.021). Our findings suggest that dissemination of targeted information about COVID-19 vaccine by considering means of communication, gender and people who are isolated during measures of social distancing may help to increase parental vaccine acceptance.

COVID-19 Pneumonia in Vaccinated Population: A Six Clinical and Radiological Case Series

Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) and its related disease (COVID-19) continue to represent a challenge for humans. To date, vaccination programs have represented an opportunity to navigate the pandemic. However, the advent of new genetic COVID-19 variants has increased more attention representing a worrying threat not only for not vaccinated but also for vaccinated people as virus infections have been shown also in the last ones. Herein, we report different clinical cases and radiological findings of COVID-19 pneumonia in six fully vaccinated patients. Two patients had a history of Rituximab therapy for follicular lymphoma and with persistent positivity for SARS-CoV-2 on nasopharyngeal/oropharyngeal (NP/OP) swabs and with moderate pneumonia on the chest computed tomography (CT). One patient who resulted to be positive to delta variant 8 days after the second vaccination dose, died shortly after. Two patients were hospitalized due to the worsening of fever and dyspnea in presence of mild pneumonia on CT. In one patient mild pneumonia was found on the chest-CT performed after a lipothymic episode associated with chest pain and positive NP/OP swab tested for SARS-CoV-2. These data suggested that in fully vaccinated people, caution should be preserved, and the use of masks and social distancing should be continued in all closed environments. However, further clinical trials should be done to better understand how various factors can influence vaccine immunogenicity as the presence of virus mutations, age factors, and the presence of an immunocompromised state.