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Muthiah D, Chan M, Low YW, Ramasamy SN, Amin Z, Chan-Ng PPL, Low JL, Low JM. Multisystem inflammatory syndrome in neonates (MIS-N): an updated systematic review. Front Pediatr 2024; 12:1382133. [PMID: 39026941 PMCID: PMC11256206 DOI: 10.3389/fped.2024.1382133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 06/11/2024] [Indexed: 07/20/2024] Open
Abstract
Introduction The aim of the study was to summarize and update clinical features and outcomes of multisystem inflammatory syndrome in neonates (MIS-N). Methods A systematic literature search was conducted of studies on MIS-N published in PubMed, MEDLINE, EMBASE, CNKI, and WHO COVID-19 databases between 1 December 2019 and 30 June 2023. Reference lists of selected articles, Google Scholar, and pre-print servers were searched for additional studies. The methodological quality of included studies was assessed. Results Of 1,572 records screened after the initial search, 35 studies involving a total of 201 neonates with MIS-N were included. One study was retrieved from a pre-print server. For those with available data, 34/47 (78.7%) mothers were infected in the third trimester. Of the 199 mothers (two with twin pregnancies), 183 (92.0%) were from India. The median age of neonates at presentation was 2.0 days (interquartile range 1.0-9.5). Over two-thirds (144/201, 71.6%) presented with respiratory distress, while 112 (55.7%) had cardiac involvement, such as ventricular dysfunctions, involvement of coronary arteries, and atrioventricular blocks. Arrhythmias and thrombosis were reported in 15/201 (7.5%) and 2/201 (3.0%) neonates, respectively. All neonates, except one, required critical care; 64/160 (40.0%) required inotropic support and 105/187 (56.1%) required respiratory support, of whom 59/105 (56.2%) were specified to require intubation. The mortality rate was 5.0% (10/201). Discussion/Conclusion MIS-N should be considered in ill neonates presenting with involvement of two or more organ systems, especially among those neonates with cardiorespiratory dysfunctions, in the presence of proven or suspected maternal COVID-19 infection during pregnancy. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021278717, PROSPERO, identifier CRD42021278717.
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Affiliation(s)
| | - Ming Chan
- Department of Nursing, Changi General Hospital, Singapore, Singapore
| | - Yue Wey Low
- Ministry of Health Holdings, Singapore, Singapore
| | - Sheena Nishanti Ramasamy
- Department of Paediatrics, Khoo Teck Puat—National University Children’s Medical Institute, National University Hospital, National University Health System, Singapore, Singapore
| | - Zubair Amin
- Department of Paediatrics, Khoo Teck Puat—National University Children’s Medical Institute, National University Hospital, National University Health System, Singapore, Singapore
- Department of Neonatology, Khoo Teck Puat—National University Children’s Medical Institute, National University Hospital, National University Health System, Singapore, Singapore
| | - Pauline Poh Lin Chan-Ng
- Department of Paediatrics, Khoo Teck Puat—National University Children’s Medical Institute, National University Hospital, National University Health System, Singapore, Singapore
| | | | - Jia Ming Low
- Department of Paediatrics, Khoo Teck Puat—National University Children’s Medical Institute, National University Hospital, National University Health System, Singapore, Singapore
- Department of Neonatology, Khoo Teck Puat—National University Children’s Medical Institute, National University Hospital, National University Health System, Singapore, Singapore
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2
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Cimolai N. COVID-19 among infants: key clinical features and remaining controversies. Clin Exp Pediatr 2024; 67:1-16. [PMID: 38013408 PMCID: PMC10764668 DOI: 10.3345/cep.2023.00794] [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: 06/07/2023] [Revised: 08/11/2023] [Accepted: 09/19/2023] [Indexed: 11/29/2023] Open
Abstract
Infants aged <1 year represent a seemingly more susceptible pediatric subset for infections. Despite this, coronavirus disease 2019 (COVID-19) infection has not been proven as more serious in this age group (outside the very early neonatal period) than in others. Indeed, a considerable number of asymptomatic infections have been recorded, and the symptoms and morbidity associated with COVID- 19 differ minimally from those of other respiratory viral infections. Whether due to an abundance of caution or truly reduced susceptibility, infections in infants have not raised the same profile as those in other age groups. In addition to direct severe acute respiratory syndrome coronavirus 2 diagnostic tests, laboratory markers that differentiate COVID-19 from other viral infections lack specificity in infants. Gastrointestinal presentations are common, and the neurological complications of infection mirror those of other respiratory viral infections. There have been relatively few reports of infant deaths. Under appropriate precautions, breastfeeding in the context of maternal infections has been associated with tangible but infrequent complications. Vaccination during pregnancy provides protection against infection in infants, at least in the early months of life. Multi-inflammatory syndrome in children and multi-inflammatory syndrome in neonates are commonly cited as variants of COVID-19; however, their clinical definitions remain controversial. Similarly, reliable definitions of long COVID in the infant group are controversial. This narrative review examines the key clinical and laboratory features of COVID-19 in infants and identifies several areas of science awaiting further clarification.
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Affiliation(s)
- Nevio Cimolai
- Faculty of Medicine, The University of British Columbia and Children’s and Women’s Health Centre of British Columbia, Vancouver, Canada
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3
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Siramdas D, Anudeep P, Subramanian P, Chitgupikar S. Case Series of Multisystem Inflammatory Syndrome in Neonates (MIS-N) With a Link to Coagulopathy. Cureus 2023; 15:e49681. [PMID: 38161855 PMCID: PMC10756854 DOI: 10.7759/cureus.49681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2023] [Indexed: 01/03/2024] Open
Abstract
Introduction Multisystem inflammatory syndrome in neonates (MIS-N) is an emerging clinical entity observed in neonates born to mothers with exposure to the SARS-CoV-2 virus before or during the antenatal period. Methods We report 18 neonates diagnosed with MIS-N from retrospectively collected data. A total of 18 neonates (13 term and five late-preterm; 10 males) admitted to the neonatal intensive care unit (NICU) of a tertiary care medical institute, between June 2021 to November 2022, were diagnosed with MIS-N. Results The median age of presentation of the 18 neonates was 1.5 days of life. All the neonates were positive for SARS-CoV-2 IgG antibodies and had elevated D-dimer levels. Respiratory system involvement was the most common (12 of 18 neonates: 66.67%). Ten out of 18 neonates (55.55%) had coagulopathy. Seven of the ten neonates with coagulopathy had central nervous system (CNS) involvement as seizures and/or intracerebral infarcts/bleeds. Cardiovascular and gastrointestinal system involvement was observed in nine (50%) and seven (38.89%) neonates, respectively. One out of 18 neonates died due to intraventricular and cerebral hemorrhage. The mortality rate was 5.55% (n=1). Ten of 18 neonates with coagulopathy required fresh frozen plasma along with repeated therapeutic doses of injection vitamin K. Eight neonates (44.44%) required human intravenous immunoglobulin (IVIG), and three neonates (16.67%) required steroids and IVIG for recovery along with supportive care. Conclusion Coagulopathy can be one of the salient features of presentation in MIS-N. In the immediate post-pandemic era, it is essential that MIS-N is considered in the differential diagnosis of neonates presenting with intracerebral bleeds/infarcts. IVIG and steroids might play an important role in the treatment of neonates with MIS-N.
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Affiliation(s)
- Deepthi Siramdas
- Pediatrics, MediCiti Institute of Medical Sciences, Hyderabad, IND
| | - Peddi Anudeep
- Pediatrics, MediCiti Institute of Medical Sciences, Hyderabad, IND
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4
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Diwakar K, Sarangi T, Srivastava P, Tanti SK, Swaroop S. Human Adenovirus Infection Causing Hyperinflammatory Syndrome Mimicking Multisystem Inflammatory Syndrome in Children (MIS-C): A Case Report. Cureus 2023; 15:e40239. [PMID: 37440807 PMCID: PMC10333626 DOI: 10.7759/cureus.40239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2023] [Indexed: 07/15/2023] Open
Abstract
Transmission of human adenovirus (HAdV) infection and the associated clinical disease can be sporadic or epidemic and manifestations may range from mild infection to severe disease. HAdV has been seen to behave as a proinflammatory virus that can trigger the release of high levels of inflammatory cytokines and chemokines in children. Here, we report an unusual case of an infant with HAdV infection who presented with respiratory illness, with a protracted course, complicated with hyperinflammation and multi-system involvement with clinical characteristics mimicking multisystem inflammatory syndrome in children (MIS-C) and Kawasaki disease. The patient was an 11-month-old male infant with a background of infantile epilepsy, epileptic encephalopathy, hemimegaloencephaly, and global developmental delay, diagnosed as Ohtahara syndrome. He was admitted with a three-day history of cough, cold, fever, and respiratory distress. Management was initiated with a heated humidified high-flow nasal cannula and given ceftriaxone and hypertonic saline nebulization. Additionally, he developed loose motion on the fifth day of admission. The reverse transcriptase polymerase chain reaction (RT-PCR) of the nasopharyngeal swab was positive for HAdV. Due to persistent fever, elevated inflammatory markers, multisystem involvement (diarrhea, coagulopathy), an absence of a clear microbial etiology, and an epidemiologic link to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, MIS-C was diagnosed. The first dose of intravenous immunoglobulins (IVIG) was administered over the course of 48 hours and the baby required a second dose of IVIG as the fever failed to settle after the first dose. Within 24 hours of the second IVIG dose, defervescence occurred. His platelet count started to rise, and the baby developed thrombocytosis in the third week of illness. Echocardiography was suggestive of dilatation of mild left main coronary artery. He was weaned off oxygen support by day 14 and discharged on day 17. To our knowledge, this is the first reported case of HAdV infection with hyperinflammatory syndrome and vasculitis akin to MIS-C and Kawasaki disease.
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Affiliation(s)
- Kumar Diwakar
- Pediatrics, Tata Main Hospital, Jamshedpur, IND
- Pediatrics, Manipal Tata Medical College, Jamshedpur, IND
| | | | - Preeti Srivastava
- Pediatrics, Tata Main Hospital, Jamshedpur, IND
- Pediatrics, Manipal Tata Medical College, Jamshedpur, IND
| | - Sanjay K Tanti
- Pediatrics, Tata Main Hospital, Jamshedpur, IND
- Pediatrics, Manipal Tata Medical College, Jamshedpur, IND
| | - Shikha Swaroop
- Pediatrics, Tata Main Hospital, Jamshedpur, IND
- Pediatrics, Manipal Tata Medical College, Jamshedpur, IND
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5
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Ramaswamy VV, Abiramalatha T, Pullattayil S AK, Trevisanuto D. Multisystem inflammatory disease in neonates (MIS-N) due to maternal COVID-19. Semin Fetal Neonatal Med 2023; 28:101431. [PMID: 37061425 DOI: 10.1016/j.siny.2023.101431] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2023]
Abstract
Multisystem inflammatory disease in neonates (MIS-N) is a disease of immune dysregulation presenting in the newborn period. Thouvgh its etiopathogenesis is proposed to be similar to multisystem inflammatory disease in Children (MIS-C), the exact pathophysiology is largely unknown as of present. The definition of MIS-N is contentious. The evidence for its incidence, the clinical features, profile of raised inflammatory markers, treatment strategies and outcomes stem from case reports, case series and cohort studies with small sample sizes. Though the incidence of MIS-N in severe acute respiratory syndrome caused by the coronavirus CoVID-2 (SARS-CoV-2) infected asymptomatic neonates is low, its incidence in symptomatic neonates is relatively higher. Further, amongst the neonates who are treated as MIS-N, the mortality rate is high. The review also evaluates the various other unresolved aspects of MIS-N from limited published literature and identifies knowledge gaps which could be areas of future research.
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Affiliation(s)
| | | | | | - Daniele Trevisanuto
- Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy.
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6
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Multisystem inflammatory syndrome in neonates (MIS-N): a systematic review. Eur J Pediatr 2023; 182:2283-2298. [PMID: 36877274 PMCID: PMC9986661 DOI: 10.1007/s00431-023-04906-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/16/2023] [Accepted: 02/26/2023] [Indexed: 03/07/2023]
Abstract
Recently, a new pattern of multisystem inflammatory syndrome following an infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has emerged globally. The initial cases were described in the adult population followed by sporadic cases in the pediatric population also. By the end of 2020, similar reports were recognised in the neonatal age group. The purpose of this study was to systematically review clinical characteristics, laboratory parameters, treatment, and outcomes of neonates with multisystem inflammatory syndrome in neonates (MIS-N). A systematic review was conducted after registering with PROSPERO and electronic databases including MEDLINE, EMBASE, PubMed, SCOPUS, Google Scholar, and Web of Science were searched from January 1st 2020 till September 30th 2022. A total of 27 studies describing 104 neonates were analysed. The mean gestation age and birth weight was 35.9 ± 3.3 weeks and 2255.7 ± 783.7 g respectively. A large proportion (91.3%) of the reported cases belonged to the South-East Asian region. The median age of presentation was 2 days (range: 1-28 days) with cardiovascular system being the predominant system involved in 83.65% followed by respiratory (64.42%). Fever was noted in only 20.2%. Commonly elevated inflammatory markers were IL-6 in 86.7% and D-dimer in 81.1%. Echocardiographic evaluation suggested ventricular dysfunction in 35.8% and dilated coronary arteries in 28.3%. Evidence of SARS-CoV-2 antibodies (IgG or IgM) was seen in 95.9% neonates and evidence of maternal SARS-CoV-2 infection, either as history of COVID infection or positive antigen or antibody test, was noted in 100% of the cases. Early MIS-N was reported in 58 (55.8%) cases, late MIS-N in 28 (26.9%), and 18 cases (17.3%) did not report the timing of presentation. There was a statistically increased proportion of preterm infants (67.2%, p < 0.001), and a trend towards increased low birth weight infants, in the early MIS-N group when compared to the infants with late MIS-N. Fever (39.3%), central nervous system (50%), and gastrointestinal manifestations (57.1%) were significantly higher in the late MIS-N group (p = 0.03, 0.02, 0.01 respectively). The anti-inflammatory agents used for the treatment of MIS-N included steroids 80.8% which were given for a median of 10 (range 3-35) days and IVIg in 79.2% with a median of 2 (range 1-5) doses. The outcomes were available for 98 cases, of whom 8 (8.2%) died during treatment in hospital and 90 (91.8%) were successfully discharged home. Conclusion: MIS-N has a predilection for late preterm males with predominant cardiovascular involvement. The diagnosis is challenging in neonatal period due to overlap with neonatal morbidities and a high risk of suspicion is warranted, especially in presence of supportive maternal and neonatal clinical history. The major limitation of the review was inclusion of case reports and case series, and highlights need of global registries for MIS-N. What is Known: • A new pattern of multisystem inflammatory syndrome following SARS-CoV-2 infection has emerged in adult population with sporadic cases now being reported in neonates. What is New: • MIS-N is an emerging condition with a heterogeneous spectrum and has a predilection for late preterm male infants. Cardiovascular system is the predominant system involved followed by respiratory, however fever remains an uncommon presentation unlike other age-groups. There are two subtypes based on timing of presentation, with early MIS-N being reported more in preterm and low-birth weight infants.
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7
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Asghar Z, Sharaf K, Butt FA, Shaikh OA, Shekha M, Waris A, Ullah I, Nashwan AJ. A global review of racial, ethnic and socio-economic disparities in multisystem inflammatory syndrome in children related to COVID-19. Front Public Health 2022; 10:996311. [PMID: 36339223 PMCID: PMC9632619 DOI: 10.3389/fpubh.2022.996311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 09/30/2022] [Indexed: 01/26/2023] Open
Abstract
With over 500 million confirmed cases and 6.2 million deaths worldwide, the novel coronavirus has highlighted the underlying disparities in healthcare, unpreparedness to deal with a new disease and the need for monitoring and surveillance for a post-infectious syndrome as well as complicated diseases. Initially, children were thought to be spared but reports of a new phenomenon manifesting as Kawasaki-like disease, toxic shock syndrome, and multi-system inflammatory syndrome, which developed after a few weeks of severe COVID-19 infection, emerged in the pediatric population. As the pandemic progressed, increased prevalence of multi-system inflammatory syndrome in children (MIS-C) related to COVID-19 was seen in non-Hispanic blacks, Asians, and Latinos as compared to the white population drawing attention to a possible role of ethnicity and socio-economic disparities. The CDC currently reports that 31% of MIS-C cases were seen in Black Non-Hispanics and 26% in Latinos, who were historically more affected in previous pandemics. Furthermore, MIS-C cases in developing countries showed higher mortality as compared to high-income countries, which points toward the role of social determinants of health and limitations in a low-resource set up in increasing the disease burden of MIS-C, which should be treated as a public health emergency. Our review highlights the role of ethnicity, socio-economic factors, comorbidities, and differences in populations affected by MIS-C in high-income vs. low- and middle-income countries.
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Affiliation(s)
- Zoha Asghar
- Department of Medicine, Ziauddin University, Karachi, Pakistan
| | - Kanza Sharaf
- Department of Medicine, Ziauddin University, Karachi, Pakistan
| | | | | | - Manahil Shekha
- Department of Medicine, Ziauddin University, Karachi, Pakistan
| | - Abdul Waris
- Kabir Medical College, Gandhara University, Peshawar, Pakistan
| | - Irfan Ullah
- Kabir Medical College, Gandhara University, Peshawar, Pakistan
- Institute of Public Health and Social Science (IPH&SS), Khyber Medical University, Peshawar, Pakistan
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Costa S, Delogu AB, Bottoni A, Purcaro V, D'Andrea V, Paladini A, Muto S, Marano R, Savino G, Secinaro A, De Benedetti F, Carsetti R, Mortari EP, Spanu T, Vento G. COVID-19-Associated Multisystem Inflammatory Syndrome in a Neonate with Atypical Coronary Artery Involvement. Am J Perinatol 2022; 29:1514-1518. [PMID: 34996119 DOI: 10.1055/a-1733-4163] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE The study aimed to report a novel coronavirus disease 2019 (COVID-19)-associated multisystem inflammatory syndrome in children (MIS-C) in a neonate found to have an atypical diffuse thickening in coronary artery walls whose diagnosis required a multi-imaging approach. STUDY DESIGN A neonate presented at birth with multiple organ involvement and coronary artery anomalies. A diagnosis of MIS-C associated with COVID-19 was supported by maternal severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection during pregnancy, and by the presence of both immunoglobulin (Ig)-G against SARS-CoV-2 and spike-specific memory B-cells response in the neonatal blood. Other plausible causes of the multiple organ involvement were excluded. RESULT At admission, a severe coronary artery dilatation was identified on echocardiography, supporting the diagnosis of the MIS-C Kawasaki-like disease; however, coronary artery internal diameters were found to be normal using cardiac computed tomography angiography. At discharge, comparing the two imaging techniques each other, the correct diagnosis resulted to be an abnormal thickening in coronary arterial walls. These findings suggest that the inflammatory process affecting the coronary arterial wall in MIS-C could result not only in typical coronary artery lesions such as dilatation of the lumen or aneurysms development but also in abnormal thickening of the coronary artery wall. CONCLUSION Our case provides an alert for pediatric cardiologists about the complexity to assess coronary artery involvement in MIS-C and raises the question that whether an abnormal vascular remodeling, with normal inner diameters, is to be considered like coronary artery dilatation for risk stratification. KEY POINTS · COVID-19 associated MIS-C can present in neonates with multiple organ involvement.. · Coronary artery assessment in neonatal MIS-C could be complex, and a multi-imaging approach could be required.. · Beside the typical coronary artery lesions, such as dilatation of the lumen or aneurysms, also abnormal thickening of the coronary artery wall can occur..
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Affiliation(s)
- Simonetta Costa
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli Istituto Di Ricovero E Cura A Carattere Scientifico, Rome, Italy
| | - Angelica B Delogu
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli Istituto Di Ricovero E Cura A Carattere Scientifico, Rome, Italy.,Dipartimento di Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Anthea Bottoni
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli Istituto Di Ricovero E Cura A Carattere Scientifico, Rome, Italy
| | - Velia Purcaro
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli Istituto Di Ricovero E Cura A Carattere Scientifico, Rome, Italy
| | - Vito D'Andrea
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli Istituto Di Ricovero E Cura A Carattere Scientifico, Rome, Italy
| | - Angela Paladini
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli Istituto Di Ricovero E Cura A Carattere Scientifico, Rome, Italy
| | - Sara Muto
- Dipartimento di Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Riccardo Marano
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli Istituto Di Ricovero E Cura A Carattere Scientifico, Rome, Italy.,Dipartimento di Scienze radiologiche ed ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giancarlo Savino
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli Istituto Di Ricovero E Cura A Carattere Scientifico, Rome, Italy
| | - Aurelio Secinaro
- Department of Imaging, Ospedale Pediatrico Bambino Gesù, Istituto Di Ricovero E Cura A Carattere Scientifico, Rome, Italy
| | - Fabrizio De Benedetti
- Division of Rheumatology and Laboratory of Immuno-Rheumatology, Ospedale Pediatrico Bambino Gesù, Istituto Di Ricovero E Cura A Carattere Scientifico, Rome, Italy
| | - Rita Carsetti
- Diagnostic Immunology Research Unit, Multimodal Medicine Research Area, Ospedale Pediatrico Bambino Gesù, Istituto Di Ricovero E Cura A Carattere Scientifico, Rome, Italy.,Microbiology and Diagnostic Immunology Unit, Ospedale Pediatrico Bambino Gesù, Istituto Di Ricovero E Cura A Carattere Scientifico, Rome, Italy
| | - Eva Piano Mortari
- Diagnostic Immunology Research Unit, Multimodal Medicine Research Area, Ospedale Pediatrico Bambino Gesù, Istituto Di Ricovero E Cura A Carattere Scientifico, Rome, Italy
| | - Teresa Spanu
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli Istituto Di Ricovero E Cura A Carattere Scientifico, Rome, Italy.,Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Vento
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli Istituto Di Ricovero E Cura A Carattere Scientifico, Rome, Italy.,Dipartimento di Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, Rome, Italy
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9
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Multisystem inflammatory syndrome in children (MIS-C) and neonates (MIS-N) associated with COVID-19: optimizing definition and management. Pediatr Res 2022; 93:1499-1508. [PMID: 36050390 PMCID: PMC9436161 DOI: 10.1038/s41390-022-02263-w] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 06/07/2022] [Accepted: 07/08/2022] [Indexed: 12/15/2022]
Abstract
During the SARS-CoV-2-associated infection (COVID-19), pandemic initial reports suggested relative sparing of children inversely related to their age. Children and neonates have a decreased incidence of SARS-CoV-2 infection, and if infected they manifested a less severe phenotype, in part due to enhanced innate immune response. However, a multisystem inflammatory syndrome in children (MIS-C) or paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 emerged involving coronary artery aneurysms, cardiac dysfunction, and multiorgan inflammatory manifestations. MIS-C has many similarities to Kawasaki disease and other inflammatory conditions and may fit within a spectrum of inflammatory conditions based on immunological results. More recently neonates born to mothers with SARS-CoV-2 infection during pregnancy demonstrated evidence of a multisystem inflammatory syndrome with raised inflammatory markers and multiorgan, especially cardiac dysfunction that has been described as multisystem inflammatory syndrome in neonates (MIS-N). However, there is a variation in definitions and management algorithms for MIS-C and MIS-N. Further understanding of baseline immunological responses to allow stratification of patient groups and accurate diagnosis will aid prognostication, and inform optimal immunomodulatory therapies. IMPACT: Multisystem inflammatory system in children and neonates (MIS-C and MIS-N) post COVID require an internationally recognized consensus definition and international datasets to improve management and plan future clinical trials. This review incorporates the latest review of pathophysiology, clinical information, and management of MIS-C and MIS-N. Further understanding of the pathophysiology of MIS-C and MIS-N will allow future targeted therapies to prevent and limit clinical sequelae.
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Lakshminrusimha S, Hudak ML, Dimitriades VR, Higgins RD. Multisystem Inflammatory Syndrome in Neonates following Maternal SARS-CoV-2 COVID-19 Infection. Am J Perinatol 2022; 39:1166-1171. [PMID: 34710939 DOI: 10.1055/a-1682-3075] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Satyan Lakshminrusimha
- Division of Neonatology, Department of Pediatrics, University of California Davis Children's Hospital, Sacramento, California
| | - Mark L Hudak
- Department of Pediatrics, University of Florida College of Medicine, Jacksonville, Florida
| | - Victoria R Dimitriades
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, University of California Davis Children's Hospital, Sacramento, California
| | - Rosemary D Higgins
- Department of Global and Community Health, College of Health and Human Sciences, George Mason University, Fairfax, Virginia
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11
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Buonsenso D. Partnerships in the Comprehensive Management of Multisystem Inflammatory Syndrome in Neonates (MIS-N): Translating 2 Years of Pediatric Practice to the Neonatal Wards. Am J Perinatol 2022. [PMID: 35240695 DOI: 10.1055/a-1787-8099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Danilo Buonsenso
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Center for Global Health Research Studies, Università Cattolica del Sacro Cuore, Roma, Italia.,Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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Multisystem Inflammatory Syndrome in Neonates Born to Mothers with SARS-CoV-2 Infection (MIS-N) and in Neonates and Infants Younger Than 6 Months with Acquired COVID-19 (MIS-C): A Systematic Review. Viruses 2022; 14:v14040750. [PMID: 35458480 PMCID: PMC9024762 DOI: 10.3390/v14040750] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/24/2022] [Accepted: 03/31/2022] [Indexed: 12/25/2022] Open
Abstract
(1) Introduction: There is an increasing literature describing neonates born to mothers with SARS-CoV-2 infection (MIS-N) and infants infected with SARS-CoV-2 who presented with a severe disease (MIS-C). (2) Methods: To investigate clinical features of multisystem inflammatory syndrome in neonates and infants under six months of age, we used a systematic search to retrieve all relevant publications in the field. We screened in PubMed, EMBASE and Scopus for data published until 10 October 2021. (3) Results: Forty-eight articles were considered, including 29 case reports, six case series and 13 cohort studies. Regarding clinical features, only 18.2% of MIS-N neonates presented with fever; differently from older children with MIS-C, in which gastrointestinal symptoms were the most common manifestation, we displayed that cardiovascular dysfunction and respiratory distress are the prevalent findings both in neonates with MIS-N and in neonates/infants with MIS-C. (4) Conclusions: We suggest that all infants with suspected inflammatory disease should undergo echocardiography, due to the possibility of myocardial dysfunction and damage to the coronary arteries observed both in neonates with MIS-N and in neonates/infants with MIS-C. Moreover, we also summarize how they were treated and provide a therapeutic algorithm to suggest best management of these fragile infants.
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Shaiba LA, More K, Hadid A, Almaghrabi R, Al Marri M, Alnamnakani M, Shah P. Multisystemic Inflammatory Syndrome in Neonates: A Systematic Review. Neonatology 2022; 119:405-417. [PMID: 35512651 PMCID: PMC9148888 DOI: 10.1159/000524202] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 03/11/2022] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Multisystem inflammatory syndrome in neonates (MIS-N) related to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has increasingly been reported worldwide amid the spread of the SARS-CoV-2 pandemic. METHODS We searched PubMed, EMBASE, and CINAHL and preprint servers (BioRxiv.org and MedRxiv.org) using a specified strategy integrating Medical Subject Headings terms and keywords until October 20, 2021. Our aim was to systematically review demographic profiles, clinical features, laboratory parameters, complications, treatments, and outcomes of neonates with MIS-N. Studies were selected when fulfilling the inclusion criteria. Articles were included if they fulfilled the World Health Organization (WHO), Centers for Disease Control (CDC) definitions of MIS-C, or our proposed definition. RESULTS Sixteen reports of MIS-N including 47 neonates meeting MIS-N criteria were identified. Presentation included cardiovascular compromise (77%), respiratory involvement (55%), and fever in (36%). Eighty-three percent of patients received steroids, and 76% received immunoglobulin. Respiratory support was provided to 60% of patients and inotropes to 45% of patients. Five (11%) neonates died. CONCLUSION The common presentation of MIS-N included cardiorespiratory compromise with the possibility of high mortality. Neonates with MIS-N related to SARS-CoV-2 may be at higher risk of adverse outcomes.
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Affiliation(s)
- Lana A Shaiba
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Neonatology, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Kiran More
- Neonatal Consultant, SIDRA Medicine, Ar-Rayyan, Qatar
| | - Adnan Hadid
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Neonatology, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Rana Almaghrabi
- Pediatric Infectious Disease, Pediatric Department, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Munira Al Marri
- Pediatric Rheumatology, Pediatric Department, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Mahdi Alnamnakani
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Neonatology, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Prakesh Shah
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada.,Department of Pediatrics, Toronto University, Toronto, Ontario, Canada.,Maternal-Infant Care Research Center, Mount Sinai Hospital, Toronto, Ontario, Canada
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Multisystem inflammatory syndrome in neonates (MIS-N) associated with SARS-CoV2 infection: a case series. Eur J Pediatr 2022; 181:1883-1898. [PMID: 35031848 PMCID: PMC8759431 DOI: 10.1007/s00431-022-04377-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 02/06/2023]
Abstract
Multisystem inflammatory syndrome in neonates (MIS-N) is hypothesised to be caused either following transplacental transfer of SARS-CoV2 antibodies or antibodies developed in the neonate after infection with SARS-CoV-2. In this paper, we aim to discuss the clinical manifestations, laboratory features, and management of neonates diagnosed with MIS-N. We collated information from five participating hospitals in western India. A cohort of newborn infants presenting with multi-system involvement, along with the presence of SARS-CoV2 antibodies, was identified. Current proposed international diagnostic criteria for MIS-N were used to group the cases into three categories of Most likely, Possible, and Unlikely MIS-N. A total of 20 cases were reported with a diagnosis of MIS-N, all having high titres of SARS CoV2 IgG antibodies and negative for SARS CoV2 antigens. Most likely MIS (n = 5) cases presented with respiratory distress (4/5), hypotension and shock (4/5), and encephalopathy (2/5). Inflammatory markers like CRP (1/5), Procalcitonin (1/5), Ferritin (3/5), D-dimer (4/5), and LDH (2/5) were found to be elevated, and four of them had significantly high levels of proBNP. The majority of them (4/5) responded to immunomodulators, three neonates were discharged home, and two died. Possible MIS infants (n = 9) presented with fever (7/9), respiratory distress (4/9), refusal to feed (6/9), lethargy (5/9), and tachycardia (3/9). ProBNP as a marker of cardiac dysfunction was noted to be elevated in four (4/9) infants, correlating with abnormal echocardiography findings in two. In the Unlikely MIS (n = 6) category, three (3/6) infants presented with respiratory distress, one (1/6) with shock and cardiac dysfunction, and only one (1/6) with fever. All of them had elevated inflammatory markers. However, there were other potential diagnoses that could have been responsible for the clinical scenarios in these six cases. Conclusion: MIS-N requires a high index of suspicion and should be considered in a neonate presenting with two or more systems involvement, in the presence of SARS-CoV2 antibodies, along with elevated inflammatory markers, once other common neonatal conditions have been ruled out. What is Known: • Severe acute respiratory syndrome coronavirus-2 (SARS-CoV2) associated multisystem inflammatory syndrome in children (MIS-C) is widely reported in paediatric population, however only few reports of newborn affection. • MIS-C is known to cause by virus-induced post-infective antibody mediated immune dysregulation with severe multi-system affection. What is New: • MIS-N may present with varied clinical manifestations with multi-system involvement of variable severity with milder disease in term and severe disease with cardiac dysfunction in preterm newborns. • Multisystem inflammatory syndrome in newborns (MIS-N) is postulated to occur following immune dysregulation associated with transplacental transfer of SARS-CoV2 antibodies or antibodies developed in the neonate after infection with SARS-CoV-2.
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