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Root-Bernstein R. From Co-Infections to Autoimmune Disease via Hyperactivated Innate Immunity: COVID-19 Autoimmune Coagulopathies, Autoimmune Myocarditis and Multisystem Inflammatory Syndrome in Children. Int J Mol Sci 2023; 24:ijms24033001. [PMID: 36769320 PMCID: PMC9917907 DOI: 10.3390/ijms24033001] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/21/2023] [Accepted: 01/23/2023] [Indexed: 02/05/2023] Open
Abstract
Neutrophilia and the production of neutrophil extracellular traps (NETs) are two of many measures of increased inflammation in severe COVID-19 that also accompany its autoimmune complications, including coagulopathies, myocarditis and multisystem inflammatory syndrome in children (MIS-C). This paper integrates currently disparate measures of innate hyperactivation in severe COVID-19 and its autoimmune complications, and relates these to SARS-CoV-2 activation of innate immunity. Aggregated data include activation of Toll-like receptors (TLRs), nucleotide-binding oligomerization domain (NOD) receptors, NOD leucine-rich repeat and pyrin-domain-containing receptors (NLRPs), retinoic acid-inducible gene I (RIG-I) and melanoma-differentiation-associated gene 5 (MDA-5). SARS-CoV-2 mainly activates the virus-associated innate receptors TLR3, TLR7, TLR8, NLRP3, RIG-1 and MDA-5. Severe COVID-19, however, is characterized by additional activation of TLR1, TLR2, TLR4, TLR5, TLR6, NOD1 and NOD2, which are primarily responsive to bacterial antigens. The innate activation patterns in autoimmune coagulopathies, myocarditis and Kawasaki disease, or MIS-C, mimic those of severe COVID-19 rather than SARS-CoV-2 alone suggesting that autoimmunity follows combined SARS-CoV-2-bacterial infections. Viral and bacterial receptors are known to synergize to produce the increased inflammation required to support autoimmune disease pathology. Additional studies demonstrate that anti-bacterial antibodies are also required to account for known autoantigen targets in COVID-19 autoimmune complications.
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Cardiological Monitoring – A Cornerstone for Pediatric Inflammatory Multisystem Syndrome Temporally Associated with COVID-19 Outcome: A Case Report and a Review from the Literature. J Crit Care Med (Targu Mures) 2022; 8:273-278. [DOI: 10.2478/jccm-2022-0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 08/30/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Pediatric inflammatory multisystem syndrome temporally associated with COVID-19 (PIMS-TS) is a rare life-threatening condition requiring a complex management and multidisciplinary approach, whose outcome depends on the early diagnosis.
Case report
We report the case of a 2 years and-5-month-old boy admitted in our clinic for fever, abdominal pain and diarrhea. The clinical exam at the time of admission revealed influenced gen-eral status, bilateral palpebral edema and conjunctivitis, mucocutaneous signs of dehydration, and abdominal tenderness at palpation. The laboratory tests performed pointed out lymphopenia, thrombocytopenia, anemia, elevated C-reactive protein – CRP, erythrocyte sedimentation rate and ferritin levels, hyponatremia, hypopotassemia, hypertriglyceridemia, elevated D-dimer, in-creased troponin and NT-proBNP. The real-time polymerase chain reaction (RT-PCR) test for SARS-CoV-2 infection was negative, but the serology was positive. Thus, established the diagnosis of PIMS-TS. We initiated intravenous immunoglobulin, empirical antibiotic, anticoagulation therapy and symptomatic drugs. Nevertheless, the clinical course and laboratory parameters worsened, and the 2nd echocardiography pointed out minimal pericardial effusion, slight dilation of the left cavities, dyskinesia of the inferior and septal basal segments of the left ventricle (LV), and LV systolic dysfunction. Therefore, we associated intravenous methylprednisolone, angiotensin converting enzyme inhibitors, spironolactone and hydrochlorothiazide, with outstanding favorable evolution.
Conclusions
Echocardiographic monitoring might be a lifesaving diagnostic tool in the management of PIMS-TS.
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Meliț LE, Mărginean CO, Fleșeriu T, Văsieșiu AM, Ghiga DV, Koller AMR. COVID-19 and PIMS-Two Different Entities, but the Same Trigger. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9091348. [PMID: 36138657 PMCID: PMC9497494 DOI: 10.3390/children9091348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 09/01/2022] [Accepted: 09/02/2022] [Indexed: 11/16/2022]
Abstract
COVID-19 and PIMS represent two novel pathologies that have challenged the medical world during the last two years on account of their being very similar, but yet very different. Our aim was to comparatively assess children with SARS-CoV-2 infection and PIMS in terms of symptoms, clinical findings, laboratory parameters, echocardiography, and evolution. Our retrospective study included 46 children with COVID-19 (group 1), and 20 children with confirmed PIMS (group 2). We found no significant differences in terms of age, gender, and originating area between the two groups. We noticed that fever was significantly more common in the PIMS group as compared to COVID-19 group (p = 0.0217). In terms of laboratory parameters, increased bilirubin and creatinine were significantly more frequent in children with COVID-19 (p = 0.0064/p = 0.0064), while hypoalbuminemia and elevated ESR were significantly more common in those with PIMS (p < 0.0001/p = 0.0127). Moreover, prognosis parameters such as D-dimers, NT-proBNP, and CK-MB were also found to be significantly higher in the PIMS group as compared to COVID-19 group (p = 0.0003/p = 0.0182/p = 0.0007). In terms of complications, most were identified in PIMS group, among which cardiac and liver impairment along with dehydration were significantly more common in children diagnosed with PIMS as compared to those detected with COVID-19. Similarly, children with PIMS had a significantly higher chance to have pathological echocardiography changes. Although difficult, the distinction between COVID-19 and PIMS is crucial for the patient’s long-term outcome.
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Affiliation(s)
- Lorena Elena Meliț
- Department of Pediatrics I, “George Emil Palade” University of Medicine, Pharmacy, Science, and Technology of Târgu Mureș, Gheorghe Marinescu Street No. 38, 540136 Târgu Mureș, Romania
| | - Cristina Oana Mărginean
- Department of Pediatrics I, “George Emil Palade” University of Medicine, Pharmacy, Science, and Technology of Târgu Mureș, Gheorghe Marinescu Street No. 38, 540136 Târgu Mureș, Romania
- Correspondence:
| | - Tudor Fleșeriu
- Department of Infectious Disease, County Clinical Hospital Târgu Mureș, Gheorghe Doja Street No. 89, 540394 Târgu Mureș, Romania
| | - Anca Meda Văsieșiu
- Department of Infectious Disease, “George Emil Palade” University of Medicine, Pharmacy, Science, and Technology of Târgu Mureș, Gheorghe Marinescu Street No. 38, 540136 Târgu Mureș, Romania
| | - Dana Valentina Ghiga
- Department of Scientific Medical Research Methodology, “George Emil Palade” University of Medicine, Pharmacy, Science and Technology from Târgu Mureș, Gheorghe Marinescu Street No. 38, 540136 Târgu Mureș, Romania
| | - Ana-Maria Roxana Koller
- Department of Pediatrics I, Emergency County Clinical Hospital Târgu Mureș, Gheorghe Marinescu Street No. 50, 540136 Târgu Mureș, Romania
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Mărginean CO, Meliţ LE, Săsăran MO. Pediatric Obesity-A Potential Risk Factor for Systemic Inflammatory Syndrome Associated to COVID-19, a Case Report. Front Pediatr 2021; 9:681626. [PMID: 34123977 PMCID: PMC8192702 DOI: 10.3389/fped.2021.681626] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 04/30/2021] [Indexed: 12/14/2022] Open
Abstract
The well-documented systemic inflammation associated to pediatric obesity might act as an augmenting factor for other inflammatory conditions, such as pediatric inflammatory multisystem syndrome (PIMS) associated to COVID-19. We report the case of 9-year-old boy admitted in our clinic for fever, anorexia, and fatigability. The clinical exam revealed influenced general status, palpebral edema, non-exudative conjunctivitis, and abdominal tenderness. The patient weighed 45 kg. The laboratory tests at the time of admission pointed out anemia, lymphopenia; elevated inflammatory biomarkers, NT-proBNP, D-dimers, and troponin; high liver enzymes and lactate dehydrogenase levels, as well as hypoalbuminemia. The patient tested positive for both RT-PCR and serology for SARS-CoV-2 infection. We initiated intravenous immunoglobulin and methylprednisolone, associated with empirical antibiotic, anticoagulation therapy, and symptomatic treatment. The patient was discharged on the 7th day of admission with the recommendation to continue enoxaparin and methylprednisolone at home tapering the dose for the next week. The subclinical inflammatory status associated to obesity might serve as an unfortunate trigger factor for the development of COVID-19 severe forms in children. Therefore, clinicians should be aware that children with obesity and COVID-19 represent a peculiar group that should be closely monitored and thoroughly assessed in order to preempt life-threatening complications, such as PIMS.
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Affiliation(s)
- Cristina Oana Mărginean
- Department of Pediatrics I, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureş, Târgu Mureş, Romania
| | - Lorena Elena Meliţ
- Department of Pediatrics I, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureş, Târgu Mureş, Romania
| | - Maria Oana Săsăran
- Department of Pediatrics III, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureş, Târgu Mureş, Romania
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Chang LS, Kuo HC. The role of corticosteroids in the treatment of Kawasaki disease. Expert Rev Anti Infect Ther 2020; 18:155-164. [DOI: 10.1080/14787210.2020.1713752] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Ling-Sai Chang
- Department of Pediatrics and Kawasaki Disease Center, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City, Taiwan
| | - Ho-Chang Kuo
- Department of Pediatrics and Kawasaki Disease Center, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City, Taiwan
- Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung City, Taiwan
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Mărginean CO, Meliţ LE, Simu I, Săsăran MO. The Association Between Mycoplasma pneumoniae and Chlamydia pneumoniae, a Life-Threatening Condition in Small Children-A Case Report and a Review of the Literature. Front Pediatr 2020; 8:558941. [PMID: 33240829 PMCID: PMC7683434 DOI: 10.3389/fped.2020.558941] [Citation(s) in RCA: 2] [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: 09/08/2020] [Accepted: 10/26/2020] [Indexed: 12/28/2022] Open
Abstract
Mycoplasma pneumoniae (MP) and Chlamydia pneumoniae (CP) are two atypical pathogens that may result in mild, moderate or severe acute respiratory infections. We report the case of a 2 years and 9-month-old male child admitted with prolonged fever, dry cough, and shortness of breath for which he underwent symptomatic treatment. The laboratory tests showed leukocytosis with neutrophilia, anemia, and elevated inflammatory biomarkers and the thoracic radiography revealed pleural effusion raising the suspicion of inferior right pneumonia. Although we the initial evolution was favorable being treated with 3rd class cephalosporin and Oxacillin, on the 8th day of admission the fever and the acute phase reactants levels increased as well as the quantity of the pleural effusion, requiring surgical drainage. We ruled out lung tuberculosis, but we identified positive IgM for both MP and CP. Based on these findings we changed the antibiotic therapy on Levofloxacin for 10 days with favorable evolution. MP and CP are two atypical pathogen that are difficult to be diagnosed due to their slow-growing pattern. Despite their self-limiting feature, the association between them might carry a vital risk in small children, especially in the lack of a proper and timely diagnosis.
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Affiliation(s)
- Cristina Oana Mărginean
- Department of Pediatrics I, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureş, Târgu Mureş, Romania
| | - Lorena Elena Meliţ
- Department of Pediatrics I, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureş, Târgu Mureş, Romania
| | - Iunius Simu
- Department of Radiology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureş, Târgu Mureş, Romania
| | - Maria Oana Săsăran
- Department of Pediatrics III, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureş, Târgu Mureş, Romania
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Abstract
RATIONALE Extremes of age is an important risk factor for the development of coronary arteries aneurysms (CAAs) associated to Kawasaki disease (KD) along with male gender, prolonged fever and a delay in diagnosis or treatment. PATIENT CONCERNS We report two cases of KD in the extremes of age, a 5-month-old male infant and a 9-year-old child in order to underline the features of this disorder outside the typical age range of 1 to 4 years. The 5-month-old male was admitted in our clinic for generalized polymorphous exanthema and fever for approximately 7 days. The laboratory test pointed out leukocytosis and increased inflammatory biomarkers. The 9-year-old male child was admitted in our clinic for fever and submandibular adenopathy. The onset was approximately 5 days before the admission with a sudden development of unilateral, painless, submandibular lymphadenopathy for which the ENT specialist recommended antibiotics and nonsteroid anti-inflammatory drugs. In the 2nd day of admission, he presented severe desquamation of hands and soles. DIAGNOSIS Both cases were diagnosed with KD. The echocardiography showed no cardiac impairment in the infant, while in the older patient it revealed mild dilation of the left coronary artery. INTERVENTIONS Both patients received intravenously immunoglobulin and pulsed methylprednisolone. OUTCOMES The evolution was favorable in both cases, but in the infant, the C-reactive protein levels persisted mildly elevated for approximately 2 months after the diagnosis. LESSONS The peculiarities of KD in the extremes of age are related to a higher frequency of incomplete features and an increased incidence of coronary artery lesions resulting in a delay of the diagnosis, and subsequent poorer outcomes.
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Affiliation(s)
| | | | - Maria Oana Mărginean
- Department of Paediatric, University of Medicine, Pharmacy, Sciences and Technology of Târgu Mures, Gheorghe Marinescu Street No. 38, Târgu Mures 540136, Romania
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