COVID-19-associated Severe Multisystem Inflammatory Syndrome in Children with Encephalopathy and Neuropathy in an Adolescent Girl with the Successful Outcome: An Unusual Presentation

Neurological Manifestations of Coronavirus Disease 2019 and Monkeypox in Pediatric Patients and Their Management: A State-of-the-Art Systematic Review

BACKGROUND

There is an increasing number of cases being reported of neurological manifestations of Coronavirus disease 2019 (COVID-19) infection and monkeypox, both during the course of the infection and as a presenting symptom. We aim to review the neurological manifestations of COVID-19 and monkeypox in pediatric patients and their management.

METHODS

We conducted a systematic review that included cohort studies and case series or reports involving a pediatric population of patients with a confirmed COVID-19 or monkeypox infection and their neurological manifestations. We searched the following electronic databases: PubMed, EMBASE, and Scopus.

RESULTS

From 1136 articles identified, 127 studies were included. Headache, stroke, Guillain-Barré syndrome, seizure, nerve palsies, and multisystem inflammatory syndrome in children were the most common neurological symptoms caused by COVID-19, whereas encephalitis was commonly seen in patients with monkeypox. Rare neurological manifestations of COVID-19 included cerebral venous sinus thrombosis, plexopathies, demyelinating disorders, encephalitis, etc., and rare neurological manifestations of monkeypox included headache.

CONCLUSIONS

Our review highlights the importance of investigating possible neurological manifestations and closely monitoring these patients to develop a better understanding of the treatment strategies that can be adopted.

Coronavirus disease 2019 (COVID-19) in pediatric patients with autoimmune disorders

Coronavirus disease 2019 (COVID-19) infection in pediatric patients with autoimmune disorders is an area of particular concern since autoimmune diseases can increase the risk of complications from the virus. However, as the infection rates were significantly higher in adults compared to children, this at-risk group of children was relatively underrepresented in COVID-19 research. The underlying inflammatory basis of autoimmune diseases and medications that affect the immune system, such as corticosteroids, could increase the risk of severe infection in this group of patients. COVID-19 could reportedly lead to a variety of alterations in the immune system. These alterations are plausibly dependent on the underlying immune-mediated diseases or prior use of immunomodulatory drugs. Patients administrating immunomodulatory agents, especially those with severe immune system dysregulation, can experience severe symptoms of COVID-19. Nonetheless, receiving immunosuppressive medications can benefit patients by preventing cytokine storm syndromes and lung tissue damage, threatening outcomes of COVID-19.

CONCLUSION

In this review, we sought to evaluate the currently available literature on the impact of autoimmune disease and its related therapeutic approaches on the COVID-19 infection course of disease in children and reflect on the gaps in the evidence and the need for further research in this field.

WHAT IS KNOWN

• The majority of children infected with COVID-19 demonstrate mild to moderate clinical manifestations compared to adults, whereas those children with pre-existing autoimmune conditions are at a greater risk for severe symptoms. •There is currently limited understanding of the pathophysiology and clinical outcomes of COVID-19 in pediatric patients with autoimmune disorders due to scattered reports and inadequate evidence.

WHAT IS NEW

• Generally, children with autoimmune disorders have more unfavorable outcomes than healthy children; yet, the severity is not extreme, and is highly dependent on their autoimmune disease type and severity, as well as the medication they are taking.

Possible association between Guillain‑Barré syndrome and SARS‑CoV‑2 infection in children: A case report and literature review

Neurological manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have been reported in adults and in children, varying from mild to more debilitant symptoms, including fatigue, headache and dizziness. A series of studies have revealed a possible association between Guillain-Barré syndrome (GBS), the most common cause of acute flaccid paralysis at all ages, and SARS-CoV-2 infection. Case reports of novel coronavirus disease 2019 (COVID-19)-associated GBS mainly include adult patients, while only a few pediatric cases have been reported. The present study describes a case of GBS in an Italian 9-year-old girl with previous SARS-CoV-2 infection as a possible trigger, and also conducts a literature review on pediatric COVID-19-associated GBS cases.

Neurological manifestations of Kawasaki disease and multisystem inflammatory syndrome in children associated with COVID-19: A comparison of two different clinical entities

Kawasaki disease (KD) is one of the most frequent idiopathic vasculitis in children, affecting medium- and small-sized vessels. Multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19 has recently emerged as a new systemic hyperinflammatory condition affecting children some weeks after an acute COVID-19 infection. KD and MIS-C share different aspects and differ in many others: patients affected by MIS-C are usually older, with prominent gastrointestinal manifestations, diffuse adenopathy, extensive conjunctivitis, myocardial damage, leukopenia, and thrombocytopenia at the laboratory exams. Both conditions can present neurological complications. The aim of this manuscript is to provide a narrative review of neurological involvement in KD and MIS-C. A comprehensive review literature has been performed, and the main clinical features have been analyzed, contributing to neurological differential diagnosis.

COVID-19-associated Multisystem Inflammatory Syndrome in Children: A Multicentric Retrospective Cohort Study

Background

Multisystem inflammatory syndrome in children (MIS-C) associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a new entity affecting a small percentage of children during the COVID-19 pandemic.

Materials and methods

Demography, clinical, and laboratory variables of children admitted from April to September 2020 with MIS-C were studied retrospectively at eight hospitals in Delhi, India.

Results

We identified 120 patients [median age: 7 years (interquartile range (IQR): 4–10)] with male-to-female ratio of 2.3:1. Overall, 73 out of 120 children (60.8%) presented with shock, 63 (52.5%) required inopressor support, and 51 (43%) required respiratory support. We categorized the cohort into three observed clinical phenotypes: MIS-C with shock (n = 63), MIS-C with Kawasaki disease (KD) (n = 23), and MIS-C without shock and KD (n = 34). Atypical presentations were hypothermia, orchitis, meningoencephalitis, demyelination, polyneuropathy, pancreatitis, and appendicitis. Ninety-four percent had laboratory evidence of SARS-CoV-2 (78.3%, seropositive and 15.8%, RT-PCR positive). The median C-reactive protein (CRP) was 136 mg/L (IQR, 63.5–212.5) and ferritin was 543 ng/mL (IQR, 225–1,127). More than 90% received immunomodulatory therapy (intravenous immunoglobulins and/or steroids) with an excellent outcome (96% survived). CRP and absolute neutrophil count (ANC) were correlated statistically with severity.

Conclusion

MIS-C data from Delhi are presented. Rising CRP and ANC predict the severe MIS-C.

How to cite this article

Mehra B, Pandey M, Gupta D, Oberoi T, Jerath N, Sharma R, et al. COVID-19-associated Multisystem Inflammatory Syndrome in Children: A Multicentric Retrospective Cohort Study. Indian J Crit Care Med 2021;25(10):1176–1182.

The First Case of Multisystem Inflammatory Syndrome in Children Successfully Treated with Combined Therapies Including Extracorporeal Membrane Oxygenation and Plasmapheresis

Multisystem inflammatory syndrome in children (MIS-C) is a severe disease that can lead to death. There is no definitive treatment for MIS-C yet. It has been reported that intravenous immunoglobulin, intravenous methylprednisolone, fluid supplements, antibiotics, inotropics, extracorporeal membrane oxygenation (ECMO), plasmapheresis, biological therapy, and anticoagulation therapy can be used for treatment. In this article, we presented an 8-year-old girl child patient who survived due to timely administered ECMO and combined therapies including plasmapheresis without any sequela despite her life-threatening condition due to MIS-C.

Acute Disseminated Encephalomyelitis in a 2-Year-Old Patient Following COVID-19

This report presents the case of acute disseminated encephalomyelitis in a 2-year-old patient following a positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test. She presented with ataxic gait, truncal ataxia, and reduced coordination following 10 days of intermittent fever and lethargy. She did not have any respiratory symptoms. Magnetic resonance imaging of the brain and spine showed widespread T2 high signal within the gray and white matters and within the spinal cord. She was treated with intravenous methylprednisolone followed by tapering oral prednisolone; this led to resolution of her neurological symptoms. This case highlights that neurological complications can occur secondary to SARS-CoV-2 infection.

Spectrum of neuroimaging mimics in children with COVID-19 infection

Coronavirus disease 2019 (COVID-19), caused by SARS-CoV-2, has affected over 200 million people globally (including over 30 million people in the United States), with children comprising 12.9% of reported cases in the United States. In children, COVID-19 infection appears to be associated with mild respiratory symptoms; however, serious neurological complications may occur in conjunction with multisystem inflammatory syndrome. A wide spectrum of neurological diseases have been observed in children with COVID-19 infection including encephalitis, acute necrotizing encephalopathy, acute disseminated encephalomyelitis, cytotoxic lesion of the callosal splenium, posterior reversible encephalopathy syndrome, venous sinus thrombosis, vasculitis and infarction, Guillain-Barré syndrome, transverse myelitis, and myositis. This review describes the characteristic magnetic resonance neuroimaging features of these diseases and their differentiations from other imaging mimics. In addition, we review the possible pathophysiology underlying the association between these diseases and COVID-19-infection. As new SARS-CoV-2 variants emerge and COVID-19 infection continues to spread worldwide, pediatricians, radiologists, and first-line care givers should be aware of possible neurological diseases associated with COVID-19 infection when these reported neuroimaging patterns are observed in children during this pandemic.

Neuro-COVID Requires Comprehensive Work-up

Finsterer J, Scorza FA. Neuro-COVID Requires Comprehensive Work-up. Indian J Crit Care Med 2021;25(8):956-957.

MIS-C is a Clinically Different Entity from Acute COVID-19 in Adults

Mehra B, Aggarwal V, Kumar P, Gupta D, Kundal M, Kumar A, et al. MIS-C is a Clinically Different Entity from Acute COVID-19 in Adults. Indian J Crit Care Med 2021;25(8):954–955.

SARS-CoV-2-associated acute disseminated encephalomyelitis: a systematic review of the literature

The literature on cases of acute disseminated encephalomyelitis (ADEM) associated with SARS-CoV-2 infection has been rapidly increasing. However, the specific clinical features of ADEM associated with SARS-CoV-2 (SARS-CoV-2-ADEM) have not been previously evaluated. We screened all articles resulting from a search of PubMed and Web of Science databases looking for reports of ADEM published between December 01, 2019, and June 5, 2021. Of the 48 ADEM cases identified from 37 studies, 34 (71%) had ADEM while 14 (29%) were of AHLE. RT-PCR for SARS-CoV-2 was positive in 83% (n = 19) of patients. 26 patients (54%) were male, and 18 patients (38%) were female, with a male to female sex ratio of 1.4:1; median age was 44 (1.4–71) years. 9 patients (19%, 9/48) were children. Of the 9 children patients, their median age was 9 years (range 1.4–13 years), 6 patients (67%) were female, and 2 patients (22%) were male, with a female to male sex ratio of 3:1.39 patients (81%) was performed CSF analysis. PCR for SARS-CoV-2 tested positive in 3 patients (14%, 3/22) on CSF sample. 31 (64%) of patients had a poor outcome on discharge from hospital. Five (10%) patients died in hospital. Compared to classic ADEM, SARS-CoV-2-ADEM have a more longer duration between the onset of the antecedent infective symptoms and the start of ADEM symptoms, the older age distribution of the patients, relatively poor outcome, a lower full recovery rate, a more frequently brain lesions involved the periventricular white matter and corpus callosum, and less frequently affected the deep gray matter. Taken together, the present comprehensive review reveals that although rare, ADEM can be associated with SARS-CoV-2 infection. SARS-CoV-2-ADEM seems to share most features of classic ADEM, with moderate discrepancies from the classical ADEM.

Innate Immunity in Children and the Role of ACE2 Expression in SARS-CoV-2 Infection

COVID-19 (Coronavirus Disease 2019) is an emerging viral disease caused by the coronavirus SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), which leads to severe respiratory infections in humans. The first reports came in December 2019 from the city of Wuhan in the province of Hubei in China. It was immediately clear that children developed a milder disease than adults. The reasons for the milder course of the disease were attributed to several factors: innate immunity, difference in ACE2 (angiotensin-converting enzyme II) receptor expression, and previous infections with other common coronaviruses (CovH). This literature review aims to summarize aspects of innate immunity by focusing on the role of ACE2 expression and viral infections in children in modulating the antibody response to SARS-CoV-2 infection. This review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles deemed potentially eligible were considered, including those dealing with COVID-19 in children and providing more up-to-date and significant data in terms of epidemiology, prognosis, course, and symptoms, focusing on the etiopathogenesis of SARS-CoV-2 disease in children. The bibliographic search was conducted using the search engines PubMed and Scopus. The following search terms were entered in PubMed and Scopus: COVID-19 AND ACE2 AND Children; COVID-19 AND Immunity innate AND children. The search identified 857 records, and 18 studies were applicable based on inclusion and exclusion criteria that addressed the issues of COVID-19 concerning the role of ACE2 expression in children. The scientific literature agrees that children develop milder COVID-19 disease than adults. Milder symptomatology could be attributed to innate immunity or previous CovH virus infections, while it is not yet fully understood how the differential expression of ACE2 in children could contribute to milder disease.

Long COVID in children and adolescents

BACKGROUND

To identify the prevalence and also the full spectrum of symptoms/complaints of children and adolescents who are suffering from long COVID. Furthermore, we investigated the risk factors of long COVID in children and adolescents.

METHODS

All consecutive children and adolescents who were referred to the hospitals anywhere in Fars province, Iran, from 19 February 2020 until 20 November 2020 were included. All patients had a confirmed diagnosis of COVID-19. In a phone call to patients/parents, at least 3 months after their discharge from the hospital, we obtained their current status and information if their parents agreed to participate.

RESULTS

In total, 58 children and adolescents fulfilled the inclusion criteria. Twenty-six (44·8%) children/adolescents reported symptoms/complaints of long COVID. These symptoms included fatigue in 12 (21%), shortness of breath in 7 (12%), exercise intolerance in 7 (12%), weakness in 6 (10%), and walking intolerance in 5 (9%) individuals. Older age, muscle pain on admission, and intensive care unit admission were significantly associated with long COVID.

CONCLUSIONS

Long COVID is a frequent condition in children and adolescents. The scientific community should investigate and explore the pathophysiology of long COVID to ensure that these patients receive appropriate treatments for their condition.