Kawasaki Disease in the Time of COVID-19 and MIS-C: The International Kawasaki Disease Registry

BACKGROUND

Patients with multisystem inflammatory syndrome in children (MIS-C) and Kawasaki disease (KD) have overlapping clinical features. We compared demographics, clinical presentation, management, and outcomes of patients according to evidence of previous SARS-CoV-2 infection.

METHODS

The International Kawasaki Disease Registry (IKDR) enrolled KD and MIS-C patients from sites in North, Central, and South America, Europe, Asia, and the Middle East. Evidence of previous infection was defined as: Positive (household contact or positive polymerase chain reaction [PCR]/serology), Possible (suggestive clinical features of MIS-C and/or KD with negative PCR or serology but not both), Negative (negative PCR and serology and no known exposure), and Unknown (incomplete testing and no known exposure).

RESULTS

Of 2345 enrolled patients SARS-CoV-2 status was Positive for 1541 (66%) patients, Possible for 89 (4%), Negative for 404 (17%) and Unknown for 311 (13%). Clinical outcomes varied significantly among the groups, with more patients in the Positive/Possible groups presenting with shock, having admission to intensive care, receiving inotropic support, and having longer hospital stays. Regarding cardiac abnormalities, patients in the Positive/Possible groups had a higher prevalence of left ventricular dysfunction, and patients in the Negative and Unknown groups had more severe coronary artery abnormalities.

CONCLUSIONS

There appears to be a spectrum of clinical features from MIS-C to KD with a great deal of heterogeneity, and one primary differentiating factor is evidence for previous acute SARS-CoV-2 infection/exposure. SARS-CoV-2 Positive/Possible patients had more severe presentations and required more intensive management, with a greater likelihood of ventricular dysfunction but less severe coronary artery adverse outcomes, in keeping with MIS-C.

A Case With Typical Clinical Manifestations of Kawasaki Disease and Multisystem Inflammatory Syndrome in Children Temporally Associated With SARS-CoV-2 Infection

Whether Kawasaki disease (KD) and multisystem inflammatory syndrome in children (MIS-C) temporally associated with SARS-CoV-2 infection are two distinct syndromes or part of the same spectrum is not fully understood. In this report, we present the case of a five-year-old boy who fully satisfied the diagnostic criteria for both KD and MIS-C associated with SARS-CoV-2 infection. He tested positive for SARS-CoV-2 on an oropharyngeal swab antigen test approximately four weeks before the onset of symptoms. He had severe abdominal pain. Abdominal ultrasound showed ascites. He improved with initial (2 g/kg) and additional (1 g/kg) intravenous immunoglobulin (IVIG) therapy and intravenous methylprednisolone (initial dose, 2 mg/kg/day). Our case may lead to clarification of the pathogenesis of both diseases. Additionally, the recent history of SARS-CoV-2 infection for children with prolonged fever and no clear focus of infection should be checked, and, if present, clinicians should consider MIS-C temporally associated with SARS-CoV-2 infection. IVIG therapy is important for children with MIS-C who meet the diagnostic criteria for KD, even if diagnosed with MIS-C.

Characteristics and Outcomes of Children With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection Admitted to a Quaternary Hospital: A Single-Center Experience

Objectives In the setting of the recent global pandemic, children infected with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus causing the coronavirus disease 2019 (COVID-19) presented to our hospital with a variety of symptoms ranging from mild to severe disease including multiorgan dysfunction. Our objective was to study the clinical profile, risk factors, complications, and outcomes in pediatric patients admitted to our center with SARS-CoV-2 infection. Methods This retrospective observational study was conducted at a large quaternary center in Riyadh between May 2020 and September 2021. The study population was comprised of children between 0 and ≤14 years with SARS-CoV-2 suspicion or positivity. Results One hundred and fifty-six children were included in the study, the majority of whom were 1-10 years old. One hundred and twenty of them (76.93%) were SARS-CoV-2 positive. Fifty-nine patients (37.18%) were labelled as multisystem inflammatory syndrome in children (MIS-C) based on clinical and lab criteria, of whom 35 (22.44%) tested SARS-CoV-2 positive. Hematological disease was found to be the most common comorbidity, followed by neurological and chronic lung diseases. The most common symptoms encountered were fever, cough, vomiting, fatigue, and diarrhea. Eighty patients (51%) required pediatric intensive care unit (PICU) admission (length of stay: 5-12 days), among whom 32 (40%) required ventilation, 26 (32.5%) needed hemodynamic support, and three patients (3.75%) underwent continuous renal replacement therapy (CRRT). The overall mortality rate was 4.5% (seven patients) among the studied population. The most frequent lab abnormalities were found to be elevated serum ferritin, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and lactate dehydrogenase (LDH) levels. Ninety-one percent received antibiotics, and prophylactic anticoagulant was used in 32%. In the MIS-C subset, 80.5% received steroids, 71.43% intravenous immunoglobulin (IVIG), and 5.17% (three patients) tocilizumab. Conclusion The SARS-CoV-2 infection presented with a range of severity among our cohort of children; however, most of the patients responded well to appropriate supportive treatment. A slight male preponderance was noted. The most common symptoms encountered were fever, cough, vomiting, fatigue, and diarrhea. Inflammatory markers such as ESR, CRP, serum ferritin, and LDH levels were found to be elevated in nearly all patients. Raised serum lactate and serum creatinine and lymphopenia were of significant note in patients with MIS-C. Higher mortality rates were observed in patients with MIS-C and those requiring respiratory support. In addition to these two factors, the presence of comorbidities and the need for CRRT were associated with prolonged PICU length of stay.

Cardiovascular Manifestations of Multisystem Inflammatory Syndrome in Children (MIS-C) Associated With COVID-19

Since 2019, the global pandemic caused by the SARS-CoV-2 virus, also known as COVID-19, has dramatically affected every aspect of health and society. With wide-ranging socio-economic ramifications and the morbidity/mortality associated with the disease, a lot of research has been done on this disease. With recent surges and new variants of the COVID-19 virus, we must have regularly updated information on this disease to effectively manage this disease and to maximize outcomes for patients. Worldwide data, so far, has suggested that children have milder or asymptomatic acute infectious phase, most often presenting with mild upper respiratory infection (URI) symptoms compared to the adult population. However, in the post-acute phase, it was observed that children presented with a syndrome that strongly resembled Kawasaki's disease (KD), and like in KD, they could potentially develop severe life-threatening complications. The significant difference between KD and this syndrome is the association with COVID-19 infection. This syndrome was observed to affect almost all organ systems including cardiovascular, gastrointestinal, and integumentary and was later named multisystem inflammatory syndrome in children (MIS-C) by the Pediatric Intensive Care Society in April 2020. The cardiovascular manifestations of this clinical entity have been associated with significant morbidity and mortality. This review is an attempt to give consolidated information from the studies done so far about the cardiac changes that occur from SARS-CoV-2 infection/MIS-C.

Expanding the Differential for Alternative Diagnoses in the Workup of Multisystem Inflammatory Syndrome in Children

BACKGROUND

Multisystem inflammatory syndrome in children (MIS-C) is a rare inflammatory syndrome associated with SARS-CoV-2 infection. Children are increasingly admitted for MIS-C evaluation, but instead found to have alternative diagnoses.

METHODS

Retrospective study of all pediatric patients <21 years of age hospitalized between August 1, 2020, and July 31, 2021, with clinical concern for MIS-C at the time of presentation were identified through use of an institutional computerized MIS-C order entry set. Final diagnoses were then collected through primary review of the medical record from the time of initial presentation through 1-month postdischarge.

RESULTS

Of 359 cases identified through the MIS-C order entry set, 126 (35.1%) met criteria for MIS-C, 28 had Kawasaki Disease (KD) (7.8%), and 11 cases met criteria for both MIS-C and KD (3.1%), leaving 194 (54.0%) patients ruled out and categorized as "MIS-C mimickers." Infectious diagnoses were the most common MIS-C mimickers (78.9%). Of the infectious etiologies, bacterial (51.0%) and viral (52.3%) etiologies were seen with similar frequency.

CONCLUSIONS

We describe MIS-C mimickers spanning multiple subspecialties, with infectious etiologies predominating, which can aid clinicians in the consideration of diagnostic testing, with the goal of achieving timely and accurate diagnoses.

Longitudinal Anthropometry and Body Composition in Children With SARS-CoV-2-Associated Multisystem Inflammatory Syndrome

OBJECTIVES

Acute coronavirus disease 2019 infection has been shown to negatively affect body composition among adult and malnourished or obesity children. Our aim is to longitudinally evaluate body composition in children affected by the Multisystem Inflammatory Syndrome (MIS-C).

METHODS

In this cohort study, we recruited 40 patients affected by MIS-C, aged 2-18 years old, who were admitted in our clinic between December 2020 and February 2021. Physical examination for each participant included weight, height, body mass index (BMI) z score, circumferences, and skinfolds assessment. The same measurements were repeated during outpatient follow-up at 10 (T2), 30 (T3), 90 (T4), and 180 (T5) days after hospital discharge. Fat mass and fat free mass were calculated according to skinfolds predictive equations for children and adolescents. A control group was randomly selected among patients attending a pediatric nutritional outpatient clinic.

RESULTS

BMI z score significantly decrease between preadmission and hospital discharge. Similarly, arm circumference z score, arm muscular area z score, and arm fat area z score significantly decreased, during hospital stay. Fat mass index (FMI) significantly increased over time, peaking at T3. Fat free mass index decreased during hospitalization.

CONCLUSIONS

To the best of our knowledge, this is the first study to assess body composition in a numerically large pediatric MIS-C population from acute infection to 6 months after triggering event. FMI and anthropometric parameters linked to fat deposits were significantly higher 6 months after acute event. Thus, limiting physical activity and having sedentary lifestyle may lead to an accumulation of adipose tissue even in healthy children who experienced MIS-C and long hospitalization.

The impact of the COVID-19 pandemic on the field of pediatric rheumatology

PURPOSE OF REVIEW

The purpose of this review is to discuss the clinical management of children with pediatric rheumatic disease (PRD) during the Coronavirus disease of 2019 (COVID-19) pandemic, as well as the unique role of the pediatric rheumatologist during a time of emerging post-COVID inflammatory sequelae including, multisystem inflammatory syndrome in children (MIS-C).

RECENT FINDINGS

To date, there has been little evidence to suggest that children with PRD, including those on immunomodulatory therapies, are at increased risk for severe COVID-19. Clinical guidance statements have been created to support clinical providers in providing care to children with PRD during the COVID-19 pandemic. Pediatric rheumatologists have also been called upon to assist in the identification and management of post-COVID sequelae, including the rapidly emerging inflammatory illness, MIS-C.

SUMMARY

The COVID-19 era has been defined by a rapid expansion in scientific knowledge and a time of extraordinary local and worldwide collaboration, both within the pediatric rheumatology community, as well as across multiple disciplines. Through collective efforts, we have learned that children with PRD, including those on immunomodulatory therapies, are not at increased risk for severe COVID-19. Pediatric rheumatologists have also worked alongside other disciplines to develop guidance for the management of MIS-C, with the majority of patients experiencing excellent clinical outcomes.

Multisystem Inflammatory Syndrome in Infants <12 months of Age, United States, May 2020-January 2021

BACKGROUND

Multisystem inflammatory syndrome in children (MIS-C), temporally associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been identified in infants <12 months old. Clinical characteristics and follow-up data of MIS-C in infants have not been well described. We sought to describe the clinical course, laboratory findings, therapeutics and outcomes among infants diagnosed with MIS-C.

METHODS

Infants of age <12 months with MIS-C were identified by reports to the CDC's MIS-C national surveillance system. Data were obtained on clinical signs and symptoms, complications, treatment, laboratory and imaging findings, and diagnostic SARS-CoV-2 testing. Jurisdictions that reported 2 or more infants were approached to participate in evaluation of outcomes of MIS-C.

RESULTS

Eighty-five infants with MIS-C were identified and 83 (97.6%) tested positive for SARS-CoV-2 infection; median age was 7.7 months. Rash (62.4%), diarrhea (55.3%) and vomiting (55.3%) were the most common signs and symptoms reported. Other clinical findings included hypotension (21.2%), pneumonia (21.2%) and coronary artery dilatation or aneurysm (13.9%). Laboratory abnormalities included elevated C-reactive protein, ferritin, d-dimer and fibrinogen. Twenty-three infants had follow-up data; 3 of the 14 patients who received a follow-up echocardiogram had cardiac abnormalities during or after hospitalization. Nine infants had elevated inflammatory markers up to 98 days postdischarge. One infant (1.2%) died after experiencing multisystem organ failure secondary to MIS-C.

CONCLUSIONS

Infants appear to have a milder course of MIS-C than older children with resolution of their illness after hospital discharge. The full clinical picture of MIS-C across the pediatric age spectrum is evolving.

Outcome of Children Admitted With SARS-CoV-2 Infection: Experiences From a Pediatric Public Hospital

OBJECTIVE

To study clinical characteristics and outcome of children with admitted to a paediatric hospital in Mumbai, India.

METHODS

Review of medical records of 969 children admitted between 19 March and 7 August, 2020, to assess the clinico-demographic characteristics, disease severity and factors predicting outcome in COVID-19 children. Variables were compared between children who were previously healthy (Group I) and those with co-morbidity (Group II).

RESULTS

123 (71 boys) children with median (IQR) age of 3 (0.7- 6) years were admitted, of which 47 (38%) had co-morbidities. 39 (32 %) children required intensive care and 14 (11.4%) died. Male sex, respiratory manifestation, oxygen saturation <94%; at admission, mechanical ventilation, inotrope, hospital stay of <10 days were independent predictors of mortality. Oxygen saturation <94% at admission (OR 35.9, 95% CI 1.5-856) and hospital stay <10 days (OR 9.1, 95% CI 1.04-99.1) were significant.

CONCLUSION

COVID-19 in children with co-morbidities causes severe disease. Association of mortality with oxygen saturation by pulse oximeter <94% on admission, and hospital stay <10 days, needs further evaluation.

Mistaken MIS-C: A Case Series of Bacterial Enteritis Mimicking MIS-C

Multisystem inflammatory syndrome in children following severe acute respiratory syndrome coronavirus 2 infection is characterized by fever, elevated inflammatory markers, and multisystem organ involvement. Presentations are variable but often include gastrointestinal symptoms. We describe 5 children with fever and gastrointestinal symptoms initially concerning for multisystem inflammatory syndrome in children who were ultimately diagnosed with bacterial enteritis, highlighting the diagnostic challenges presented by the severe acute respiratory syndrome coronavirus 2 pandemic.