Winter 2021 Issue
Volume 13 | Number 1
At the onset of the COVID-19 pandemic in the United States, the risk of severe disease and death appeared to be highest among the elderly and those with comorbidities.Preliminary research from China also indicated pediatric COVID-19 cases to be less severe than adult cases.1 Recently, however, there have been growing reports of pediatric patients with COVID-19 presenting with clinical features of Kawasaki disease and toxic shock syndrome. This condition, now referred to as Multisystem Inflammatory Syndrome in Children (MIS-C), has increased ICU admissions among children and adolescents. We describe a 5-year old female who tested positive for COVID-19 antibodies during outpatient therapy and was subsequently hospitalized with symptoms consistent with MIS-C.
Since first documented in December 2019, COVID-19, which is caused by the severe acute respiratory syndrome coronavirus (SARS-CoV-2), has affected more than 4 million people worldwide. In the US, as of May 18, 2020, there are 1.4 million confirmed cases of COVID-19 and 87,180 reported deaths (WHO, 18 May 2020). Initially, respiratory failure was the primary main cause of hospitalization and ICU admission in affected individuals. Initial management goals focused on the maintenance of adequate pulmonary support and prevention of respiratory failure. Mechanical ventilation was widely used to minimize lung injury (Marini & Gattinoni, 2020). However, there has since been a growing body of evidence suggesting that COVID-19 may affect via other mechanisms. Occasionally individuals endure an overwhelming immune response with increased levels of cytokine release (Chaolin, et al., 15-21 February 2020). This is consistent with previous human coronavirus (hCoV) infections such as severe acute respiratory syndrome CoV (SARS-CoV) and Middle East respiratory syndrome CoV (MERS-CoV). Cardiovascular risk is particularly prominent secondary only to pulmonary injury in patients with COVID-19 infection. Whilst myocarditis is a known complication of viral infection, in patients with COVID-19 infection, an increased number of cases with refractory hypertension/hypotension, heart failure and coagulopathy have been observed (Thomas, et al., 2020). Gastroenterology syndromes are well-documented in the pediatric population, suggesting a pattern of multi-system involvement in a subgroup of patients with COVID-19 infection (Li-Na, et al., 2020).
At the onset of the COVID-19 pandemic in the United States, the risk of severe disease and death appeared to be highest among elderly individuals and those with comorbidities including obesity, diabetes, and chronic lung disease. Recent CDC data showed 30% of hospitalizations occurred between the ages of 50–64, and 40% were over 65.Preliminary research from China indicated pediatric COVID-19 cases to be less severe than adult cases (Li-Na, et al. 2020). This is consistent with the CDC’s preliminary description of pediatric COVID-19 cases in the country released in April 2020. At the time, relatively few children with COVID-19 were hospitalized and those who were affected appeared to have milder respiratory symptoms compared to adults (CDC MMWR Feb 2-April 2). The hypothesis suggested that children were experiencing different symptoms than adults, without clear understanding how COVID-19 would manifest in the pediatric population. Recently, there have been growing reports of pediatric patients with COVID-19 presenting with clinical features of Kawasaki disease and toxic shock syndrome. This condition, now referred to as Multisystem Inflammatory Syndrome in Children (MIS-C), has increased ICU admissions among children and adolescents. These cases also highlight the importance of managing COVID-19 from a non-respiratory perspective. Other management approaches, including immunosuppressive therapy, may improve outcomes.
We describe a 5-year old female who tested positive for SARS-CoV-2 antibodies during outpatient therapy and was subsequently hospitalized with symptoms consistent with MIS-C.
A 5-year-old Hispanic female with no significant past medical history was referred to the Emergency Room from an Urgent Care Center. Outpatient blood work revealed elevated ESR and CRP as well as positive SARS CoV-2 antibody testing prompting concerns for MIS-C.
The patient presented complaining of persistent vomiting. The mother accompanied the patient and provided history. She stated that the child had four days of tactile fevers. On the second day of illness the child developed a rash on her torso as well as conjunctival erythema. Initially, patient was noted to have a fever of 103F. She was diagnosed with Coxsackie infection and discharged with supportive care. On day three and four of illness the patient had multiple episodes of vomiting. There was no associated diarrhea. She denied any coughing or shortness of breath. There were no changes in urination. The patient had no known exposure to COVID-19 but was cared for by a babysitter with multiple children in the house. The patient’s three-year-old brother lived at home and had no symptoms of the illness. Her vaccines were current. Worsening of symptoms prompted mother to seek urgent care where additional blood work was drawn. COVID IgG, ESR and CRP were performed on admission; mother was informed COVID IgG was positive.
Emergency Room vitals revealed blood pressure of 103mmHg/57mmHg (reference range systolic blood pressure of 89-112mmHg, diastolic blood pressure of 57-79mmHg), pulse of 141 beats per minute (reference range – 80-120 beats per minute), Temp 102.2 F, Respirations of 32 breaths per minute (reference range – 20-28 breaths per minute), Sp02 100% and weight of 32 kg (99.7 percentile). Physical examination was significant for bilateral, bulbar, conjunctivitis, and diffuse circinate, blanchable rash on her extremities and trunk (image 1). The child appeared fatigued yet interactive with the staff. Lips were dry without evidence of “strawberry tongue.” No lymphadenopathy was appreciated. Cardiac exam was notable for tachycardia without murmur. Her abdomen was soft and nontender, and there was no extremity edema noted.
Labs revealed significant for elevated troponin, NR-proBNP, ESR, CRP, and D-dimer (Table 1). SARS-CoV2 PCR testing via nasal swab returned positive. CBC, CMP, and PT/INR were unremarkable. The patient’s ferritin level was found to be in the upper limit of normal range at 246ng/ml (reference range 8-252ng/mL). Chest X-ray was normal. EKG showed sinus tachycardia with a rate of 140. Prolonged QT interval was not appreciated by EKG and QRS duration was within normal limits. Significant lab data is displayed in Table 1.
The patient’s examination and lab features appeared consistent with either a COVID-19-related MIS-C or incomplete Kawasaki disease. She was admitted to the Pediatric Intensive Care Unit (PICU) for increased monitoring and evaluation. Patient was evaluated by the Pediatric Cardiologist and Infectious Disease Specialist. Echocardiogram demonstrated normal cardiac anatomy, great vessels, as well as normal biventricular sizes and cystic function. However, the left coronary artery was noted to be very prominent, yet without aneurysm or ectasia. Patient received intravenous immunoglobulin and high dose aspirin. She tolerated treatments well with improvement of symptoms. Repeat blood work showed defervescence of inflammatory markers. Her troponin levels remained elevated but stable. The patient had an unremarkable hospital course of 3 days. She was discharged home on aspirin 3mg/kg daily for 3 days. She was instructed to follow-up with cardiology.
Discussion and Conclusion
This patient was diagnosed with COVID-19 and had clinical as well as laboratory findings consistent with incomplete Kawasaki disease. Patient was presumed to exhibit COVID-19-related MIS-C per diagnostic criteria defined by the New York State Department of Health (NYSDOH) and World Health Organization. The interim case definition is shown in Tables 2 and 3.
Although MIS-C remains relatively rare in pediatrics, the condition is potentially fatal and may engender lifelong health complications. Timely recognition of this condition is important. Likewise, timely symptomatic management as well as treatment with IVIG and high-dose aspirin are critical in ensuring good health outcomes. Steroid and immunosuppressive agents such as Acterma should also be considered in patients with COVID-19. These therapies are especially prudent in the pediatric population due to potential overwhelming inflammatory response. As the definition of MIS-C continues to evolve as does the management of MIS-C based on continued case reports.
Further research is necessary to better understand MIS-C and to guide best practices. Practitioners and healthcare professionals should also continue identifying other disease processes that may be related to COVID-19. Cases of MIS-C demonstrate how SARS-CoV-2 may affect the body in previously unrecognized manners, especially among children and adolescents. The management of COVID-19 should therefore not be limited to the respiratory manifestations of the disease.
Image 1. Patient presented with bulbar conjunctival injection and diffuse blanchable rash on her extremities and trunk
Table 1. Initial significant laboratory results
Table 2: NYSDOH Interim case definition- MIS-C temporally associated with SAR-CoV-2
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