COVID-19 related MIS-C in kids can spark a treatable type of heart failure

Last Updated: 2020-05-21

By Linda Carroll

Researchers have described the warning signs - and management approaches taken - in 35 French children who ended up in ICUs with a SARS-CoV-2 related fever, severe multisystem inflammation, left-ventricular dysfunction and cardiogenic shock.

"It is an emerging rare but serious problem linked to the coronavirus pandemic in children," said Dr. Damien Bonnet, a professor of congenital and pediatric cardiology and head of the French National Reference Center for Rare Cardiac Disease in Children at the Necker-Infants Malades Hospital at the University of Paris. "Being aware and knowing the presenting symptoms allow one to treat early and efficiently."

At present it's not clear why some children are struck by the syndrome, Bonnet said in an email.

"There are no obvious comorbidities as have been observed in adults (obesity, for example)," he said. "Genetic susceptibility to 'overreact' to the infection with exaggerated inflammation is probably the mechanism. Research is ongoing to test this hypothesis."

For two months during the SARS-CoV-2 pandemic in France, Bonnet and his colleagues at 14 centers in France and Switzerland collected clinical, biological, therapeutic and early outcomes data for 35 pediatric ICU patients with acute left ventricular systolic dysfunction or cardiogenic shock and multisystem inflammation.

The children's median age was 10 (range 1-16 years) and none had underlying cardiac disease. Comorbidities were limited and just 17% were overweight, Bonnet and his colleagues report in Circulation. One child had lupus and three had asthma.

SARS-CoV-2 infection was confirmed in 31 of 35 patients, and 30 of 35 had positive antibody assays. Two of the patients who were negative for SARS-CoV-2 had typical lung CT features of COVID pneumonia.

All of the patients had fever above 38.5 degrees C (101.3 degrees F) and lethargy. Most (83% of 29 patients with available data) had gastrointestinal symptoms, including abdominal pain, vomiting or diarrhea. Pain was so intense in two children that they received emergency surgery for suspected appendicitis, which was ultimately diagnosed as mesenteric lymphadenitis.

Some had rashes and other signs suggestive of Kawasaki disease, but none met the criteria for a classical form of the disease, the researchers report. Just six patients complained of chest pain.

The median interval from first clinical signs of illness to onset of heart failure symptoms was six days. At ICU admission, 80% of the children were in cardiogenic shock. Ten of 35 required extracorporeal membrane oxygenation (ECMO). Two-thirds of the patients had respiratory distress severe enough to require a ventilator.

Most patients, 28 of 35, received IV inotropic support and 25 of 35 received immunoglobulin. Twelve received intravenous steroids and three were treated with an interleukin I receptor antagonist because of a persistent severe inflammatory state. In addition, 23 of 35 patients were treated with heparin.

At the time of the paper's submission, 25 of the 35 children had been discharged from the ICU. None had died and all of those who had been treated with ECMO had been successfully weaned from the treatment.

The new report highlights the early signs of the illness, including severe abdominal pain, said Dr. George Ofori-Amanfo, a professor of pediatric cardiology and pediatric intensive care medicine at the Icahn School of Medicine at Mount Sinai and chief of pediatric critical care medicine at Mount Sinai Kravis Children's Hospital.

"In the U.S. we've seen patients diagnosed with appendicitis, some of whom have had operations for it," he said. "The disease is rare but the presentation of abdominal pain and fever is not subtle and when parents see that, it's time to alert the pediatrician."

"The report also shows how little was understood about this illness," Dr. Ofori-Amanfo said. "Not all patients got all the medications. And there were no specific criteria being used to determine who got what."

There is now an algorithm (https://bit.ly/2ymHrBj) that experts and professional societies have developed for treating these kids, Dr. Ofori-Amanfo said. Now, for example, all children with the syndrome get heparin to prevent COVID-19-related clotting, he added.

SOURCE: https://bit.ly/2TofXCu Circulation, online May 17, 2020.

(Reuters Health) - Researchers describe the diagnoses and treatment as well as initial warning signs seen in 35 French children who ended up in pediatric ICUs with a SARS-CoV-2 related fever, severe multisystem inflammation, left-ventricular dysfunction and cardiogenic shock.

"It is an emerging rare but serious problem linked to the coronavirus pandemic in children," said Dr. Damien Bonnet, a professor of congenital and pediatric cardiology and head of the French National Reference Center for Rare Cardiac Disease in Children at the Necker-Infants Malades Hospital at the University of Paris. "Being aware and knowing the presenting symptoms allow one to treat early and efficiently."

At present it's not clear why some children are struck by the syndrome, Bonnet said in an email.

"There are no obvious comorbidities as have been observed in adults (obesity, for example)," he said. "Genetic susceptibility to 'overreact' to the infection with exaggerated inflammation is probably the mechanism. Research is ongoing to test this hypothesis."

Over a two month period contemporary with the SARS-CoV-2 pandemic in France, Bonnet and his colleagues collected clinical, biological, therapeutic and early outcomes data for children with acute left ventricular systolic dysfunction or cardiogenic shock and multisystem inflammation who were admitted to pediatric intensive care in 14 centers in France and Switzerland.

The children's median age was 10 (range 1-16 years) and none had underlying cardiac disease. Comorbidities were limited and just 17% were overweight, Bonnet and his colleagues report in Circulation. One child had lupus and three had asthma.

SARS-CoV-2 infection was confirmed in 31 of 35 patients, and 30 of 35 had positive antibody assays. Two of the patients who were negative for SARS-CoV-2 had typical lung CT features of COVID pneumonia.

All of the patients had a fever of greater than 38.5 degrees C (101.3 degrees F) and lethargy. Most (83% of 29 patients with available data) had gastrointestinal symptoms, including abdominal pain, vomiting or diarrhea. Pain was so intense in two children that they received emergency surgery for suspected appendicitis, which was ultimately diagnosed as mesenteric lymphadenitis.

Some had rashes and other signs suggestive of Kawasaki disease, but none met the criteria for a classical form of the disease, the researchers report. Just six patients complained of chest pain.

Within a median of six days from the first clinical signs of illness, symptoms of heart failure began. At admission to the ICU, 80% of the children were in cardiogenic shock requiring the administration of inotropic drugs. Ten of 35 required mechanical circulatory assistance with ECMO. Two-thirds of the patients had respiratory distress severe enough to require a ventilator.

Most patients, 28 of 35, received IV inotropic support and 25 of 35 received immunoglobulin. Twelve received intravenous steroids and three were treated with an interleukin I receptor antagonist because of a persistent severe inflammatory state. In addition, 23 of 35 patients were treated with heparin.

At the time of the paper's submission, 25 of 35 children had been discharged from the ICU. None had died and all of those who had been treated with ECMO had been successfully weaned from the treatment.

The new report may be the first to describe this multisystem inflammatory syndrome in children, said Dr. George Ofori-Amanfo, a professor of pediatric cardiology and pediatric intensive care medicine at the Icahn School of Medicine at Mount Sinai and chief of pediatric critical care medicine at Mount Sinai Kravis Children's Hospital.

It highlights the early signs of the illness, including severe abdominal pain, Dr. Ofori-Amanfo said. "In the U.S. we've seen patients diagnosed with appendicitis, some of whom have had operations for it," he added. "The disease is rare but the presentation of abdominal pain and fever is not subtle and when parents see that, it's time to alert the pediatrician."

"The report also shows how little was understood about this illness," Dr. Ofori-Amanfo said. "Not all patients got all the medications. And there were no specific criteria being used to determine who got what."

There is now an algorithm (https://bit.ly/2ymHrBj) that experts and professional societies have developed for treating these kids, Dr. Ofori-Amanfo said. Now, for example, all children with the syndrome get heparin to prevent COVID-19-related clotting, he added.

SOURCE: https://bit.ly/2TofXCu Circulation, online May 17, 2020.