Acute myocarditis and multisystem inflammatory emerging disease following SARS-CoV-2 infection in critically ill
Marion Grimaud1, Julie Starck2, Michael Levy3
1Pediatric Intensive Care Unit, Necker-Enfants-Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.
Insights
A severe new pediatric illness linked to SARS-CoV-2 infection causes acute myocarditis and atypical Kawasaki disease. Early recognition and expert care are crucial for recovery in children with this inflammatory condition.
Area of Science:
- Pediatric critical care medicine
- Infectious diseases
- Cardiology
Background:
- Increased pediatric admissions with hypotensive shock and fever during the COVID-19 pandemic.
- Need to characterize the role of SARS-CoV-2 infection in these critically ill children.
Purpose of the Study:
- To describe the clinical characteristics and outcomes of children admitted to the pediatric intensive care unit (PICU) with shock, fever, and suspected SARS-CoV-2 infection.
Main Methods:
- Case series of 20 children admitted to 4 tertiary care centers in Paris between April 15-27, 2020.
- Analysis of clinical presentation, laboratory findings, cardiac function, SARS-CoV-2 testing, and treatments received.
Main Results:
- All 20 children presented with acute myocarditis, vasoplegic shock, and intense systemic inflammation (elevated CRP and procalcitonin).
- Features of atypical Kawasaki disease were present in all patients; SARS-CoV-2 infection was confirmed in most.
- All children required intensive care support, including inotropic/vasoactive drugs and mechanical ventilation for 8 patients. Treatments included IV immunoglobulin and other immunomodulators.
Conclusions:
- A severe pediatric inflammatory syndrome associated with SARS-CoV-2 infection, presenting as acute myocarditis and atypical Kawasaki disease, has emerged.
- Early recognition and referral to specialized centers are recommended for optimal management.
- The underlying mechanisms likely involve a dysregulated host immune response, warranting further investigation for targeted therapies.
Background:
A recent increase in children admitted with hypotensive shock and fever in the context of the COVID-19 outbreak requires an urgent characterization and assessment of the involvement of SARS-CoV-2 infection. This is a case series performed at 4 academic tertiary care centers in Paris of all the children admitted to the pediatric intensive care unit (PICU) with shock, fever and suspected SARS-CoV-2 infection between April 15th and April 27th, 2020.
Results:
20 critically ill children admitted for shock had an acute myocarditis (left ventricular ejection fraction, 35% (25-55); troponin, 269 ng/mL (31-4607)), and arterial hypotension with mainly vasoplegic clinical presentation. The first symptoms before PICU admission were intense abdominal pain and fever for 6 days (1-10). All children had highly elevated C-reactive protein (> 94 mg/L) and procalcitonin (> 1.6 ng/mL) without microbial cause. At least one feature of Kawasaki disease was found in all children (fever, n = 20, skin rash, n = 10; conjunctivitis, n = 6; cheilitis, n = 5; adenitis, n = 2), but none had the typical form. SARS-CoV-2 PCR and serology were positive for 10 and 15 children, respectively. One child had both negative SARS-CoV-2 PCR and serology, but had a typical SARS-CoV-2 chest tomography scan. All children but one needed an inotropic/vasoactive drug support (epinephrine, n = 12; milrinone, n = 10; dobutamine, n = 6, norepinephrine, n = 4) and 8 were intubated. All children received intravenous immunoglobulin (2 g per kilogram) with adjuvant corticosteroids (n = 2), IL 1 receptor antagonist (n = 1) or a monoclonal antibody against IL-6 receptor (n = 1). All children survived and were afebrile with a full left ventricular function recovery at PICU discharge.
Conclusions:
Acute myocarditis with intense systemic inflammation and atypical Kawasaki disease is an emerging severe pediatric disease following SARS-CoV-2 infection. Early recognition of this disease is needed and referral to an expert center is recommended. A delayed and inappropriate host immunological response is suspected. While underlying mechanisms remain unclear, further investigations are required to target an optimal treatment.
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