Multisystem Inflammatory Syndrome in Children Associated With Severe Acute Respiratory Syndrome Coronavirus-2 in an 8-Week-Old Infant

Mother to Newborn Transmission of SARS-CoV-2 Infection: Evolution of Evidence in 1.5 Years of COVID-19 Pandemic

Coronavirus disease 2019 (COVID-19) pandemic caused significant mortality and morbidity in people of all age groups worldwide. Given the uncertainty regarding the mode of transmission and potential effects of COVID-19 on pregnant mothers and their newborns, guidelines for taking care of maternal-newborn dyads have evolved tremendously since the pandemic began. There has been an enormous influx of published materials regarding the outcomes of mothers and newborns. Still, multiple knowledge gaps regarding comprehensive information about risk to the mothers and newborns exist, which need to be addressed. Current evidence suggests that mothers with symptomatic COVID-19 infection are at increased risk of severe illness during pregnancy, with a higher need for respiratory support and premature deliveries. Neonates born to mothers with COVID-19 are at increased risk of needing intensive care; however, most newborns do well after birth. As new mutant variants arise, we need to be cautious while proactively understanding any new evolving patterns. All leading health authorities strongly recommend COVID-19 vaccination before or during pregnancy to reduce the risk of maternal morbidities and benefit from passing antibodies to newborns prenatally and via breastmilk. Additionally, there are racial, ethnic, and socioeconomic disparities in outcomes and vaccination coverage for pregnant women. This article summarizes the rapidly evolving evidence for the last 1.5 years and aims to help health care professionals care for mothers with COVID-19 and their newborns. KEY POINTS: · COVID-19 in pregnancy can cause perinatal morbidities.. · Breastfeeding and breast milk are safe for newborns.. · COVID-19 vaccination reduces the risk for morbidities..

Multisystem inflammatory syndrome in neonates associated with SARS-CoV-2 infection, a different entity?

BACKGROUND: Multisystemic inflammatory syndrome in children (MIS-C) is a novel disease that is associated with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2). MIS-C usually affects children older than 5 years of age and adolescents, with a median of 8-years and an interquartile range of 3 to 11 years. A multisystemic inflammatory disease has been described in neonates and named MIS-N (multisystemic inflammatory syndrome in Neonates). We report three cases of Mexican newborns with MIS-N presenting with multiorgan compromise and a positive anti-SARS-CoV-2 IgG who developed Kawasaki disease (KD)-like cardiac features and discuss the current dilemma regarding diagnosis and treatment in these patients.

Epidemiology of Neonatal COVID-19 in the United States

OBJECTIVES

Data on coronavirus disease 2019 (COVID-19) infections in neonates are limited. We aimed to identify and describe the incidence, presentation, and clinical outcomes of neonatal COVID-19.

METHODS

Over 1 million neonatal encounters at 109 United States health systems, from March 2020 to February 2021, were extracted from the Cerner Real World Database. COVID-19 diagnosis was assessed using severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) laboratory tests and diagnosis codes. Incidence of COVID-19 per 100 000 encounters was estimated.

RESULTS

COVID-19 was diagnosed in 918 (0.1%) neonates (91.1 per 100 000 encounters [95% confidence interval 85.3-97.2]). Of these, 71 (7.7%) had severe infection (7 per 100 000 [95% confidence interval 5.5-8.9]). Median time to diagnosis was 14.5 days from birth (interquartile range 3.1-24.2). Common signs of infection were tachypnea and fever. Those with severe infection were more likely to receive respiratory support (50.7% vs 5.2%, P < .001). Severely ill neonates received analgesia (38%), antibiotics (33.8%), anticoagulants (32.4%), corticosteroids (26.8%), remdesivir (2.8%), and COVID-19 convalescent plasma (1.4%). A total of 93.6% neonates were discharged home after care, 1.1% were transferred to another hospital, and discharge disposition was unknown for 5.2%. One neonate (0.1%) with presentation suggestive of multisystem inflammatory syndrome in children died after 11 days of hospitalization.

CONCLUSIONS

Most neonates infected with SARS-CoV-2 were asymptomatic or developed mild illness without need for respiratory support. Some had severe illness requiring treatment of COVID-19 with remdesivir and COVID-19 convalescent plasma. SARS-CoV-2 infection in neonates, though rare, may result in severe disease.

Prognosis of COVID-19 in the middle eastern population, knowns and unknowns

Since its emergence in China in 2019, the SARS-CoV-2 virus has affected all countries worldwide. The virus is easily transmitted from one person to another via infected aerosols or contaminated surfaces. Unlike its counterparts, the prognosis of COVID-19 ranges from asymptomatic to critical disease or death. Several factors play a role in determining the severity of the disease in infected patients. Among others, is the pre-existence of an underlying medical condition such as diabetes, cancer, and others. Furthermore, although children are less prone to the severe form of the COVID-19 disease, they require attention due to the report of many atypical presentations of the infection, post-asymptomatic exposure. In the Middle East, little is known about the prognosis of the SARS-CoV-2 infection in high-risk categories, notably patients with diabetes, cancer, and pregnant women. The aim of this review is to summarize the current knowledge about this group of population in the middle eastern region as well as to highlight the gap in the literature. We have found that the majority of the papers were from the Gulf countries. Although, few studies were conducted; high-risk patients appear to have an increased risk of morbidity and mortality from COVID-19 compared to their counterparts. Higher levels of inflammatory markers, C-reactive protein, erythrocyte sedimentation rate, D-dimer, and ferritin levels were also observed. Children are often asymptomatic or present with atypical presentations. More studies should be conducted to determine the clinical biomarkers of COVID-19 in high-risk categories to help in patient risk stratification and management in the middle eastern population.

Multisystem Inflammatory Syndrome in Neonates Born to Mothers with SARS-CoV-2 Infection (MIS-N) and in Neonates and Infants Younger Than 6 Months with Acquired COVID-19 (MIS-C): A Systematic Review

(1) Introduction: There is an increasing literature describing neonates born to mothers with SARS-CoV-2 infection (MIS-N) and infants infected with SARS-CoV-2 who presented with a severe disease (MIS-C). (2) Methods: To investigate clinical features of multisystem inflammatory syndrome in neonates and infants under six months of age, we used a systematic search to retrieve all relevant publications in the field. We screened in PubMed, EMBASE and Scopus for data published until 10 October 2021. (3) Results: Forty-eight articles were considered, including 29 case reports, six case series and 13 cohort studies. Regarding clinical features, only 18.2% of MIS-N neonates presented with fever; differently from older children with MIS-C, in which gastrointestinal symptoms were the most common manifestation, we displayed that cardiovascular dysfunction and respiratory distress are the prevalent findings both in neonates with MIS-N and in neonates/infants with MIS-C. (4) Conclusions: We suggest that all infants with suspected inflammatory disease should undergo echocardiography, due to the possibility of myocardial dysfunction and damage to the coronary arteries observed both in neonates with MIS-N and in neonates/infants with MIS-C. Moreover, we also summarize how they were treated and provide a therapeutic algorithm to suggest best management of these fragile infants.

Cardiac manifestations and diagnostic imaging in pediatric inflammatory multisystem syndrome temporally associated with COVID-19: a systematic review

BACKGROUND Several studies have reported pediatric inflammatory multisystem syndrome temporally associated with COVID-19 (PIMS-TS) cases with their cardiac manifestations, but only few studies synthesize the cardiovascular characteristics in children with PIMS-TS. However, detecting cardiac abnormalities is crucial in improving patients' outcomes and reducing mortality. This review aimed to summarize the overall symptoms, laboratory, and workup findings in PIMS-TS patients, focusing on cardiovascular manifestations. METHODS We searched 4 medical databases (PubMed, Science Direct, Medline, and Scielo) and 4 preprint databases (Medrxiv, Research Square, SSRN, and Biorxiv). The literature search was done on November 8, 2021. All case reports, case series, cross-sectional studies, cohort studies, and possible clinical trials published from December 2020 onward that studied PIMS-TS on cardiac manifestation (aged 0–18 years) were included. Studies on multisystem inflammatory syndrome in children, animal studies, and studies without full-text availability were excluded. This review was registered in PROSPERO (CRD42021194468). RESULTS 59 studies were included with a total of 698 patients. The most common cardiovascular findings were the presence of cardiogenic shock (37%) and hypotension (8.5%). Almost all laboratory values were deranged. Cardiac computed tomography scan mostly showed normal results (56%), followed by cardiomegaly with pericardial effusion (14%). Electrocardiography showed normal findings (46%), ST-segment abnormalities (32%), and abnormal T wave (12%). Echocardiography findings showed left ventricle dysfunction (40.6%), which can be considered most significant, followed by pericardial effusion together with pericarditis (11.4%) and tricuspid regurgitation (6.9%). CONCLUSIONS This review found various cardiac abnormalities that may develop during PIMS-TS. Due to these findings, we should be more vigilant and not underestimate the consequences in pediatric COVID-19 patients.

Multisystem inflammatory syndrome in neonates (MIS-N) associated with SARS-CoV2 infection: a case series

Multisystem inflammatory syndrome in neonates (MIS-N) is hypothesised to be caused either following transplacental transfer of SARS-CoV2 antibodies or antibodies developed in the neonate after infection with SARS-CoV-2. In this paper, we aim to discuss the clinical manifestations, laboratory features, and management of neonates diagnosed with MIS-N. We collated information from five participating hospitals in western India. A cohort of newborn infants presenting with multi-system involvement, along with the presence of SARS-CoV2 antibodies, was identified. Current proposed international diagnostic criteria for MIS-N were used to group the cases into three categories of Most likely, Possible, and Unlikely MIS-N. A total of 20 cases were reported with a diagnosis of MIS-N, all having high titres of SARS CoV2 IgG antibodies and negative for SARS CoV2 antigens. Most likely MIS (n = 5) cases presented with respiratory distress (4/5), hypotension and shock (4/5), and encephalopathy (2/5). Inflammatory markers like CRP (1/5), Procalcitonin (1/5), Ferritin (3/5), D-dimer (4/5), and LDH (2/5) were found to be elevated, and four of them had significantly high levels of proBNP. The majority of them (4/5) responded to immunomodulators, three neonates were discharged home, and two died. Possible MIS infants (n = 9) presented with fever (7/9), respiratory distress (4/9), refusal to feed (6/9), lethargy (5/9), and tachycardia (3/9). ProBNP as a marker of cardiac dysfunction was noted to be elevated in four (4/9) infants, correlating with abnormal echocardiography findings in two. In the Unlikely MIS (n = 6) category, three (3/6) infants presented with respiratory distress, one (1/6) with shock and cardiac dysfunction, and only one (1/6) with fever. All of them had elevated inflammatory markers. However, there were other potential diagnoses that could have been responsible for the clinical scenarios in these six cases.   Conclusion: MIS-N requires a high index of suspicion and should be considered in a neonate presenting with two or more systems involvement, in the presence of SARS-CoV2 antibodies, along with elevated inflammatory markers, once other common neonatal conditions have been ruled out. What is Known: • Severe acute respiratory syndrome coronavirus-2 (SARS-CoV2) associated multisystem inflammatory syndrome in children (MIS-C) is  widely reported in paediatric population, however only few reports of newborn affection. • MIS-C is known to cause by virus-induced post-infective antibody mediated immune dysregulation with severe multi-system affection. What is New: • MIS-N may present with varied clinical manifestations with multi-system involvement of variable severity with milder disease in term and severe disease with cardiac dysfunction in preterm newborns. • Multisystem inflammatory syndrome in newborns (MIS-N) is postulated to occur following immune dysregulation associated with transplacental transfer of SARS-CoV2 antibodies or antibodies developed in the neonate after infection with SARS-CoV-2.

Multisystem inflammatory syndrome in a neonate masquerading as surgical abdomen

Worldwide, thousands of cases of multisystem inflammatory syndrome in children (MIS-C) have already been reported in children. Evidence regarding neonatal MIS-C is limited. We present the first case report of a neonate presenting within 48 hours of life with predominant abdominal signs mimicking surgical abdomen. Clinical picture comprised fever, multiorgan dysfunction (gastrointestinal, cardiorespiratory, hepatic and dermatological), positive inflammatory markers, high ferritin and high D-dimer levels. Cardiac enzyme N-terminal-pro-B-type natriuretic peptide as well as D-dimer levels were elevated. Blood, urine, stool and cerebrospinal fluid cultures were sterile. Positive anti-SARS-CoV-2 IgG in both the mother and the infant, along with an epidemiological evidence of maternal contact with COVID-19, clinched the diagnosis of MIS-C. Immunomodulatory drugs (intravenous immunoglobulin and systemic steroids) were administered and showed good clinical response. A high index of suspicion of MIS-C in critically ill neonates can improve 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.

Sixteen Weeks Later: Expanding the Risk Period for Multisystem Inflammatory Syndrome in Children

Multisystem inflammatory syndrome in children (MIS-C) has been observed in temporal association with coronavirus disease 2019 (COVID-19), typically within 2 to 6 weeks of illness or exposure. We present a case of MIS-C occurring 16 weeks after initial COVID-19 illness to highlight the prolonged period of risk for developing MIS-C.

Perinatal SARS-CoV-2 Infection and Neonatal COVID-19: A 2021 Update

The coronavirus disease 2019 pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has swept across the world like an indiscriminating wildfire. Pregnant women and neonates are particularly vulnerable to this infection compared with older children and healthy young adults, with unique challenges in their management. Unfamiliarity with the consequences of this novel virus and lack of high-quality data led to considerable heterogeneity in obstetrical and neonatal management early in the pandemic. The aim of the this review is to summarize the impact of SARS-CoV-2 infection on pregnancy and childbirth and to examine care and possible outcomes for neonates with Covid-19-positive mothers. A brief review of vaccines currently approved by the United States Food and Drug Administration for emergency use and their potential effects on pregnant and lactating women in included.

Perinatal SARS-CoV-2 Infection and Neonatal COVID-19: A 2021 Update

The coronavirus disease 2019 pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has swept across the world like an indiscriminating wildfire. Pregnant women and neonates are particularly vulnerable to this infection compared with older children and healthy young adults, with unique challenges in their management. Unfamiliarity with the consequences of this novel virus and lack of high-quality data led to considerable heterogeneity in obstetrical and neonatal management early in the pandemic. The aim of the this review is to summarize the impact of SARS-CoV-2 infection on pregnancy and childbirth and to examine care and possible outcomes for neonates with Covid-19-positive mothers. A brief review of vaccines currently approved by the United States Food and Drug Administration for emergency use and their potential effects on pregnant and lactating women in included.

Multisystem inflammatory syndrome in children. An emerging clinical challenge for pediatric surgeons in the COVID 19 era

Background/purpose

Multisystem inflammatory syndrome in children (MIS-C) is a potentially life-threatening condition occurring 2–6 weeks after Coronavirus disease 2019 (COVID-19) in previously healthy children and adolescents, characterized by clinical and laboratory evidence of multiorgan inflammation. We reported the case of a 6-year-old child presented with acute abdomen and then diagnosed with MIS-C. In addition, to better portray this new entity, we performed a systematic review of MIS-C gastrointestinal features and particularly on those mimicking surgical emergencies.

Methods

We described the clinical presentation, the diagnostic approach and the therapeutic outcomes of our MIS-C patient. Parallel to this, we conducted a systematic literature search using Google Scholar, PubMed, EMBASE, Scopus, focusing on gastrointestinal MIS-C.

Results

Our patient was initially assessed by the surgical team due to his query acute abdomen. Following the diagnosis of MIS-C with myocarditis, intravenous methylprednisolone (2 mg/Kg/day) and intravenous immunoglobulins (2 gr/Kg single infusion) were promptly started, leading to clinical improvement. According to our literature search, patients with MIS-C have a high rate of severe abdominal symptoms resembling surgical emergencies (appendicitis, obstruction, etc.) and a not negligible number of those patients have been surgically explored with variable findings.

Conclusions

We encourage pediatric surgeons in the upcoming months of COVID-19 pandemic to evaluate myocardial function prior to surgical abdominal exploration. In children with query acute abdomen, MIS-C should be promptly ruled out in order to avoid unnecessary surgeries that could worsen the already frail outcome of this new syndrome. Nevertheless, it should be considered that MIS-C might well encompass complications (e.g. appendicitis, segmental intestinal ischemia) which need swift surgical treatment.