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Netea SA, Biesbroek G, Groenink M, Planken RNN, de Winter RJ, Blom NA, Kuijpers TW, Kuipers IM. Long-term global longitudinal strain abnormalities in paediatric patients after multisystem inflammatory syndrome in children correlate with cardiac troponin T: a single-centre cohort study. Cardiol Young 2024:1-10. [PMID: 38584315 DOI: 10.1017/s1047951124000465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
BACKGROUND Multisystem inflammatory syndrome in children is an inflammatory syndrome related to severe acute respiratory syndrome coronavirus 2 with a high risk of cardiovascular complications (vasoplegia, cardiac shock). We investigated the cardiac outcomes in multisystem inflammatory syndrome in children, focusing on the identification of predictors for late cardiac function impairment. METHODS Clinical characteristics, conventional echocardiography (left ventricle ejection fraction, fractional shortening), 4-chamber left ventricular global longitudinal strain, and cardiac MRI of multisystem inflammatory syndrome in children patients (n = 48) were collected during admission, 6 weeks, 6 months, >12-≤18 months, and >18-≤24 months post-onset. Paired over-time patterns were assessed and multivariable regression analyses were performed to identify predictors for late global longitudinal strain impairment. RESULTS In total, 81.3% of patients had acute cardiac dysfunction (left ventricle ejection fraction <50% and/or fractional shortening <28%). The left ventricle ejection fraction and fractional shortening reached a plateau level ≤6 weeks, while the global longitudinal strain continued to decrease in the first 6 months post-onset (median -17.3%, P < 0.001 [versus acute]). At 6 months, 35.7% of the patients still had an abnormal global longitudinal strain, which persisted in 5/9 patients that underwent echocardiography >12-≤18 months post-onset and in 3/3 patients >18-≤24 months post-onset. In a multivariable analysis, soluble troponin T (>62.0 ng/L [median]) was associated with reduced global longitudinal strain at 6 months. Our cardiac MRI findings indicated acute myocardial involvement (increased T1/T2 value) in 77.8% (7/9), which recovered quickly without signs of fibrosis on convalescent cardiac MRIs. CONCLUSIONS Late global longitudinal strain impairment is seen in some multisystem inflammatory syndrome in children patients up to one-year post-onset. Careful cardiac follow-up in patients with elevated troponin in the acute phase and patients with persistent abnormal global longitudinal strain is warranted until resolution of the global longitudinal strain since the long-term implications of such abnormalities are still unclear.
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Affiliation(s)
- Stejara A Netea
- Emma Children's Hospital, Paediatric Immunology, Rheumatology and Infectious Disease, Amsterdam UMC, Amsterdam, The Netherlands
| | - Giske Biesbroek
- Emma Children's Hospital, Paediatric Immunology, Rheumatology and Infectious Disease, Amsterdam UMC, Amsterdam, The Netherlands
| | - Maarten Groenink
- Department of Radiology, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
| | - R N Nils Planken
- Department of Radiology, Amsterdam UMC, Amsterdam, The Netherlands
| | | | - Nico A Blom
- Emma Children's Hospital, Paediatric Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
- Pediatric Cardiology, Leiden University Medical Centre, Leiden, Netherlands
| | - Taco W Kuijpers
- Emma Children's Hospital, Paediatric Immunology, Rheumatology and Infectious Disease, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Molecular Haematology, Sanquin Research Institute, Amsterdam, The Netherlands
| | - Irene M Kuipers
- Emma Children's Hospital, Paediatric Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
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Lee S, Erdem G, Yasuhara J. Multisystem inflammatory syndrome in children associated with COVID-19: from pathophysiology to clinical management and outcomes. Minerva Pediatr (Torino) 2024; 76:268-280. [PMID: 37284807 DOI: 10.23736/s2724-5276.23.07205-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Multisystem inflammatory syndrome in children (MIS-C), also known as pediatric inflammatory multisystem syndrome (PIMS), is a new postinfectious illness associated with COVID-19, affecting children after SARS-CoV-2 exposure. The hallmarks of this disorder are hyperinflammation and multisystem involvement, with gastrointestinal, cardiac, mucocutaneous, and hematologic disturbances seen most commonly. Cardiovascular involvement includes cardiogenic shock, ventricular dysfunction, coronary artery abnormalities, and myocarditis. Now entering the fourth year of the pandemic, clinicians have gained some familiarity with the clinical presentation, initial diagnosis, cardiac evaluation, and treatment of MIS-C. This has led to an updated definition from the Centers for Disease Control and Prevention in the USA driven by increased experience and clinical expertise. Furthermore, the available evidence established expert consensus treatment recommendations supporting a combination of immunoglobulin and steroids. However, the pathophysiology of the disorder and answers to what causes this remain under investigation. Fortunately, long-term outcomes continue to look promising, although continued follow-up is still needed. Recently, COVID-19 mRNA vaccination is reported to be associated with reduced risk of MIS-C, while further studies are warranted to understand the impact of COVID-19 vaccines on MIS-C. We review the findings and current literature on MIS-C, including pathophysiology, clinical features, evaluation, management, and medium- to long-term follow-up outcomes.
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Affiliation(s)
- Simon Lee
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
| | - Guliz Erdem
- Division of Infectious Diseases, Nationwide Children's Hospital, Columbus, OH, USA
| | - Jun Yasuhara
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA -
- Center for Cardiovascular Research, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Cardiology, Royal Children's Hospital, Parkville, Australia
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3
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McAree D, Hauck A, Arzu J, Carr M, Acevedo J, Patel AB, Husain N. Clinical Predictors of Subacute Myocardial Dysfunction in Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with COVID-19. Pediatr Cardiol 2024; 45:876-887. [PMID: 36260103 PMCID: PMC9580417 DOI: 10.1007/s00246-022-03021-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 09/28/2022] [Indexed: 12/01/2022]
Abstract
Multisystem Inflammatory Syndrome in Children (MIS-C) often involves a post-viral myocarditis and associated left ventricular dysfunction. We aimed to assess myocardial function by strain echocardiography after hospital discharge and to identify risk factors for subacute myocardial dysfunction. We conducted a retrospective single-center study of MIS-C patients admitted between 03/2020 and 03/2021. Global longitudinal strain (GLS), 4-chamber longitudinal strain (4C-LS), mid-ventricular circumferential strain (CS), and left atrial strain (LAS) were measured on echocardiograms performed 3-10 weeks after discharge and compared with controls. Among 60 MIS-C patients, hypotension (65%), ICU admission (57%), and vasopressor support (45%) were common, with no mortality. LVEF was abnormal (< 55%) in 29% during hospitalization but only 4% at follow-up. Follow-up strain abnormalities were prevalent (GLS abnormal in 13%, 4C-LS in 18%, CS in 16%, LAS in 5%). Hypotension, ICU admission, ICU and hospital length of stay, and any LVEF < 55% during hospitalization were factors associated with lower strain at follow-up. Higher peak C-reactive protein (CRP) was associated with hypotension, ICU admission, total ICU days, and with lower follow-up GLS (r = - 0.55; p = 0.01) and CS (r = 0.41; p = 0.02). Peak CRP < 18 mg/dL had negative predictive values of 100% and 88% for normal follow-up GLS and CS, respectively. A subset of MIS-C patients demonstrate subclinical systolic and diastolic function abnormalities at subacute follow-up. Peak CRP during hospitalization may be a useful marker for outpatient cardiac risk stratification. MIS-C patients with hypotension, ICU admission, any LVEF < 55% during hospitalization, or a peak CRP > 18 mg/dL may warrant closer monitoring than those without these risk factors.
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Affiliation(s)
- Daniel McAree
- Department of Pediatric Cardiology, Northwestern University Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Ave., Chicago, IL 60611 USA
| | - Amanda Hauck
- Department of Pediatric Cardiology, Northwestern University Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Ave., Chicago, IL 60611 USA
| | - Jennifer Arzu
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | - Michael Carr
- Department of Pediatric Cardiology, Northwestern University Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Ave., Chicago, IL 60611 USA
| | - Jennifer Acevedo
- Department of Pediatric Cardiology, Northwestern University Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Ave., Chicago, IL 60611 USA
| | - Ami B. Patel
- Department of Infectious Diseases, Northwestern University Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL USA
| | - Nazia Husain
- Department of Pediatric Cardiology, Northwestern University Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Ave., Chicago, IL 60611 USA
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4
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Jepson BM, Beaver M, Colquitt JL, Truong DT, Crandall H, McFarland C, Williams R, Ou Z, Jensen D, Minich LL, Binka E. Left Atrial Strain in Multisystem Inflammatory Syndrome in Children and Associations with Systemic Inflammation and Cardiac Injury. Pediatr Cardiol 2024; 45:729-739. [PMID: 38360919 DOI: 10.1007/s00246-024-03417-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 01/10/2024] [Indexed: 02/17/2024]
Abstract
Multisystem inflammatory syndrome in children (MIS-C) commonly involves cardiac injury with both systolic and diastolic dysfunction. Left atrial strain (LAS) detects subclinical diastolic dysfunction in adults but is infrequently used in children. We evaluated LAS in MIS-C and the associations with systemic inflammation and cardiac injury. In this retrospective cohort study, LAS parameters [reservoir (LAS-r), conduit (LAS-cd), and contractile (LAS-ct)] obtained from admission echocardiograms of MIS-C patients were compared to healthy controls and between MIS-C patients with and without cardiac injury (BNP > 500 pg/ml or troponin-I > 0.04 ng/ml). Correlation and logistic regression analyses were performed to assess LAS associations with admission inflammatory and cardiac biomarkers. Reliability testing was performed. We identified 118 patients with MIS-C and 20 healthy controls. Median LAS parameters were reduced in MIS-C patients compared to controls (LAS-r: 31.8 vs. 43.1%, p < 0.001; LAS-cd: - 28.8 vs. - 34.5%, p = 0.006; LAS-ct: - 5.2 vs. - 9.3%, p < 0.001) and reduced in MIS-C patients with cardiac injury (n = 59) compared to no injury (n = 59) (LAS-r: 29.6 vs. 35.8%, p = 0.001; LAS-cd: - 26.5 vs. - 30.4%, p = 0.036; LAS-ct: - 4.6 vs. - 9.3%, p = 0.008). A discrete LAS-ct peak was absent in 65 (55%) MIS-C patients but present in all controls (p < 0.001). Procalcitonin correlated strongly with averaged E/e' (r = 0.55, p = 0.001). Moderate correlations were found for ESR and LAS-ct (r = - 0.41, p = 0.007) as well as BNP and LAS-r (r = - 0.39, p < 0.001) and LAS-ct (r = 0.31, p = 0.023). Troponin-I had only weak correlations. Intra-rater reliability was good for all LAS parameters, and inter-rater reliability was good to excellent for LAS-r, and fair for LAS-cd and LAS-ct. LAS analysis, particularly the absence of a LAS-ct peak, was reproducible and may be superior to conventional echocardiographic parameters for detecting diastolic dysfunction in MIS-C. No strain parameters on admission were independently associated with cardiac injury.
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Affiliation(s)
- Bryan M Jepson
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA.
- Primary Children's Hospital Outpatient Services, 81 N. Mario Capecchi Drive, Salt Lake City, UT, 84113, USA.
| | - Matthew Beaver
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - John L Colquitt
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Dongngan T Truong
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Hillary Crandall
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Carol McFarland
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Richard Williams
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Zhining Ou
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Devri Jensen
- Intermountain Primary Children's Hospital, Salt Lake City, UT, USA
| | - L LuAnn Minich
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Edem Binka
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
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Gasparini PA, Lodi E, Rodighiero E, Rosero Morales J, Fantini G, Modena MG. Echocardiographic screening in pediatric asymptomatic or paucisymptomatic coronavirus disease 2019 outpatients: is it a useful test or an excess of zeal? J Cardiovasc Med (Hagerstown) 2024; 25:234-238. [PMID: 37577859 PMCID: PMC10849130 DOI: 10.2459/jcm.0000000000001549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 07/27/2023] [Accepted: 07/27/2023] [Indexed: 08/15/2023]
Abstract
INTRODUCTION Data regarding echocardiographic findings during follow-up of asymptomatic or pauci-symptomatic coronavirus disease 2019 (COVID-19) are scarce in pediatric patients. The aim of the present study is to assess post-COVID-19 sequelae through echocardiography in children who have experienced mild SARS-CoV-2. METHODS This single-center, retrospective, observational study enrolled a cohort of 133 pediatric outpatients, born between 2005 and 2022, with a history of asymptomatic or paucisymptomatic SARS-CoV-2 infection, who underwent transthoracic echocardiographic (TTE) evaluation at an outpatient pediatric clinic in Northern Italy. RESULTS The percentage of the pediatric activity of the clinic which was focused on post-COVID evaluation was not negligible, representing almost 10% of the ∼1500 pediatric patients examined from 1 January 2021 to 31 August 2022. According to ACEP classification, children enrolled in this study had previously experienced in 72.9% (97) asymptomatic COVID-19 and nearly 27% (36) a mild illness. Clinical and instrumental examinations did not show any relevant abnormality in the functional [left ventricular ejection fraction (LVEF), tricuspid annular plane systolic excursion (TAPSE), pulmonary artery systolic pressure (PASP)] or structural [interventricular septum diameter (IVSd), left ventricular internal diameter (LViD, end-diastolic volume (EDV), left atrium volume (LAV)] parameters examined related to SARS-CoV-2 infection in the total of 133 children. CONCLUSION According to our results, children who experienced an asymptomatic or mild SARS-CoV-2 infection should not be systematically investigated with second-level techniques, such as TTE, in the absence of clinical suspicion or other risk conditions such as congenital heart diseases, comorbidities or risk factors.
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Affiliation(s)
| | - Elisa Lodi
- P.A.S.C.I.A. Center (Heart Failure Care Program, Childhood Heart Diseases and Those at Risk), University of Modena and Reggio Emilia, AOU Polyclinic of Modena, Modena, Italy
| | - Eleonora Rodighiero
- P.A.S.C.I.A. Center (Heart Failure Care Program, Childhood Heart Diseases and Those at Risk), University of Modena and Reggio Emilia, AOU Polyclinic of Modena, Modena, Italy
| | - Jonathan Rosero Morales
- P.A.S.C.I.A. Center (Heart Failure Care Program, Childhood Heart Diseases and Those at Risk), University of Modena and Reggio Emilia, AOU Polyclinic of Modena, Modena, Italy
| | - Giuseppe Fantini
- P.A.S.C.I.A. Center (Heart Failure Care Program, Childhood Heart Diseases and Those at Risk), University of Modena and Reggio Emilia, AOU Polyclinic of Modena, Modena, Italy
| | - Maria Grazia Modena
- P.A.S.C.I.A. Center (Heart Failure Care Program, Childhood Heart Diseases and Those at Risk), University of Modena and Reggio Emilia, AOU Polyclinic of Modena, Modena, Italy
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Begic Z, Djukic M, Begic E, Aziri B, Mladenovic Z, Iglica A, Sabanovic-Bajramovic N, Begic N, Kovacevic-Preradovic T, Stanetic B, Badnjevic A. Left atrial strain analysis in the realm of pediatric cardiology: Advantages and implications. Technol Health Care 2024; 32:1255-1272. [PMID: 37840514 DOI: 10.3233/thc-231087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
BACKGROUND Left atrial (LA) strain analysis has emerged as a noninvasive technique for assessing LA function and early detection of myocardial deformation. Recently, its application has also shown promise in the pediatric population, spanning diverse cardiac conditions that demand accurate and sensitive diagnostic measures. OBJECTIVE This research article endeavors to explore the role of LA strain parameters and contribute to the growing body of knowledge in pediatric cardiology, paving the way for more effective and tailored approaches to patient care. METHODS A comprehensive literature review was conducted to gather evidence from studies using echocardiographic strain imaging techniques across pediatric populations. RESULTS LA strain parameters exhibited greater sensitivity than conventional atrial function indicators, with early detection of diastolic dysfunction and LA remodeling in pediatric cardiomyopathy, children with multisystem inflammatory syndrome, rheumatic heart disease, as well as childhood renal insufficiency and obesity offering prognostic relevance as potential markers in these pediatric subpopulations. However, there remains a paucity of evidence concerning pediatric mitral valve pathology, justifying further exploration. CONCLUSION LA strain analysis carries crucial clinical and prognostic implications in pediatric cardiac conditions, with reliable accuracy and sensitivity to early functional changes.
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Affiliation(s)
- Zijo Begic
- Department of Cardiology, Pediatric Clinic, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Milan Djukic
- Department of Cardiology, University Children's Hospital, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Edin Begic
- Department of Pharmacology, Sarajevo Medical School, Sarajevo School of Science and Technology, Sarajevo, Bosnia and Herzegovina
- Department of Cardiology, General Hospital "Prim. Dr. Abdulah Nakas", Sarajevo, Bosnia and Herzegovina
| | - Buena Aziri
- Department of Pharmacology, Sarajevo Medical School, Sarajevo School of Science and Technology, Sarajevo, Bosnia and Herzegovina
| | - Zorica Mladenovic
- Department of Cardiology, Military Medical Academy, University of Defense, Belgrade, Serbia
| | - Amer Iglica
- Intensive Care Unit, Clinic for Heart, Blood Vessels and Rheumatism, Clinical Center University of Sarajevo, Bosnia and Herzegovina
| | - Nirvana Sabanovic-Bajramovic
- Intensive Care Unit, Clinic for Heart, Blood Vessels and Rheumatism, Clinical Center University of Sarajevo, Bosnia and Herzegovina
| | - Nedim Begic
- Department of Cardiology, Pediatric Clinic, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Tamara Kovacevic-Preradovic
- Department of Cardiology, University Clinical Centre of the Republic of Srpska, Banja Luka, Bosnia and Herzegovina
- Department of Internal Medicine, Medical Faculty, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
| | - Bojan Stanetic
- Department of Cardiology, University Clinical Centre of the Republic of Srpska, Banja Luka, Bosnia and Herzegovina
- Department of Internal Medicine, Medical Faculty, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
| | - Almir Badnjevic
- Verlab Research Institute for Biomedical Engineering, Medical Devices and Artificial Intelligence, Sarajevo, Bosnia and Herzegovina
- Faculty of Pharmacy, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
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Zimmerman D, Shwayder M, Souza A, Su JA, Votava-Smith J, Wagner-Lees S, Kaneta K, Cheng A, Szmuszkovicz J. Cardiovascular Follow-up of Patients Treated for MIS-C. Pediatrics 2023; 152:e2023063002. [PMID: 37964674 DOI: 10.1542/peds.2023-063002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2023] [Indexed: 11/16/2023] Open
Abstract
OBJECTIVES To assess the prevalence of residual cardiovascular pathology by cardiac MRI (CMR), ambulatory rhythm monitoring, and cardiopulmonary exercise testing (CPET) in patients ∼6 months after multisystem inflammatory disease in children (MIS-C). METHODS Patients seen for MIS-C follow-up were referred for CMR, ambulatory rhythm monitoring, and CPET ∼6 months after illness. Patients were included if they had ≥1 follow-up study performed by the time of data collection. MIS-C was diagnosed on the basis of the Centers for Disease Control and Prevention criteria. Myocardial injury during acute illness was defined as serum Troponin-I level >0.05 ng/mL or diminished left ventricular systolic function on echocardiogram. RESULTS Sixty-nine of 153 patients seen for MIS-C follow-up had ≥1 follow-up cardiac study between October 2020-June 2022. Thirty-seven (54%) had evidence of myocardial injury during acute illness. Of these, 12 of 26 (46%) had ≥1 abnormality on CMR, 4 of 33 (12%) had abnormal ambulatory rhythm monitor results, and 18 of 22 (82%) had reduced functional capacity on CPET. Of the 37 patients without apparent myocardial injury, 11 of 21 (52%) had ≥1 abnormality on CMR, 1 of 24 (4%) had an abnormal ambulatory rhythm monitor result, and 11 of 15 (73%) had reduced functional capacity on CPET. The prevalence of abnormal findings was not statistically significantly different between groups. CONCLUSIONS The high prevalence of abnormal findings on follow-up cardiac studies and lack of significant difference between patients with and without apparent myocardial injury during hospitalization suggests that all patients treated for MIS-C warrant cardiology follow-up.
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Affiliation(s)
- Dayna Zimmerman
- Division of Cardiology
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | - Mark Shwayder
- Division of Cardiology
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Andrew Souza
- Division of Cardiology
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Jennifer A Su
- Division of Cardiology
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Jodie Votava-Smith
- Division of Cardiology
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Sharon Wagner-Lees
- Division of Cardiology
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | - Kelli Kaneta
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | - Andrew Cheng
- Division of Cardiology
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Jacqueline Szmuszkovicz
- Division of Cardiology
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
- Keck School of Medicine, University of Southern California, Los Angeles, California
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El Tal T, Morin MP, Morris SK, Farrar DS, Berard RA, Kakkar F, Moore Hepburn C, Baerg K, Beaufils C, Bennett TL, Benseler SM, Beaudoin-Bussières G, Chan K, Cyr C, Dahdah N, Donner EJ, Drouin O, Edjoc R, Eljaouhari M, Embree JE, Farrell C, Finzi A, Forgie S, Giroux R, Kang KT, King M, Laffin Thibodeau M, Lang B, Laxer RM, Luu TM, McCrindle BW, Orkin J, Papenburg J, Pound CM, Price VE, Proulx-Gauthier JP, Purewal R, Sadarangani M, Salvadori MI, Thibeault R, Top KA, Viel-Thériault I, Haddad E, Scuccimarri R, Yeung RSM. Paediatric inflammatory multisystem syndrome in Canada: population-based surveillance and role of SARS-CoV-2 linkage. Pediatr Res 2023; 94:1744-1753. [PMID: 37277605 PMCID: PMC10241135 DOI: 10.1038/s41390-023-02668-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 04/28/2023] [Accepted: 05/09/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND Paediatric inflammatory multisystem syndrome (PIMS) is a rare condition temporally associated with SARS-CoV-2 infection. Using national surveillance data, we compare presenting features and outcomes among children hospitalized with PIMS by SARS-CoV-2 linkage, and identify risk factors for intensive care (ICU). METHODS Cases were reported to the Canadian Paediatric Surveillance Program by a network of >2800 pediatricians between March 2020 and May 2021. Patients with positive versus negative SARS-CoV-2 linkages were compared, with positive linkage defined as any positive molecular or serologic test or close contact with confirmed COVID-19. ICU risk factors were identified with multivariable modified Poisson regression. RESULTS We identified 406 children hospitalized with PIMS, including 49.8% with positive SARS-CoV-2 linkages, 26.1% with negative linkages, and 24.1% with unknown linkages. The median age was 5.4 years (IQR 2.5-9.8), 60% were male, and 83% had no comorbidities. Compared to cases with negative linkages, children with positive linkages experienced more cardiac involvement (58.8% vs. 37.4%; p < 0.001), gastrointestinal symptoms (88.6% vs. 63.2%; p < 0.001), and shock (60.9% vs. 16.0%; p < 0.001). Children aged ≥6 years and those with positive linkages were more likely to require ICU. CONCLUSIONS Although rare, 30% of PIMS hospitalizations required ICU or respiratory/hemodynamic support, particularly those with positive SARS-CoV-2 linkages. IMPACT We describe 406 children hospitalized with paediatric inflammatory multisystem syndrome (PIMS) using nationwide surveillance data, the largest study of PIMS in Canada to date. Our surveillance case definition of PIMS did not require a history of SARS-CoV-2 exposure, and we therefore describe associations of SARS-CoV-2 linkages on clinical features and outcomes of children with PIMS. Children with positive SARS-CoV-2 linkages were older, had more gastrointestinal and cardiac involvement, and hyperinflammatory laboratory picture. Although PIMS is rare, one-third required admission to intensive care, with the greatest risk amongst those aged ≥6 years and those with a SARS-CoV-2 linkage.
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Affiliation(s)
- Tala El Tal
- Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Marie-Paule Morin
- Division of Paediatric Rheumatology-Immunology, CHU Sainte-Justine, Department of Pediatrics, University of Montreal, Montreal, QC, Canada
| | - Shaun K Morris
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
- Division of Infectious Diseases, The Hospital for Sick Children, Toronto, ON, Canada.
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada.
- Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
| | - Daniel S Farrar
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada
| | - Roberta A Berard
- Division of Rheumatology, Department of Pediatrics, London Health Sciences Centre, London, ON, Canada
| | - Fatima Kakkar
- Division of Infectious Diseases, CHU Sainte-Justine, Montreal, QC, Canada
| | - Charlotte Moore Hepburn
- Department of Pediatrics, Division of Paediatric Medicine, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Krista Baerg
- Department of Pediatrics, University of Saskatchewan, Saskatoon, SK, Canada
- Division of General Pediatrics, Jim Pattison Children's Hospital, Saskatchewan Health Authority, Saskatoon, SK, Canada
| | - Camille Beaufils
- Division of Paediatric Rheumatology-Immunology, CHU Sainte-Justine, Department of Pediatrics, University of Montreal, Montreal, QC, Canada
| | | | - Susanne M Benseler
- Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Division of Rheumatology, Department of Pediatrics, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
| | - Guillaume Beaudoin-Bussières
- Department of Microbiology, Immunology and Infectious Diseases, Université de Montréal, Montreal, QC, Canada
- Centre de Recherche du CHUM, Montreal, QC, Canada
| | - Kevin Chan
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Children's and Women's Health, Trillium Health Partners, Mississauga, ON, Canada
| | - Claude Cyr
- Service de Soins Intensifs Pédiatriques, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Nagib Dahdah
- Division of Pediatric Cardiology, CHU Sainte-Justine, Department of Pediatrics, University of Montreal, Montreal, QC, Canada
| | - Elizabeth J Donner
- Division of Neurology, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Olivier Drouin
- Division of General Pediatrics, Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada
- Department of Social and Preventive Medicine, School of Public Health, Université de Montréal, Montreal, QC, Canada
| | | | | | - Joanne E Embree
- Department of Paediatrics and Child Health, University of Manitoba, Winnipeg, MB, Canada
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, MB, Canada
| | - Catherine Farrell
- Division of Paediatric Intensive Care, Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada
| | - Andrés Finzi
- Department of Microbiology, Immunology and Infectious Diseases, Université de Montréal, Montreal, QC, Canada
- Centre de Recherche du CHUM, Montreal, QC, Canada
| | - Sarah Forgie
- Division of Infectious Diseases, Department of Pediatrics, University of Alberta and Stollery Children's Hospital, Edmonton, AB, Canada
| | - Ryan Giroux
- Women's and Children's Health Program, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Kristopher T Kang
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Melanie King
- Canadian Paediatric Surveillance Program, Canadian Paediatric Society, Ottawa, ON, Canada
| | | | - Bianca Lang
- Division of Rheumatology, Department of Pediatrics, Dalhousie University, Halifax, NS, Canada
| | - Ronald M Laxer
- Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Thuy Mai Luu
- Division of General Pediatrics, Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada
| | - Brian W McCrindle
- The Labatt Family Heart Centre, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Julia Orkin
- Department of Pediatrics, Division of Paediatric Medicine, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jesse Papenburg
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Montreal Children's Hospital, Montreal, QC, Canada
- Division of Microbiology, Department of Clinical Laboratory Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Catherine M Pound
- Division of Consulting Pediatrics, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Victoria E Price
- Division of Paediatric Hematology/Oncology, Department of Pediatrics, Dalhousie University, Halifax, NS, Canada
| | | | - Rupeena Purewal
- Department of Pediatrics, University of Saskatchewan, Saskatoon, SK, Canada
- Division of Paediatric Infectious Diseases, Jim Pattison Children's Hospital, Saskatchewan Health Authority, Saskatoon, SK, Canada
| | - Manish Sadarangani
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | | | - Roseline Thibeault
- Division of Pediatric Infectious Diseases, Department of Paediatrics, CHU de Quebec-University of Laval, Quebec City, QC, Canada
| | - Karina A Top
- Department of Pediatrics, Dalhousie University, Halifax, NS, Canada
| | - Isabelle Viel-Thériault
- Division of Infectious Diseases, Department of Pediatrics, CHU de Québec-Université Laval, Quebec City, QC, Canada
| | - Elie Haddad
- Division of Paediatric Rheumatology-Immunology, CHU Sainte-Justine, Department of Pediatrics, University of Montreal, Montreal, QC, Canada.
| | - Rosie Scuccimarri
- Division of Paediatric Rheumatology, Montreal Children's Hospital/McGill University Health Centre, Montreal, QC, Canada
| | - Rae S M Yeung
- Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
- Cell Biology Program, The Hospital for Sick Children Research Institute, Toronto, ON, Canada.
- Department of Immunology and Institute of Medical Science, University of Toronto, Toronto, ON, Canada.
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9
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Başkan S, Özer PK, Keskin GY, Gövdeli EA, Ömeroğlu RE. Subclinical myocardial assessment after BNT162b2 messenger RNA COVID-19 vaccination in adolescents with chronic heart disease: a speckle-tracking echocardiography study. Cardiol Young 2023; 33:2252-2257. [PMID: 36650738 DOI: 10.1017/s104795112200422x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE Case reports of the development of perimyocarditis in adolescents and young adults after BNT162b2 messenger RNA (mRNA) COVID-19 vaccination have raised concerns about the cardiac side effects of the vaccine. The aim of the study was to evaluate clinical follow-up and subclinical myocardial function after mRNA COVID-19 vaccine in adolescents with chronic heart disease. METHODS Forty-one adolescents aged 12-18 who were followed up at paediatric cardiology clinic between December 2021 and May 2022, and who had received two doses of the Pfizer-BioNTech COVID-19 mRNA vaccine were included in the study. The patients were evaluated five times in total - before the vaccination, one week after receiving the first dose, one month after receiving the first dose, one week after receiving the second dose, and one month after receiving the second dose. Cardiac assessment for all patients included an electrocardiogram, transthoracic echocardiography, and two-dimensional speckle-tracking strain echocardiography for left ventricular subclinical myocardial function. RESULTS The mean age of the adolescents was 16.2 ± 1.5 years, and 56% (n = 23) were male. There was no statistically significant difference in patients' echocardiographic measurements including left ventricular global longitudinal strain and electrocardiogram parameters including PR, QRS, and QTc intervals through the follow-up. Seven patients reported cardiac complaints at post-vaccination follow-up visits, but laboratory and echocardiographic evidence of cardiac involvement was not observed. CONCLUSIONS Based on the results of our study, the mRNA COVID-19 vaccine did not cause impairment in subclinical myocardial function assessed by speckle-tracking echocardiography in adolescents with chronic heart disease.
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Affiliation(s)
- Serra Başkan
- Department of Pediatric Cardiology, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Pelin Karaca Özer
- Department of Cardiology, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Gülperi Yağar Keskin
- Department of Pediatric Cardiology, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Elif Ayduk Gövdeli
- Department of Cardiology, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Rukiye Eker Ömeroğlu
- Department of Pediatric Cardiology, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
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10
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McAree D, Griffith GJ, Husain N, Koenig P, Carr M, Ward K. Multisystem Inflammatory Syndrome in Children (MIS-C): Reduced Exercise Duration and Capacity at Six Month Follow-Up. Pediatr Cardiol 2023; 44:1605-1612. [PMID: 37344558 DOI: 10.1007/s00246-023-03217-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 06/18/2023] [Indexed: 06/23/2023]
Abstract
Myocarditis is common in Multisystem Inflammatory Syndrome in Children (MIS-C), and the mechanism may differ from idiopathic/viral myocarditis as MIS-C involves a hyper-inflammatory state weeks after COVID-19. We sought to evaluate exercise stress testing (EST) in these patients as EST may help guide return-to-play recommendations. Retrospective cohort study evaluating ESTs (standard Bruce treadmill protocol) from MIS-C patients from 2020 to 2022, compared to myocarditis patients and age, sex, and weight matched controls from 2005 to 2019. ESTs included 22 MIS-C patients (mean age 11.9 years) with 14 cardiopulmonary and 8 cardiovascular tests, 33 myocarditis (15.5 years), and 44 controls (12.0 years). Percent-predicted peak VO2 was abnormal (< 80% predicted) in 11/14 (79%) MIS-C patients, 13/33 (39%) myocarditis, and 17/44 (39%) controls (p = 0.04). Exercise duration was shorter in MIS-C than myocarditis or control cohorts (p = 0.01). Isolated atrial or ventricular ectopy was seen in 8/22 (36%) MIS-C, 9/33 (27%) myocarditis, and 5/44 (11%) controls (p = 0.049). No arrhythmias/complex ectopy or evidence of ischemia were noted, though non-specific ST/T wave abnormalities occurred in 4/22 (18%) MIS-C, 5/33 (15%) myocarditis, and 3/44 (7%) controls. Exercise duration and percent-predicted peak VO2 were significantly reduced in MIS-C at mean 6-month follow-up compared to pre-COVID era idiopathic/viral myocarditis and control cohorts. This may be secondary to deconditioning during the pandemic and/or chronic cardiopulmonary or autonomic effects of COVID/MIS-C. Although there were no exercise-induced arrhythmias in our MIS-C patients, larger cohort studies are warranted. EST in MIS-C follow-up may help evaluate safety and timing of return to play and potentially mitigate further deconditioning.
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Affiliation(s)
- Daniel McAree
- Department of Pediatric Cardiology, Northwestern University, Ann & Robert H. Lurie Children's Hospital, 225 E. Chicago Ave, Chicago, IL, 60611, USA.
| | - Garett J Griffith
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL, USA
| | - Nazia Husain
- Department of Pediatric Cardiology, Northwestern University, Ann & Robert H. Lurie Children's Hospital, 225 E. Chicago Ave, Chicago, IL, 60611, USA
| | - Peter Koenig
- Department of Pediatric Cardiology, Northwestern University, Ann & Robert H. Lurie Children's Hospital, 225 E. Chicago Ave, Chicago, IL, 60611, USA
| | - Michael Carr
- Department of Pediatric Cardiology, Northwestern University, Ann & Robert H. Lurie Children's Hospital, 225 E. Chicago Ave, Chicago, IL, 60611, USA
| | - Kendra Ward
- Department of Pediatric Cardiology, Northwestern University, Ann & Robert H. Lurie Children's Hospital, 225 E. Chicago Ave, Chicago, IL, 60611, USA
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11
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Arora R, Sethuraman U, Merolla DM, Sanil Y, Bharadwaj M, Kannikeswaran N. Efficacy of Biomarkers in Identifying Abnormal Echocardiogram in Multisystem Inflammatory Syndrome in Children. Clin Pediatr (Phila) 2023; 62:908-913. [PMID: 36585758 DOI: 10.1177/00099228221145271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Cardiac involvement in multisystem inflammatory syndrome in children (MIS-C) is common and contributes to significant morbidity and mortality. We evaluated the efficacy of cardiac biomarkers in detection of an abnormal echocardiogram in MIS-C patients. A retrospective chart review of children ≤18 years diagnosed with MIS-C at our hospital was performed. Sensitivity and specificity of high-sensitivity troponin I (hs-TnI) and B-type natriuretic peptide (BNP) were estimated for an abnormal echocardiogram. Of the 83 patients with MIS-C, 33 (39.8%) had an abnormal echocardiogram. While BNP was more sensitive, hs-TnI >50 ng/L was more specific for detecting an abnormal echocardiogram. Compared with children who had normal hs-TnI levels (<17 ng/L), those with hs-TnI >50 ng/L were more likely to have an echocardiographic abnormality (relative risk: 4.9; 95% CI, 2.9-10.9). Children with abnormal BNP and/or troponin (especially greater than 3-fold the upper limit of normal) would benefit from an urgent echocardiogram in the emergency department.
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Affiliation(s)
- Rajan Arora
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Usha Sethuraman
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - David M Merolla
- Department of Sociology, Wayne State University, Detroit, MI, USA
| | - Yamuna Sanil
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Madhumithaa Bharadwaj
- Pediatric Residency Program, Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Nirupama Kannikeswaran
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
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12
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Rybkina K, Bell JN, Bradley MC, Wohlbold T, Scafuro M, Meng W, Korenberg RC, Davis-Porada J, Anderson BR, Weller RJ, Milner JD, Moscona A, Porotto M, Luning Prak ET, Pethe K, Connors TJ, Farber DL. SARS-CoV-2 infection and recovery in children: Distinct T cell responses in MIS-C compared to COVID-19. J Exp Med 2023; 220:e20221518. [PMID: 37133746 PMCID: PMC10163842 DOI: 10.1084/jem.20221518] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 02/09/2023] [Accepted: 04/07/2023] [Indexed: 05/04/2023] Open
Abstract
SARS-CoV-2 infection for most children results in mild or minimal symptoms, though in rare cases severe disease can develop, including a multisystem inflammatory syndrome (MIS-C) with myocarditis. Here, we present longitudinal profiling of immune responses during acute disease and following recovery in children who developed MIS-C, relative to children who experienced more typical symptoms of COVID-19. T cells in acute MIS-C exhibited transient signatures of activation, inflammation, and tissue residency which correlated with cardiac disease severity, while T cells in acute COVID-19 upregulated markers of follicular helper T cells for promoting antibody production. The resultant memory immune response in recovery showed increased frequencies of virus-specific memory T cells with pro-inflammatory functions in children with prior MIS-C compared to COVID-19 while both cohorts generated comparable antibody responses. Together our results reveal distinct effector and memory T cell responses in pediatric SARS-CoV-2 infection delineated by clinical syndrome, and a potential role for tissue-derived T cells in the immune pathology of systemic disease.
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Affiliation(s)
- Ksenia Rybkina
- Department of Microbiology and Immunology, Columbia University Irving Medical Center, New York, NY, USA
| | - Joseph N. Bell
- Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Marissa C. Bradley
- Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Teddy Wohlbold
- Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Marika Scafuro
- Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Wenzhao Meng
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Rebecca C. Korenberg
- Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Julia Davis-Porada
- Department of Microbiology and Immunology, Columbia University Irving Medical Center, New York, NY, USA
| | - Brett R. Anderson
- Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Rachel J. Weller
- Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Joshua D. Milner
- Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Anne Moscona
- Department of Microbiology and Immunology, Columbia University Irving Medical Center, New York, NY, USA
- Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Matteo Porotto
- Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Eline T. Luning Prak
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kalpana Pethe
- Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Thomas J. Connors
- Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Donna L. Farber
- Department of Microbiology and Immunology, Columbia University Irving Medical Center, New York, NY, USA
- Department of Surgery, Columbia Irving University Medical Center, New York, NY, USA
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13
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Clark JD, Albers EL, Albert JE, Berkman ER, Englund JA, Farris RWD, Johnson BA, Lewis‐Newby M, McGuire J, Rogers M, Thompson HM, Wagner TA, Wells C, Yanay O, Zerr DM, Limaye AP. SARS-CoV-2 RNA positive pediatric organ donors: A case report. Pediatr Transplant 2023; 27:e14452. [PMID: 36518025 PMCID: PMC9878170 DOI: 10.1111/petr.14452] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/23/2022] [Accepted: 10/24/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Preliminary evidence suggests that non-lung organ donation from resolved, asymptomatic or mildly symptomatic SARS-CoV-2 infected adults may be safe. However, several biological aspects of SARS-CoV-2 infection differ in children and the risk for transmission and outcomes of recipients from pediatric donors with SARS-CoV-2 infection are not well described. METHODS We report two unvaccinated asymptomatic pediatric non-lung organ deceased donors who tested positive for SARS-CoV-2 RNA by RT-PCR. Donor One unexpectedly had SARS-CoV-2 RNA detected in nasopharyngeal swab and plasma specimens at autopsy despite several negative tests (upper and lower respiratory tract) in the days prior to organ recovery. Donor Two had SARS-CoV- 2 RNA detected in multiple nasopharyngeal swabs but not lower respiratory tract specimens (endotracheal aspirate and bronchoalveolar lavage) during routine surveillance prior to organ recovery and was managed with remdesivir and monoclonal antibodies prior to organ recovery. RESULTS Two hearts, two livers and four kidneys were successfully transplanted into seven recipients. No donor to recipient transmission of SARS-CoV-2 was observed and graft function of all organs has remained excellent for up to 7 months of followup. CONCLUSIONS Due to the persistent gap between organ availability and the number of children waiting for transplants, deceased pediatric patients with non-disseminated SARS-CoV-2 infection, isolated to upper and/or lower respiratory tract, should be considered as potential non-lung organ donors.
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Affiliation(s)
- Jonna D. Clark
- Division of Bioethics and Palliative Care, Department of PediatricsUniversity of Washington School of MedicineSeattleWashingtonUSA
- Treuman Katz Center for Pediatric BioethicsSeattle Children's Hospital and Research InstituteSeattleWashingtonUSA
- Division of Pediatric Critical Care MedicineUniversity of Washington, Seattle Children's Research InstituteSeattleWashingtonUSA
| | - Erin L. Albers
- Division of Pediatric CardiologyUniversity of Washington School of MedicineSeattleWashingtonUSA
| | - Jesselle E. Albert
- Division of Pediatric Critical Care MedicineUniversity of Washington, Seattle Children's Research InstituteSeattleWashingtonUSA
| | - Emily R. Berkman
- Division of Bioethics and Palliative Care, Department of PediatricsUniversity of Washington School of MedicineSeattleWashingtonUSA
- Treuman Katz Center for Pediatric BioethicsSeattle Children's Hospital and Research InstituteSeattleWashingtonUSA
- Division of Pediatric Critical Care MedicineUniversity of Washington, Seattle Children's Research InstituteSeattleWashingtonUSA
| | - Janet A. Englund
- Division of Pediatric Infectious DiseasesUniversity of Washington, Seattle Children's Research InstituteSeattleWashingtonUSA
| | - Reid W. D. Farris
- Division of Pediatric Critical Care MedicineUniversity of Washington, Seattle Children's Research InstituteSeattleWashingtonUSA
| | | | - Mithya Lewis‐Newby
- Division of Bioethics and Palliative Care, Department of PediatricsUniversity of Washington School of MedicineSeattleWashingtonUSA
- Treuman Katz Center for Pediatric BioethicsSeattle Children's Hospital and Research InstituteSeattleWashingtonUSA
- Division of Pediatric Critical Care MedicineUniversity of Washington, Seattle Children's Research InstituteSeattleWashingtonUSA
| | - John McGuire
- Division of Pediatric Critical Care MedicineUniversity of Washington, Seattle Children's Research InstituteSeattleWashingtonUSA
| | | | | | - Thor A. Wagner
- Division of Pediatric Infectious DiseasesUniversity of Washington, Seattle Children's Research InstituteSeattleWashingtonUSA
| | | | - Ofer Yanay
- Division of Pediatric Critical Care MedicineUniversity of Washington, Seattle Children's Research InstituteSeattleWashingtonUSA
| | - Danielle M. Zerr
- Division of Pediatric Infectious DiseasesUniversity of Washington, Seattle Children's Research InstituteSeattleWashingtonUSA
| | - Ajit P. Limaye
- Department of Medicine, Division of Allergy and Infectious DiseasesUniversity of WashingtonSeattleWashingtonUSA
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14
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Dizon BLP, Redmond C, Gotschlich EC, Sule S, Ronis T, Vazzana KM, Sherman MA, Connor R, Bosk A, Dham N, Harahsheh AS, Wells E, DeBiasi R, Srinivasalu H. Clinical outcomes and safety of anakinra in the treatment of multisystem inflammatory syndrome in children: a single center observational study. Pediatr Rheumatol Online J 2023; 21:76. [PMID: 37525200 PMCID: PMC10388456 DOI: 10.1186/s12969-023-00858-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/04/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Evidence for the treatment of multisystem inflammatory syndrome in children (MIS-C) is lacking. Anakinra, which targets IL-1-mediated inflammation, is reserved for refractory cases of MIS-C; however, its use in the treatment of MIS-C is not clearly established. PATIENTS AND METHODS To examine a role for anakinra in MIS-C, we performed a single center observational cohort study of all MIS-C patients diagnosed at our children's hospital from May 15 to November 15, 2020. Demographics, clinical features, diagnostic testing, and cardiac function parameters were compared between MIS-C patients treated with intravenous immunoglobulin (IVIG) monotherapy and IVIG with anakinra (IVIG + anakinra). RESULTS Among 46 patients with confirmed MIS-C, 32 (70%) were in the IVIG + anakinra group, of which 9 (28%) were also given corticosteroids (CS). No patients were treated with anakinra alone. MIS-C patients in the IVIG + anakinra group were enriched in a CV shock phenotype (p = 0.02), and those with CV shock were treated with higher doses of anakinra for a longer duration. Furthermore, MIS-C patients in the IVIG + anakinra group exhibited improvements in fever and cardiac function with or without CS. No significant adverse events were observed, and no differences in IL-1β levels were found among MIS-C patients in the IVIG + anakinra group. CONCLUSIONS Anakinra treatment, which was co-administered with IVIG primarily in patients with severe MIS-C, was associated with improvements in fever and cardiac function, and demonstrated a favorable side-effect profile. These findings suggest a role for adjunctive anakinra in the treatment of severe MIS-C.
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Affiliation(s)
- Brian L P Dizon
- Division of Rheumatology, Children's National Hospital, Washington, DC, USA
- Rheumatology Fellowship and Training Branch, The National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, MD, USA
| | - Christopher Redmond
- Division of Rheumatology, Children's National Hospital, Washington, DC, USA
- Rheumatology Fellowship and Training Branch, The National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, MD, USA
| | - Emily C Gotschlich
- Division of Rheumatology, Children's National Hospital, Washington, DC, USA
| | - Sangeeta Sule
- Division of Rheumatology, Children's National Hospital, Washington, DC, USA
- Department of Pediatrics, George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Tova Ronis
- Division of Rheumatology, Children's National Hospital, Washington, DC, USA
- Department of Pediatrics, George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Kathleen M Vazzana
- Division of Rheumatology, Children's National Hospital, Washington, DC, USA
- Department of Pediatric Rheumatology, Arnold Palmer Hospital for Children, Orlando, FL, USA
| | - Matthew A Sherman
- Division of Rheumatology, Children's National Hospital, Washington, DC, USA
| | - Rachael Connor
- Division of Rheumatology, Children's National Hospital, Washington, DC, USA
| | - Abigail Bosk
- Division of Rheumatology, Children's National Hospital, Washington, DC, USA
- Department of Pediatrics, George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Niti Dham
- Department of Pediatrics, George Washington University School of Medicine & Health Sciences, Washington, DC, USA
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - Ashraf S Harahsheh
- Department of Pediatrics, George Washington University School of Medicine & Health Sciences, Washington, DC, USA
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - Elizabeth Wells
- Department of Pediatrics, George Washington University School of Medicine & Health Sciences, Washington, DC, USA
- Division of Neurology, Children's National Hospital, Washington, DC, USA
| | - Roberta DeBiasi
- Department of Pediatrics, George Washington University School of Medicine & Health Sciences, Washington, DC, USA
- Division of Infectious Diseases, Children's National Hospital, Washington, DC, USA
| | - Hemalatha Srinivasalu
- Division of Rheumatology, Children's National Hospital, Washington, DC, USA.
- Department of Pediatrics, George Washington University School of Medicine & Health Sciences, Washington, DC, USA.
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15
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Castaldo P, d’Alanno G, Biserni GB, Moratti M, Conti F, Fabi M, Lanari M. Exploring Factors Influencing Changes in Incidence and Severity of Multisystem Inflammatory Syndrome in Children. Pathogens 2023; 12:997. [PMID: 37623957 PMCID: PMC10458149 DOI: 10.3390/pathogens12080997] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/16/2023] [Accepted: 07/25/2023] [Indexed: 08/26/2023] Open
Abstract
Multisystem inflammatory syndrome (MIS-C) is a rare condition associated with COVID-19 affecting children, characterized by severe and aberrant systemic inflammation leading to nonspecific symptoms, such as gastrointestinal, cardiac, respiratory, hematological, and neurological disorders. In the last year, we have experienced a progressive reduction in the incidence and severity of MIS-C, reflecting the worldwide trend. Thus, starting from the overall trend in the disease in different continents, we reviewed the literature, hypothesizing the potential influencing factors contributing to the reduction in cases and the severity of MIS-C, particularly the vaccination campaign, the spread of different SARS-CoV-2 variants (VOCs), and the changes in human immunological response. The decrease in the severity of MIS-C and its incidence seem to be related to a combination of different factors rather than a single cause. Maturation of an immunological memory to SARS-CoV-2 over time, the implication of mutations of key amino acids of S protein in VOCs, and the overall immune response elicited by vaccination over the loss of neutralization of vaccines to VOCs seem to play an important role in this change.
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Affiliation(s)
- Pasquale Castaldo
- Specialty School of Pediatrics, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (P.C.); (G.d.); (M.M.)
| | - Gabriele d’Alanno
- Specialty School of Pediatrics, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (P.C.); (G.d.); (M.M.)
| | | | - Mattia Moratti
- Specialty School of Pediatrics, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy; (P.C.); (G.d.); (M.M.)
| | - Francesca Conti
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Marianna Fabi
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (M.F.); (M.L.)
| | - Marcello Lanari
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (M.F.); (M.L.)
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16
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Jepson BM, Beaver M, Colquitt JL, Truong DT, Crandall H, McFarland C, Williams R, Ou Z, Jensen D, Minich LL, Binka E. Left atrial strain in multisystem inflammatory syndrome in children (MIS-C) and associations with systemic inflammation and cardiac injury. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.05.22.23290346. [PMID: 37292768 PMCID: PMC10246144 DOI: 10.1101/2023.05.22.23290346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Background Multisystem inflammatory syndrome in children (MIS-C) commonly involves cardiac injury with both systolic and diastolic dysfunction. Left atrial strain (LAS) detects subclinical diastolic dysfunction in adults but is infrequently used in children. We evaluated LAS in MIS-C and the associations with systemic inflammation and cardiac injury. Methods In this retrospective cohort study, conventional parameters and LAS (reservoir [LAS-r], conduit [LAS-cd], and contractile [LAS-ct]) obtained from admission echocardiograms of MIS-C patients were compared to healthy controls and between MIS-C patients with and without cardiac injury (BNP >500 pg/ml or troponin-I >0.04 ng/ml). Correlation and logistic regression analyses were performed to assess LAS associations with admission inflammatory and cardiac biomarkers. Reliability testing was performed. Results Median LAS components were reduced in MIS-C patients (n=118) compared to controls (n=20) (LAS-r: 31.8 vs. 43.1%, p<0.001; LAS-cd: -28.8 vs. -34.5%, p=0.006; LAS-ct: -5.2 vs. -9.3%, p<0.001) and reduced in MIS-C patients with cardiac injury (n=59) compared to no injury (n=59) (LAS-r: 29.6 vs. 35.8%, p=0.001; LAS-cd: -26.5 vs. -30.4%, p=0.036; LAS-ct: -4.6 vs. -9.3%, p=0.008). An LAS-ct peak was absent in 65 (55%) MIS-C patients but present in all controls (p<0.001). Procalcitonin had strong correlation with averaged E/e' (r=0.55, p=0.001); ESR had moderate correlation with LAS-ct (r=-0.41, p=0.007); BNP had moderate correlation with LAS-r (r=-0.39, p<0.001) and LAS-ct (r=0.31, p=0.023), and troponin-I had only weak correlations. No strain indices were independently associated with cardiac injury on regression analysis. Intra-rater reliability was good for all LAS components; and inter-rater reliability was good to excellent for LAS-r, and fair for LAS-cd and LAS-ct. Conclusions LAS analysis, particularly the absence of a LAS-ct peak, was reproducible and may be superior to conventional echocardiographic parameters for detecting diastolic dysfunction in MIS-C. No strain parameters on admission were independently associated with cardiac injury.
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Sherif ZA, Gomez CR, Connors TJ, Henrich TJ, Reeves WB. Pathogenic mechanisms of post-acute sequelae of SARS-CoV-2 infection (PASC). eLife 2023; 12:e86002. [PMID: 36947108 PMCID: PMC10032659 DOI: 10.7554/elife.86002] [Citation(s) in RCA: 45] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/10/2023] [Indexed: 03/23/2023] Open
Abstract
COVID-19, with persistent and new onset of symptoms such as fatigue, post-exertional malaise, and cognitive dysfunction that last for months and impact everyday functioning, is referred to as Long COVID under the general category of post-acute sequelae of SARS-CoV-2 infection (PASC). PASC is highly heterogenous and may be associated with multisystem tissue damage/dysfunction including acute encephalitis, cardiopulmonary syndromes, fibrosis, hepatobiliary damages, gastrointestinal dysregulation, myocardial infarction, neuromuscular syndromes, neuropsychiatric disorders, pulmonary damage, renal failure, stroke, and vascular endothelial dysregulation. A better understanding of the pathophysiologic mechanisms underlying PASC is essential to guide prevention and treatment. This review addresses potential mechanisms and hypotheses that connect SARS-CoV-2 infection to long-term health consequences. Comparisons between PASC and other virus-initiated chronic syndromes such as myalgic encephalomyelitis/chronic fatigue syndrome and postural orthostatic tachycardia syndrome will be addressed. Aligning symptoms with other chronic syndromes and identifying potentially regulated common underlining pathways may be necessary for understanding the true nature of PASC. The discussed contributors to PASC symptoms include sequelae from acute SARS-CoV-2 injury to one or more organs, persistent reservoirs of the replicating virus or its remnants in several tissues, re-activation of latent pathogens such as Epstein-Barr and herpes viruses in COVID-19 immune-dysregulated tissue environment, SARS-CoV-2 interactions with host microbiome/virome communities, clotting/coagulation dysregulation, dysfunctional brainstem/vagus nerve signaling, dysautonomia or autonomic dysfunction, ongoing activity of primed immune cells, and autoimmunity due to molecular mimicry between pathogen and host proteins. The individualized nature of PASC symptoms suggests that different therapeutic approaches may be required to best manage specific patients.
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Affiliation(s)
- Zaki A Sherif
- Department of Biochemistry & Molecular Biology, Howard University College of MedicineWashington, District of ColumbiaUnited States
| | - Christian R Gomez
- Division of Lung Diseases, National Institutes of Health (NIH), National Heart, Lung and Blood Institute (NHLBI)BethesdaUnited States
| | - Thomas J Connors
- Department of Pediatrics, Division of Critical Care, Columbia University Vagelos College of Physicians and Surgeons and New York - Presbyterian Morgan Stanley Children's HospitalNew YorkUnited States
| | - Timothy J Henrich
- Division of Experimental Medicine, University of CaliforniaSan FranciscoUnited States
| | - William Brian Reeves
- Department of Medicine, Joe R. and Teresa Lozano Long School of Medicine, University of TexasSan AntonioUnited States
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18
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Das B, Deshpande S, Akam-Venkata J, Shakti D, Moskowitz W, Lipshultz SE. Heart Failure with Preserved Ejection Fraction in Children. Pediatr Cardiol 2023; 44:513-529. [PMID: 35978175 DOI: 10.1007/s00246-022-02960-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/22/2022] [Indexed: 11/27/2022]
Abstract
Diastolic dysfunction (DD) refers to abnormalities in the mechanical function of the left ventricle (LV) during diastole. Severe LVDD can cause symptoms and the signs of heart failure (HF) in the setting of normal or near normal LV systolic function and is referred to as diastolic HF or HF with preserved ejection fraction (HFpEF). Pediatric cardiologists have long speculated HFpEF in children with congenital heart disease and cardiomyopathy. However, understanding the risk factors, clinical course, and validated biomarkers predictive of the outcome of HFpEF in children is challenging due to heterogeneous etiologies and overlapping pathophysiological mechanisms. The natural history of HFpEF varies depending upon the patient's age, sex, race, geographic location, nutritional status, biochemical risk factors, underlying heart disease, and genetic-environmental interaction, among other factors. Pediatric onset HFpEF is often not the same disease as in adults. Advances in the noninvasive evaluation of the LV diastolic function by strain, and strain rate analysis with speckle-tracking echocardiography, tissue Doppler imaging, and cardiac magnetic resonance imaging have increased our understanding of the HFpEF in children. This review addresses HFpEF in children and identifies knowledge gaps in the underlying etiologies, pathogenesis, diagnosis, and management, especially compared to adults with HFpEF.
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Affiliation(s)
- Bibhuti Das
- Department of Pediatrics, Division of Cardiology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216, USA.
| | - Shriprasad Deshpande
- Department of Pediatrics, Children's National Hospital, The George Washington University, Washington, DC, USA
| | - Jyothsna Akam-Venkata
- Department of Pediatrics, Division of Cardiology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216, USA
| | - Divya Shakti
- Department of Pediatrics, Division of Cardiology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216, USA
| | - William Moskowitz
- Department of Pediatrics, Division of Cardiology, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216, USA
| | - Steven E Lipshultz
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Oishei Children's Hospital, Buffalo, NY, 14203, USA
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Pinninti S, Hebson C, Collins J, Trieu C, Boppana S, Buchfellner M, Seripin C, Yarbrough A, Poole C, Ross S, James S, Hutto C, Boppana S. Impact of Severe Acute Respiratory Syndrome Coronavirus 2 Variants on Short- and Mid-term Cardiac Outcomes in Multisystem Inflammatory Syndrome in Children. Open Forum Infect Dis 2023; 10:ofad009. [PMID: 36686629 PMCID: PMC9850272 DOI: 10.1093/ofid/ofad009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 01/09/2023] [Indexed: 01/13/2023] Open
Abstract
Cardiac outcomes of 131 children with multisystem inflammatory syndrome (MIS-C) were examined. The majority of the cohort was male (66.4%) and half were Black (49.6%). Cardiac involvement was evident in 25% of the cohort at diagnosis. Favorable short- and mid-term outcomes were documented on follow-up, irrespective of the severe acute respiratory syndrome coronavirus 2 variants causing the infection.
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Affiliation(s)
- Swetha Pinninti
- Correspondence: Swetha Pinninti, MD, Division of Pediatric Infectious Diseases, University of Alabama at Birmingham, CHB 114A, 1600 7th Ave S, Birmingham, AL 35233 (); Suresh Boppana, MD, Heersink School of Medicine I, University of Alabama at Birmingham, CHB 114B, 1600 6th Ave S, Birmingham, AL 35233 ()
| | - Camden Hebson
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jacqueline Collins
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Connie Trieu
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - Sushma Boppana
- National Institutes of Health Medical Scientist Training Program, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Markus Buchfellner
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | | | - Claudette Poole
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Shannon Ross
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Scott James
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Cecelia Hutto
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Suresh Boppana
- Correspondence: Swetha Pinninti, MD, Division of Pediatric Infectious Diseases, University of Alabama at Birmingham, CHB 114A, 1600 7th Ave S, Birmingham, AL 35233 (); Suresh Boppana, MD, Heersink School of Medicine I, University of Alabama at Birmingham, CHB 114B, 1600 6th Ave S, Birmingham, AL 35233 ()
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20
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Das BB, Shakti D, Ghaleb S, Akam-Venkata J, Moskowitz WB, Osakwe O, Weiland MD, Arya S, Gajula V, Taylor MB. Racial and Ethnic Disparity in Multisystem Inflammatory Syndrome in Children Associated With SARS-CoV-2 in Mississippi, USA. Clin Pediatr (Phila) 2023; 62:8-16. [PMID: 35801262 PMCID: PMC9720419 DOI: 10.1177/00099228221108591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
We aimed to study the disparity in the clinical profile and outcomes of hospitalized Multisystem Inflammatory Syndrome in Children (MIS-C) patients at our center. The second goal was to examine the temporal association with preceding SARS-CoV-2 infection by race/ethnicity in our community in Mississippi. We found the racial disparity in the prevalence of MIS-C exceeded its temporal association with SARS-CoV-2 infections. We included 51 consecutive MIS-C patients hospitalized, whose median age was 9 (interquartile range [IQR] 5-12) years, 58% were male, 71% were black, 25% were white, and 4% belonged to other groups. We found a delay between onset of symptoms and hospitalization in black patients compared with white patients with a median of 2 (IQR 0-7) vs median of 0 (0-5) urgent care visits (P = .022), respectively. Black patients were hospitalized longer (median 8, IQR 2-39 days) than whites (median 5, IQR 3-14 days), P = .047. A total of 38.9% of blacks and 23.1% of whites were admitted to intensive care unit (P = .498); 36.1% of blacks had severe cardiac involvement vs 23.1% of white patients, P = .531. Future studies of MIS-C are required to improve health equity for children.
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Affiliation(s)
- Bibhuti B. Das
- Division of Cardiology, Department of Pediatrics, The University of Mississippi Medical Center, Jackson, MS, USA,Bibhuti B. Das, Division of Cardiology, Department of Pediatrics, The University of Mississippi Medical Center, 2500 N State St., Jackson, MS 39216, USA.
| | - Divya Shakti
- Division of Cardiology, Department of Pediatrics, The University of Mississippi Medical Center, Jackson, MS, USA
| | - Stephanie Ghaleb
- Division of Cardiology, Department of Pediatrics, The University of Mississippi Medical Center, Jackson, MS, USA
| | - Jyothsna Akam-Venkata
- Division of Cardiology, Department of Pediatrics, The University of Mississippi Medical Center, Jackson, MS, USA
| | - William B. Moskowitz
- Division of Cardiology, Department of Pediatrics, The University of Mississippi Medical Center, Jackson, MS, USA
| | - Onyekachukwu Osakwe
- Division of Cardiology, Department of Pediatrics, The University of Mississippi Medical Center, Jackson, MS, USA
| | - Michael D. Weiland
- Division of Cardiology, Department of Pediatrics, The University of Mississippi Medical Center, Jackson, MS, USA
| | - Sandeep Arya
- Division of Critical Care, Department of Pediatrics, The University of Mississippi Medical Center, Jackson, MS, USA
| | - Viswanath Gajula
- Division of Critical Care, Department of Pediatrics, The University of Mississippi Medical Center, Jackson, MS, USA
| | - Mary B. Taylor
- Division of Critical Care, Department of Pediatrics, The University of Mississippi Medical Center, Jackson, MS, USA
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21
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Long-Term Cardiovascular Outcomes of Multisystem Inflammatory Syndrome in Children Associated with COVID-19 Using an Institution Based Algorithm. Pediatr Cardiol 2023; 44:367-380. [PMID: 36214896 PMCID: PMC9549828 DOI: 10.1007/s00246-022-03020-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/28/2022] [Indexed: 02/07/2023]
Abstract
Cardiovascular involvement is a major cause of inpatient and intensive care unit morbidity related to Multisystem inflammatory syndrome in children (MIS-C). The objective of this study was to identify long-term cardiovascular manifestations of MIS-C. We included 80 consecutive patients admitted to the intensive care unit with MIS-C who were evaluated for a year in our follow-up clinic using an institution protocol. The outcome measures were cardiac biomarkers (troponin and BNP), electrocardiogram changes, echocardiographic findings cardiovascular magnetic resonance (CMR) and graded-exercise stress test (GXT) findings. The cohort included patients aged between 6 months and 17 years (median 9 years; 48.8% females). At the peak of the disease 81.3% had abnormal BNP and 58.8% had troponin leak which reduced to 33.8% and 18.8% respectively at discharge with complete normalization by 6 weeks post-discharge. At admission 33.8% had systolic dysfunction, which improved to 11.3% at discharge with complete resolution by 2 weeks. Coronary artery abnormalities were seen in 17.5% during the illness with complete resolution by 2 weeks post discharge except one (1.9%) with persistent giant aneurysm at 1 year-follow up. CMR was performed at 6 months in 23 patient and demonstrated 4 patients with persistent late gadolinium enhancement (17.4%). Normal exercise capacity with no ectopy was seen in the 31 qualifying patients that underwent a GXT. There is significant heterogeneity in the cardiovascular manifestations of MIS-C. Although majority of the cardiovascular manifestations resolve within 6 weeks, diastolic dysfunction, CAA and myocardial scar may persist in a small subset of patients warranting a structured long-term follow-up strategy.
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22
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Longitudinal Assessment of Cardiac Function Following Multisystem Inflammatory Syndrome in Children Associated with COVID-19. Pediatr Cardiol 2023; 44:607-617. [PMID: 35864203 PMCID: PMC9302868 DOI: 10.1007/s00246-022-02972-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 07/07/2022] [Indexed: 12/04/2022]
Abstract
Multisystem inflammatory syndrome in children (MIS-C) after COVID-19 is commonly associated with cardiac involvement. Studies found myocardial dysfunction, as measured by decreased ejection fraction and abnormal strain, to be common early in illness. However, there is limited data on longitudinal cardiac outcomes. We aim to describe the evolution of cardiac findings in pediatric MIS-C from acute illness through at least 2-month follow-up. A retrospective single-center review of 36 patients admitted with MIS-C from April 2020 through September 2021 was performed. Echocardiographic data including cardiac function and global longitudinal strain (GLS) were analyzed at initial presentation, discharge, 2-4-week follow-up, and at least 2-month follow-up. Patients with mild and severe disease, normal and abnormal left ventricular ejection fraction (LVEF), and normal and abnormal GLS at presentation were compared. On presentation, 42% of patients with MIS-C had decreased LVEF < 55%. In patients in whom GLS was obtained (N = 18), 44% were abnormal (GLS < |- 18|%). Of patients with normal LVEF, 22% had abnormal GLS. There were no significant differences in troponin or brain natriuretic peptide between those with normal and abnormal LVEF. In most MIS-C patients with initial LVEF < 55% (90%), LVEF normalized upon discharge. At 2-month follow-up, all patients had normal LVEF with 21% having persistently abnormal GLS. Myocardial systolic dysfunction and abnormal deformation were common findings in MIS-C at presentation. While EF often normalized by 2 months, persistently abnormal GLS was more common, suggesting ongoing subclinical dysfunction. Our study offers an optimistic outlook for recovery in patients with MIS-C and carditis, however ongoing investigation for longitudinal effects is warranted.
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23
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Vainstein E, Baleani S, Urrutia L, Affranchino N, Ackerman J, Cazalas M, Goldsman A, Sardella A, Tolin AL, Goldaracena P, Fabi M, Cosentino M, Magliola R, Roggiero G, Manso P, Triguy J, Ballester C, Cervetto V, Vaccarello M, De Carli DN, De Carli ME, Ciotti AL, Sicurello MI, Rios Leiva C, Villalba C, Hortas M, Peña S, González G, Zold CL, Murer MG, Vázquez H, Morós C, Di Santo M, Villa A, Lazota P, Foti M, Napoli N, Katsikas MM, Tonello L, Peña J, Etcheverry M, Iglesias D, Alcalde AL, Bruera MJ, Bruzzo V, Giordano P, Acero FP, Pelandi GN, Pastaro D, Bleiz J, Rodríguez MF, Laghezza L, Molina MB, Patynok N, Chatelain, Aguilar MJ, Gamboa J, Cervan M, Ruggeri A, Marinelli I, Checcacci E, Meregalli C, Damksy Barbosa J, Fernie L, Fernández MJ, Saenz Tejeira MM, Cereigido C, Nunell A, Villar D, Mansilla AD, Darduin MD. Multicentre observational study on multisystem inflammatory syndrome related to COVID-19 in Argentina. Pediatr Int 2023; 65:e15431. [PMID: 36464947 PMCID: PMC9878215 DOI: 10.1111/ped.15431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 10/07/2022] [Accepted: 11/21/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND The impact of the pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) in low- and middle-income countries remains poorly understood. Our aim was to understand the characteristics and outcomes of PIMS-TS in Argentina. METHODS This observational, prospective, and retrospective multicenter study enrolled patients younger than 18 years-old manifesting PIMS-TS, Kawasaki disease (KD) or Kawasaki shock syndrome (KSS) between March 2020 and May 2021. Patients were followed-up until hospital discharge or death (one case). The primary outcome was pediatric intensive care unit (PICU) admission. Multiple logistic regression was used to identify variables predicting PICU admission. RESULTS Eighty-one percent, 82%, and 14% of the 176 enrolled patients fulfilled the suspect case criteria for PIMS-TS, KD, and KSS, respectively. Temporal association with SARS-CoV-2 was confirmed in 85% of the patients and 38% were admitted to the PICU. The more common clinical manifestations were fever, abdominal pain, rash, and conjunctival injection. Lymphopenia was more common among PICU-admitted patients (87% vs. 51%, p < 0.0001), who also showed a lower platelet count and higher plasmatic levels of inflammatory and cardiac markers. Mitral valve insufficiency, left ventricular wall motion alterations, pericardial effusion, and coronary artery alterations were observed in 30%, 30%, 19.8%, and 18.6% of the patients, respectively. Days to initiation of treatment, rash, lymphopenia, and low platelet count were significant independent contributions to PICU admission. CONCLUSION Rates of severe outcomes of PIMS-TS in the present study agreed with those observed in high-income countries. Together with other published studies, this work helps clinicians to better understand this novel clinical entity.
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Affiliation(s)
- Eduardo Vainstein
- Clínica Pediátrica, Hospital de Niños Dr. Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Silvia Baleani
- Clínica Pediátrica, Hospital de Niños Dr. Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Luis Urrutia
- Clínica Pediátrica, Hospital Nacional de Pediatría Juan P Garrahan, Buenos Aires, Argentina
| | - Nicolás Affranchino
- Clínica Pediátrica, Hospital Nacional de Pediatría Juan P Garrahan, Buenos Aires, Argentina
| | - Judith Ackerman
- Unidad de Cardiología, Hospital General de Niños Pedro de Elizalde, Buenos Aires, Argentina
| | - Mariana Cazalas
- División de Cardiología, Hospital de Niños Dr. Ricardo Gutiérrez y Sanatorio Sagrado Corazón, Buenos Aires, Argentina
| | - Alejandro Goldsman
- División de Cardiología, Hospital de Niños Dr. Ricardo Gutiérrez y Sanatorio Sagrado Corazón, Buenos Aires, Argentina
| | - Angela Sardella
- División de Cardiología, Hospital de Niños Dr. Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Ana Laura Tolin
- Servicio de Inmunología, Hospital H. Notti, Provincia de Mendoza, Argentina
| | - Pablo Goldaracena
- Clínica Médica, Hospital Sor María Ludovica de La Plata, Provincia de Buenos Aires, Argentina
| | - Mariana Fabi
- Servicio de Reumatología, Hospital Sor María Ludovica de La Plata, Provincia de Buenos Aires, Argentina
| | | | - Ricardo Magliola
- Clínica Pediátrica, Unidad Terapia Intensiva, Hospital Británico, Buenos Aires, Argentina
| | - Gustavo Roggiero
- Servicio de Cardiología, Hospital El Cruce Néstor Carlos Kirchner y Clínica del Niño de Quilmes, Provincia de Buenos Aires, Argentina
| | - Paula Manso
- Servicio de Cardiología, Hospital El Cruce Néstor Carlos Kirchner, Provincia de Buenos Aires, Argentina
| | - Jésica Triguy
- Servicio de Inmunología, Hospital H. Notti, Provincia de Mendoza, Argentina
| | - Celeste Ballester
- Servicio de Inmunología, Hospital H. Notti, Provincia de Mendoza, Argentina
| | - Vanesa Cervetto
- Reumatología, Hospital General de Niños Pedro de Elizalde y Hospital Británico, Buenos Aires, Argentina
| | - María Vaccarello
- Clínica Pediátrica, Sanatorio la Trinidad, Quilmes, Provincia de Buenos Aires, Argentina
| | | | - Maria Estela De Carli
- Clínica Pediátrica, Clínica del Niño de Quilmes, Provincia de Buenos Aires, Argentina
| | - Ana Laura Ciotti
- Servicio de Cardiología, Hospital A. Posadas, Provincia de Buenos Aires, Argentina
| | - María Irene Sicurello
- División de Cardiología, Hospital de Niños Dr. Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Cecilia Rios Leiva
- Servicio de Cardiología, Hospital Eva Perón de San Martín, Provincia de Buenos Aires, Argentina
| | - Claudia Villalba
- Servicio de Cardiología, Hospital Británico y Hospital Nacional de Pediatría Juan P Garrahan, Buenos Aires, Argentina
| | - María Hortas
- Servicio de Reumatología, Sanatorio la Trinidad, Quilmes, Provincia de Buenos Aires, Argentina
| | - Sonia Peña
- Servicio de Inmunología, Hospital H. Notti, Provincia de Mendoza, Argentina
| | - Gabriela González
- Servicio de Cardiología, Hospital H. Notti, Provincia de Mendoza, Argentina
| | - Camila Lidia Zold
- Universidad de Buenos Aires, CONICET, Instituto de Fisiología y Biofísica (IFIBIO) Bernardo Houssay, Buenos Aires, Argentina
| | - Mario Gustavo Murer
- Universidad de Buenos Aires, CONICET, Instituto de Fisiología y Biofísica (IFIBIO) Bernardo Houssay, Buenos Aires, Argentina
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Arslan SY, Bal ZS, Bayraktaroglu S, Ozenen GG, Bilen NM, Levent E, Ay O, Ozkaya PY, Ozkinay F, Cicek C, Cinkooglu A, Aksu G, Ak G, Kurugol Z. Cardiac Assessment in Children with MIS-C: Late Magnetic Resonance Imaging Features. Pediatr Cardiol 2023; 44:44-53. [PMID: 35916926 PMCID: PMC9343565 DOI: 10.1007/s00246-022-02977-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 07/13/2022] [Indexed: 01/24/2023]
Abstract
Multisystem Inflammatory Syndrome (MIS-C) is a new entity that emerges 2-4 weeks after the SARS-CoV-2 infection in children. MIS-C can affect all systems, the most severe of which is cardiac involvement. The duration of the cardiac symptoms is still uncertain and may be persistent or prolonged. The American College of Rheumatology Clinical Guidelines recommends cardiac magnetic resonance imaging (MRI) 2-6 months after the diagnosis of MIS-C in patients presenting with significant transient left ventricular (LV) dysfunction in the acute phase of illness (LV ejection fraction 50%) or persistent LV dysfunction. There are a few studies investigating cardiac MRI findings in MIS-C patients. In this study, we aimed to evaluate cardiac MRI findings, at the earliest 3 months after diagnosis, and compare these findings with the echocardiograms in children with MIS-C. A retrospective study including 34 MIS-C patients was conducted at a tertiary-level University Hospital between June 2020 and July 2021. Centers for Disease Control and Prevention criteria were used in the diagnosis of MIS-C. Cardiac MRI was performed at least 3 months after MIS-C diagnosis. The study included 17 (50%) boys and 17 (50%) girls with a mean age of 9.31 ± 4.72 years. Initial echocardiographic evaluation revealed cardiac abnormality in 13 (38.2) patients; 4 (11.8%) pericardial effusion, 4 (11.8%) left ventricular ejection fraction (LVEF) < 55%, and 5 (14.7%) coronary artery dilatation. Echocardiography showed normal LV systolic function in all patients during follow-up; coronary dilatation persisted in 2 of 5 (40%) patients at the 6th-month visit. Cardiac MRI was performed in 31 (91.2%) patients, and myocardial hyperemia was not detected in any patients (T1 relaxation time was < 1044 ms in all children). However, 9 (29%) patients' MRI showed isolated elevated T2 levels, and 19 (61.3%) revealed at least one of the following findings: pericardial effusion, right ventricular dysfunction, or LVEF abnormality. In patients with MIS-C, a high rate of cardiac involvement, particularly pericardial effusion was determined by cardiac MRI performed at the earliest 2-6 months after diagnosis. Even if echocardiography does not reveal any abnormality in the initial phase, cardiac MRI should be suggested in MIS-C patients in the late period. This is the first study reporting cardiac MRI findings in the late period of MIS-C patients.
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Affiliation(s)
- Sema Yildirim Arslan
- grid.8302.90000 0001 1092 2592Division of Infectious Disease, Department of Pediatrics, Medical School of Ege University, Izmir, Turkey
| | - Zumrut Sahbudak Bal
- Division of Infectious Disease, Department of Pediatrics, Medical School of Ege University, Izmir, Turkey.
| | - Selen Bayraktaroglu
- grid.8302.90000 0001 1092 2592Department of Radiology, Medical School of Ege University, Izmir, Turkey
| | - Gizem Guner Ozenen
- grid.8302.90000 0001 1092 2592Division of Infectious Disease, Department of Pediatrics, Medical School of Ege University, Izmir, Turkey
| | - Nimet Melis Bilen
- grid.8302.90000 0001 1092 2592Division of Infectious Disease, Department of Pediatrics, Medical School of Ege University, Izmir, Turkey
| | - Erturk Levent
- grid.8302.90000 0001 1092 2592Division of Pediatric Cardiology, Department of Pediatrics, Medical School of Ege University, Izmir, Turkey
| | - Oguzhan Ay
- grid.8302.90000 0001 1092 2592Division of Pediatric Cardiology, Department of Pediatrics, Medical School of Ege University, Izmir, Turkey
| | - Pinar Yazici Ozkaya
- grid.8302.90000 0001 1092 2592Division of Pediatric Intensive Care Unit, Department of Pediatrics, Medical School of Ege University, Izmir, Turkey
| | - Ferda Ozkinay
- grid.8302.90000 0001 1092 2592Division of Infectious Disease, Department of Pediatrics, Medical School of Ege University, Izmir, Turkey
| | - Candan Cicek
- grid.8302.90000 0001 1092 2592Department of Microbiology, Medical School of Ege University, Izmir, Turkey
| | - Akin Cinkooglu
- grid.8302.90000 0001 1092 2592Department of Radiology, Medical School of Ege University, Izmir, Turkey
| | - Guzide Aksu
- grid.8302.90000 0001 1092 2592Division of Immunology and Rheumatology, Department of Pediatrics, Medical School of Ege University, Izmir, Turkey
| | - Gunes Ak
- grid.8302.90000 0001 1092 2592Department of Clinic Biochemistry, Medical School of Ege University, Izmir, Turkey
| | - Zafer Kurugol
- grid.8302.90000 0001 1092 2592Division of Infectious Disease, Department of Pediatrics, Medical School of Ege University, Izmir, Turkey
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25
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Migowa A, Samia P, del Rossi S, Malande OO, Shah J, Kenei C, Ayaya J, Jeruto D, Oyiengo L, Lewandowski L. Management of Multisystem Inflammatory Syndrome in Children (MIS-C) in resource limited settings: The Kenyan Experience. Pediatr Rheumatol Online J 2022; 20:110. [PMID: 36471443 PMCID: PMC9721021 DOI: 10.1186/s12969-022-00773-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 11/16/2022] [Indexed: 12/08/2022] Open
Abstract
BACKGROUND Since the onset of the recent COVID-19 pandemic, there have been growing concerns regarding multisystem inflammatory syndrome in children (MIS-C). This study aims to describe the clinico-epidemiological profile and challenges in management of MIS-C in low-middle income countries by highlighting the Kenyan experience. METHODS A retrospective study at the Aga Khan University Hospital Nairobi, Avenue Hospital Kisumu and Kapsabet County Referral Hospital was undertaken to identify cases of MIS-C. A detailed chart review using the World Health Organization (WHO) data collection tool was adapted to incorporate information on socio-demographic details and treatment regimens. FINDINGS Twenty children with MIS-C were identified across the three facilities between August 1st 2020 and August 31st 2021. Seventy percent of the children were male (14 of 20). COVID-19 PCR testing was done for five children and only one was positive. The commonest clinical symptoms were fever (90%), tachycardia (80%), prolonged capillary refill (80%), oral mucosal changes (65%) and peripheral cutaneous inflammation (50%). Four children required admission into the critical care unit for ventilation support and inotropic support. Cardiac evaluation was available for six patients four of whom had myocardial dysfunction, three had valvulitis and one had pericarditis. Immunoglobulin therapy was availed to two children and systemic steroids provided for three children. There were no documented mortalities. INTERPRETATION We describe the first case series of MIS-C in East and Central Africa. Majority of suspected cases of MIS-C did not have access to timely COVID-19 testing and other appropriate evaluations which highlights the iniquity in access to diagnostics and treatment.
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Affiliation(s)
- Angela Migowa
- Department of Paediatrics and Child Health, Aga Khan University, 3rd Parklands Avenue, P.O.BOX 30270 00100 GPO, Nairobi, Kenya. .,Department of Public Health and Primary Care, Ghent University, Ghent, Belgium.
| | - Pauline Samia
- grid.470490.eDepartment of Paediatrics and Child Health, Aga Khan University, 3rd Parklands Avenue, P.O.BOX 30270 00100 GPO, Nairobi, Kenya ,grid.5342.00000 0001 2069 7798Department of Public Health and Primary Care, Ghent University, Ghent, Belgium ,grid.470490.eBrain and Mind institute, Aga Khan University, 3rd Parklands Avenue, Nairobi, Kenya
| | - Sean del Rossi
- grid.470490.eDepartment of Paediatrics and Child Health, Aga Khan University, 3rd Parklands Avenue, P.O.BOX 30270 00100 GPO, Nairobi, Kenya
| | | | - Jasmit Shah
- grid.470490.eBrain and Mind institute, Aga Khan University, 3rd Parklands Avenue, Nairobi, Kenya ,grid.470490.eDepartment of Medicine, Aga Khan University, Nairobi, Kenya
| | - Chemutai Kenei
- grid.10604.330000 0001 2019 0495Department of Clinical Medicine and Therapeutics, University of Nairobi, P.O. Box 19676-00202, Nairobi, Kenya
| | - Joy Ayaya
- Avenue Hospital, Kisumu-Kakamega Highway, Kisumu, Kenya
| | - Daisy Jeruto
- Kapsabet County Referral Hospital, Eldoret – Kisumu Highway, Kapsabet, Kenya
| | - Laura Oyiengo
- United Nations International Children’s Fund Kenya Country Office, United Nations Ave, Nairobi, Kenya
| | - Laura Lewandowski
- grid.94365.3d0000 0001 2297 5165National Institute of Health, 10 Center Drive, Bethesda, MD USA
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26
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Schwartz BN, Harahsheh AS, Krishnan A, Martin GR. Cardiac Effects of COVID-19 Infection, MIS-C, and the Vaccine in Infants and Children: What Is Known and Future Implications. Am J Perinatol 2022; 39:S1-S6. [PMID: 36307093 DOI: 10.1055/s-0042-1757238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The cardiac effects of novel coronavirus disease 2019 (COVID-19) infection on the pediatric heart has become an area of particular interest as elevated cardiac enzymes and abnormalities on echocardiogram and electrocardiogram were seen in a portion of children affected by the virus. In this article, we review the cardiac manifestations of acute COVID-19 infection, multisystem inflammatory syndrome in children, and postvaccine myocarditis. The limited research on the effects of COVID-19 on neonates and infants is also reported. KEY POINTS: · Cardiac involvement from MIS-C is much higher than the risk of COVID-19 vaccine-induced myocarditis.. · Neonates and infants have overall been less affected by COVID-19 than adults and older children.. · At this point in time, there is limited research on the cardiac effects of COVID-19 in neonates..
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Affiliation(s)
- Bryanna N Schwartz
- Division of Cardiology, Children's National Hospital, Washington, District of Columbia.,Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Ashraf S Harahsheh
- Division of Cardiology, Children's National Hospital, Washington, District of Columbia.,Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Anita Krishnan
- Division of Cardiology, Children's National Hospital, Washington, District of Columbia.,Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Gerard R Martin
- Division of Cardiology, Children's National Hospital, Washington, District of Columbia.,Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
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27
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Longitudinal Cardiac Outcomes of Multisystem Inflammatory Syndrome in Children: A Systematic Review and Meta-Analysis. Pediatr Cardiol 2022; 44:892-907. [PMID: 36416893 PMCID: PMC9684941 DOI: 10.1007/s00246-022-03052-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 11/14/2022] [Indexed: 11/24/2022]
Abstract
There is a paucity of longitudinal data on cardiac outcomes in multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19. We aimed to investigate the longitudinal cardiovascular outcomes in MIS-C. PubMed and EMBASE were searched through May 2022. Observational studies were included, reporting mid-term (≥ 3 months) outcomes in children (aged < 21) with MIS-C. Data were extracted by two researchers. Longitudinal outcomes were synthesized by a one-group meta-analysis using a random-effects model. Eleven studies with a follow-up period (3 months to 1 year) were identified, including 547 MIS-C patients. The mortality was 2.5% (95% CI 1.3-4.9). The majority of left ventricular (LV) systolic dysfunction present in 46.8% (95% CI 32.7-61.3) in the acute phase resolved by 3 months, and the prevalence of LV systolic dysfunction was 1.7% (95% CI 0.5-5.7) and 2.1% (95% CI 0.8-5.4) at 3 month and 6 month follow-up, respectively. Additionally, the persistent LV systolic dysfunction in the small population was mild. However, coronary abnormalities such as coronary artery dilatation or aneurysms, seen in 23.7% (95% CI 17.7-31.1) at baseline, persisted in 4.7% (95% CI 1.5-14.3) at 3 months and 5.2% (95% CI 3.0-8.9) at 6 months. Mitral regurgitation (MR), which was observed in 56.6% (95% CI 27.7-81.6) at baseline, also persisted in 7.5% at 6 months. In conclusion, our study demonstrated largely favorable cardiac outcomes, suggesting resolution of LV systolic dysfunction in the majority of cases. However, coronary abnormalities and MR persisted in a subset of patients at mid-term follow-up.
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28
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Rodriguez-Gonzalez M, Castellano-Martinez A. Age-adjusted NT-proBNP could help in the early identification and follow-up of children at risk for severe multisystem inflammatory syndrome associated with COVID-19 (MIS-C). World J Clin Cases 2022; 10:10435-10450. [PMID: 36312492 PMCID: PMC9602208 DOI: 10.12998/wjcc.v10.i29.10435] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 06/17/2022] [Accepted: 08/31/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Multisystem inflammatory syndrome in children (MIS-C) has emerged as a new disease associated with COVID-19 that presents in acute critically ill children with acute cardiovascular dysfunction.
AIM To determine whether the age-adjusted N-terminal pro-brain natriuretic peptide (NT-proBNP) value (Z-log-NT-proBNP) is associated with severe MIS-C and myocardial dysfunction.
METHODS A retrospective study was conducted which included children with MIS-C managed at our institution between April 1, 2020, and February 28, 2022. We divided the population into groups depending on severity based on pediatric intensive care unit (PICU) admission. We compared Z-log-NT-proBNP values across these groups and analyzed Z-log-NT-proBNP dynamics during the one-month follow-up.
RESULTS We included 17 participants [median age 3 (2-9) years] and seven (41%) required PICU admission. All (100%) of these cases presented very high (Z-log > 4) levels of NT-proBNP at the time of admission compared to only 5 (50%) patients with non-severe MIS-C (P = 0.025). NT-proBNP was significantly correlated with high-sensitive Troponin I levels (P = 0.045), Ross modified score (P = 0.003) and left ventricle ejection fraction (P = 0.021).
CONCLUSION Raised NT-proBNP, specifically very high values (Z-log-NT-proBNP > 4) could help in the early identification of MIS-C patients with myocardial dysfunction requiring inotropic support and PICU admission.
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Abstract
PURPOSE OF REVIEW Although acute COVID-19 has been milder in children and young people compared with adults, there is a concern that they may suffer persistent symptoms. There is a need to define the clinical phenotype, determine those most at risk, the natural course of the condition and evaluate preventive and therapeutic strategies for both mental health and physical symptoms. RECENT FINDINGS More recent studies with control groups reported a lower prevalence of persistent symptoms in children and young people exposed to SARS-CoV-2. A systematic review and meta-analysis found that the frequency of the majority of reported persistent symptoms is similar in SARS-CoV-2 positive cases and controls. Children and young people infected with SARS-COV-2 had small but significant increases in persisting cognitive difficulties, headache and loss of smell. Factors associated with persisting, impairing symptoms include increased number of symptoms at the time of testing, female sex, older age, worse self-rated physical and mental health, and feelings of loneliness preinfection. SUMMARY This review highlights the importance of a control group in studies following SARS-CoV-2 infection, the need for case definitions and research to understand the outcomes of long COVID in children and young people.
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Affiliation(s)
| | - Roz Shafran
- UCL Great Ormond Street Institute of Child Health
| | - Shamez N. Ladhani
- Paediatric Infectious Diseases Research Group, St. George's University of London, London, UK
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30
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Hirt J, Janiaud P, Gloy VL, Schandelmaier S, Pereira TV, Contopoulos-Ioannidis D, Goodman SN, Ioannidis J, Munkholm K, Hemkens LG. Robustness of reported postacute health outcomes in children with SARS-CoV-2 infection: a systematic review. Arch Dis Child 2022; 108:498-505. [PMID: 36719840 DOI: 10.1136/archdischild-2022-324455] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/31/2022] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To systematically assess the robustness of reported postacute SARS-CoV-2 infection health outcomes in children. METHODS A search on PubMed and Web of Science was conducted to identify studies published up to 22 January 2022 that reported on postacute SARS-CoV-2 infection health outcomes in children (<18 years) with follow-up of ≥2 months since detection of infection or ≥1 month since recovery from acute illness. We assessed the consideration of confounding bias and causality, as well as the risk of bias. RESULTS 21 studies including 81 896 children reported up to 97 symptoms with follow-up periods of 2.0-11.5 months. Fifteen studies had no control group. The reported proportion of children with post-COVID syndrome was between 0% and 66.5% in children with SARS-CoV-2 infection (n=16 986) and between 2.0% and 53.3% in children without SARS-CoV-2 infection (n=64 910). Only two studies made a clear causal interpretation of an association between SARS-CoV-2 infection and the main outcome of 'post-COVID syndrome' and provided recommendations regarding prevention measures. The robustness of all 21 studies was seriously limited due to an overall critical risk of bias. CONCLUSIONS The robustness of reported postacute SARS-CoV-2 infection health outcomes in children is seriously limited, at least in all the published articles we could identify. None of the studies provided evidence with reasonable certainty on whether SARS-CoV-2 infection has an impact on postacute health outcomes, let alone to what extent. Children and their families urgently need much more reliable and methodologically robust evidence to address their concerns and improve care.
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Affiliation(s)
- Julian Hirt
- Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland.,International Graduate Academy, Institute of Health and Nursing Science, Medical Faculty, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Perrine Janiaud
- Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Viktoria Luise Gloy
- Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Stefan Schandelmaier
- Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland.,Department of Clinical Epidemiology and Biostatistics, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Tiago V Pereira
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada.,Department of Health Sciences, College of Medicine, University of Leicester, Leicester, UK
| | - Despina Contopoulos-Ioannidis
- Division of Infectious Diseases, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Steven N Goodman
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California, USA.,Department of Medicine, Stanford University School of Medicine, Stanford, California, USA.,Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California, USA
| | - John Ioannidis
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California, USA.,Department of Medicine, Stanford University School of Medicine, Stanford, California, USA.,Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California, USA.,Department of Biomedical Data Science, School of Medicine, Stanford University, Stanford, California, USA.,Meta-Research Innovation Center Berlin (METRIC-B), Berlin Institute of Health, Berlin, Germany
| | - Klaus Munkholm
- Department of Clinical Research, Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark, University of Southern Denmark, Odense, Denmark.,Open Patient Data Exploratory Network (OPEN), Odense University Hospital, Odense, Denmark
| | - Lars G Hemkens
- Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland .,Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California, USA.,Meta-Research Innovation Center Berlin (METRIC-B), Berlin Institute of Health, Berlin, Germany
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31
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Caorsi R, Civino A, Ravelli A. Complications of severe acute respiratory syndrome coronavirus 2 infection in children. Curr Opin Rheumatol 2022; 34:267-273. [PMID: 35797144 DOI: 10.1097/bor.0000000000000892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW Although during the initial stages of COVID-19 pandemic, the pediatric population seemed to be less affected, a number of SARS-CoV-2-related manifestations emerged over time, the principal of which is the multisystem inflammatory syndrome in children (MIS-C). Here we provide an update on the main pediatric disorders associated with SARS-CoV-2 infection. RECENT FINDINGS MIS-C is novel postinfectious manifestation with clinical features similar to Kawasaki disease and characterized by intense systemic inflammation affecting multiple organs. Many children required intensive care therapy because of circulatory shock, usually of myocardial origin. Appropriate treatment with immunomodulatory therapies led to favorable outcomes in most patients, with recovery of overall health and cardiac dysfunction. In addition to MIS-C, a variety of other complications of COVID-19 in children have been described, including thrombotic events, neurologic manifestations, and chilblain-like lesions. There is still uncertainty about the true prevalence of long COVID in children and its distinction from pandemic-related complaints. SUMMARY The experience gained so far with MIS-C and the other SARS-CoV-2-related complications in children and adolescents will facilitate accurate diagnosis and appropriate treatment. Further studies are needed to elucidate the pathophysiology of MIS-C and to determine the real impact of long-COVID in the pediatric age group.
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Affiliation(s)
- Roberta Caorsi
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genoa
| | - Adele Civino
- UOSD Reumatologia e Immunologia Pediatrica, Ospedale Vito Fazzi, Lecce
| | - Angelo Ravelli
- Direzione Scientifica, IRCCS Istituto Giannina Gaslini
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DINOGMI), Università degli Studi di Genova, Genoa, Italy
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32
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Migowa AN, Samia P, Shah J, Rossi SD, Kenei C, Malande OO, Ayaya J, Jeruto D, Oyiengo L, Lewandowski L. Management of Multisystem Inflammatory Syndrome in Children (MIS-C) in resource limited settings: The Kenyan Experience.. [PMID: 36032967 PMCID: PMC9413710 DOI: 10.21203/rs.3.rs-1951206/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Abstract
Background
Since the onset of the recent COVID-19 pandemic, there have been growing concerns regarding multisystem inflammatory syndrome in children (MIS-C). This study aims to describe the clinico-epidemiological profile and challenges in management of MIS-C in low-middle income countries by highlighting the Kenyan experience.
Methods
A retrospective study at the Aga Khan University Hospital Nairobi, Avenue Hospital Kisumu and Kapsabet County Referral Hospital was undertaken to identify cases of MIS-C. A detailed chart review using the World Health Organization (WHO) data collection tool was adapted to incorporate information on socio-demographic details and treatment regimens.
Findings:
Twenty children with MIS-C were identified across the three facilities. Seventy percent of the children were male (14 of 20). COVID-19 PCR testing was done for five children and only one was positive. The commonest clinical symptoms were fever (90%), tachycardia (80%), prolonged capillary refill (80%), oral mucosal changes (65%) and peripheral cutaneous inflammation (50%). Four children required admission into the critical care unit for ventilation support and inotropic support. Cardiac evaluation was available for six patients four of whom had myocardial dysfunction, three had valvulitis and one had pericarditis. Immunoglobulin therapy was availed to two children and systemic steroids provided for three children. There were no documented mortalities.
Interpretation:
We describe the first case series of MIS-C in East and Central Africa. Majority of suspected cases of MIS-C did not have access to timely COVID-19 PCR testing and other appropriate evaluations which highlights the iniquity in access to diagnostics and treatment.
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Affiliation(s)
| | | | - Jasmit Shah
- Aga Khan University Medical College East Africa
| | | | - Chemutai Kenei
- University of Nairobi College of Health Sciences: University of Nairobi Faculty of Health Sciences
| | | | | | | | | | - Laura Lewandowski
- NIAMS: National Institute of Arthritis and Musculoskeletal and Skin Diseases
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33
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Das BB, Akam-Venkata J, Abdulkarim M, Hussain T. Parametric Mapping Cardiac Magnetic Resonance Imaging for the Diagnosis of Myocarditis in Children in the Era of COVID-19 and MIS-C. CHILDREN 2022; 9:children9071061. [PMID: 35884045 PMCID: PMC9320921 DOI: 10.3390/children9071061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 07/08/2022] [Accepted: 07/14/2022] [Indexed: 12/03/2022]
Abstract
Myocarditis comprises many clinical presentations ranging from asymptomatic to sudden cardiac death. The history, physical examination, cardiac biomarkers, inflammatory markers, and electrocardiogram are usually helpful in the initial assessment of suspected acute myocarditis. Echocardiography is the primary tool to detect ventricular wall motion abnormalities, pericardial effusion, valvular regurgitation, and impaired function. The advancement of cardiac magnetic resonance (CMR) imaging has been helpful in clinical practice for diagnosing myocarditis. A recent Scientific Statement by the American Heart Association suggested CMR as a confirmatory test to diagnose acute myocarditis in children. However, standard CMR parametric mapping parameters for diagnosing myocarditis are unavailable in pediatric patients for consistency and reliability in the interpretation. The present review highlights the unmet clinical needs for standard CMR parametric criteria for diagnosing acute and chronic myocarditis in children and differentiating dilated chronic myocarditis phenotype from idiopathic dilated cardiomyopathy. Of particular relevance to today’s practice, we also assess the potential and limitations of CMR to diagnose acute myocarditis in children exposed to severe acute respiratory syndrome coronavirus-2 infections. The latter section will discuss the multi-inflammatory syndrome in children (MIS-C) and mRNA coronavirus disease 19 vaccine-associated myocarditis.
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Affiliation(s)
- Bibhuti B. Das
- Department of Pediatrics, Children’s of Mississippi Heart Center, University of Mississippi Medical Center, Jackson, MS 39216, USA;
- Correspondence: ; Tel.: +1-601-984-5250; Fax: +1-601-984-5283
| | - Jyothsna Akam-Venkata
- Department of Pediatrics, Children’s of Mississippi Heart Center, University of Mississippi Medical Center, Jackson, MS 39216, USA;
| | - Mubeena Abdulkarim
- Pediatric Cardiology, Nicklaus Children’s Hospital, Miami, FL 33155, USA;
| | - Tarique Hussain
- Pediatric Cardiology, Children’s Health, UTSW Medical Center, Dallas, TX 75235, USA;
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34
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The Multifaceted Manifestations of Multisystem Inflammatory Syndrome during the SARS-CoV-2 Pandemic. Pathogens 2022; 11:pathogens11050556. [PMID: 35631077 PMCID: PMC9143280 DOI: 10.3390/pathogens11050556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/02/2022] [Accepted: 05/05/2022] [Indexed: 12/12/2022] Open
Abstract
The novel coronavirus SARS-CoV-2, which has similarities to the 2002–2003 severe acute respiratory syndrome coronavirus known as SARS-CoV-1, causes the infectious disease designated COVID-19 by the World Health Organization (Coronavirus Disease 2019). Although the first reports indicated that activity of the virus is centered in the lungs, it was soon acknowledged that SARS-CoV-2 causes a multisystem disease. Indeed, this new pathogen causes a variety of syndromes, including asymptomatic disease; mild disease; moderate disease; a severe form that requires hospitalization, intensive care, and mechanical ventilation; multisystem inflammatory disease; and a condition called long COVID or postacute sequelae of SARS-CoV-2 infection. Some of these syndromes resemble previously described disorders, including those with no confirmed etiology, such as Kawasaki disease. After recognition of a distinct multisystem inflammatory syndrome in children, followed by a similar syndrome in adults, various multisystem syndromes occurring during the pandemic associated or related to SARS-CoV-2 began to be identified. A typical pattern of cytokine and chemokine dysregulation occurs in these complex syndromes; however, the disorders have distinct immunological determinants that may help to differentiate them. This review discusses the origins of the different trajectories of the inflammatory syndromes related to SARS-CoV-2 infection.
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35
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Das BB. Therapeutic Approaches in Heart Failure with Preserved Ejection Fraction (HFpEF) in Children: Present and Future. Paediatr Drugs 2022; 24:235-246. [PMID: 35501560 DOI: 10.1007/s40272-022-00508-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/07/2022] [Indexed: 12/29/2022]
Abstract
For a long time, pediatric heart failure (HF) with preserved systolic function (HFpEF) has been noted in patients with cardiomyopathies and congenital heart disease. HFpEF is infrequently reported in children and instead of using the HFpEF terminology the HF symptoms are attributed to diastolic dysfunction. Identifying HFpEF in children is challenging because of heterogeneous etiologies and unknown pathophysiological mechanisms. Advances in echocardiography and cardiac magnetic resonance imaging techniques have further increased our understanding of HFpEF in children. However, the literature does not describe the incidence, etiology, clinical features, and treatment of HFpEF in children. At present, treatment of HFpEF in children is extrapolated from clinical trials in adults. There are significant differences between pediatric and adult HF with reduced ejection fraction, supported by a lack of adequate response to adult HF therapies. Evidence-based clinical trials in children are still not available because of the difficulty of conducting trials with a limited number of pediatric patients with HF. The treatment of HFpEF in children is based upon the clinician's experience, and the majority of children receive off-level medications. There are significant differences between pediatric and adult HFpEF pharmacotherapies in many areas, including side-effect profiles, underlying pathophysiologies, the β-receptor physiology, and pharmacokinetics and pharmacodynamics. This review describes the present and future treatments for children with HFpEF compared with adults. This review also highlights the need to urgently test new therapies in children with HFpEF to demonstrate the safety and efficacy of drugs and devices with proven benefits in adults.
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Affiliation(s)
- Bibhuti B Das
- Department of Pediatrics, Division of Cardiology, University of Mississippi Medical Center, 2500 N State St., Jackson, MS, 39216, USA.
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36
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Puchalski M, Kamińska H, Bartoszek M, Brzewski M, Werner B. COVID-19-Vaccination-Induced Myocarditis in Teenagers: Case Series with Further Follow-Up. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19063456. [PMID: 35329143 PMCID: PMC8954790 DOI: 10.3390/ijerph19063456] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/06/2022] [Accepted: 03/11/2022] [Indexed: 12/17/2022]
Abstract
Presently, the whole globe is struggling the tough challenge of the COVID-19 pandemic. Vaccination remains the most effective and safe COVID-19 weapon for adults and in the paediatric population. Aside from possible mild and moderate post-vaccination side effects, more severe side effects may occur. We retrospectively analysed a group of 5 teenagers aged from 15 to 17 years with obesity/overweight (BMI ranging from 24.8 to 30) who presented typical myocarditis symptoms following the first or second dose (3 and 2 patients, respectively) of the COVID-19 vaccine. In the whole study group, a significant increase in troponin serum concentration was observed (1674–37,279.6 ng/L) with a further quick reduction within 3–4 days. In all patients, ST segments elevation or depression with repolarisation time abnormalities in electrocardiography were noticed. Chest X-ray results were within normal limits. Echocardiography showed normal left ventricular diameter (47–56.2 mm) with ejection fraction between 61–72%. All patients were diagnosed with myocarditis based on cardiac magnetic resonance (CMR) imaging. During further hospitalisation, swift clinical improvement was notable. Follow-up in the whole study group was obtained after 106–134 days from initial CMR, revealing no myocarditis symptoms, proper troponin level, and no ECG or echocardiographic abnormalities. At the same time, persistent myocardium injury features were detected in the whole study group, including ongoing myocarditis. COVID-19-vaccine-induced myocarditis seems to be a mild disease with fast clinical recovery, but the complete resolution of the inflammatory process may last over 3 months. Further follow-up and investigation for assessing subsequent implications and long-term COVID-19-vaccine-induced myocarditis is required.
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Affiliation(s)
- Mateusz Puchalski
- Department of Pediatric Cardiology and General Pediatrics, Medical University of Warsaw, 02-091 Warsaw, Poland; (M.P.); (H.K.)
| | - Halszka Kamińska
- Department of Pediatric Cardiology and General Pediatrics, Medical University of Warsaw, 02-091 Warsaw, Poland; (M.P.); (H.K.)
| | - Marta Bartoszek
- Department of Pediatric Radiology, Medical University of Warsaw, 02-091 Warsaw, Poland; (M.B.); (M.B.)
| | - Michał Brzewski
- Department of Pediatric Radiology, Medical University of Warsaw, 02-091 Warsaw, Poland; (M.B.); (M.B.)
| | - Bożena Werner
- Department of Pediatric Cardiology and General Pediatrics, Medical University of Warsaw, 02-091 Warsaw, Poland; (M.P.); (H.K.)
- Correspondence:
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Thom K, Kahl B, Wagner T, van Egmond-Fröhlich A, Krainz M, Frischer T, Leeb I, Schuster C, Ehringer-Schetitska D, Minkov M, Male C, Michel-Behnke I. SARS-CoV-2 Associated Pediatric Inflammatory Multisystem Syndrome With a High Prevalence of Myocarditis - A Multicenter Evaluation of Clinical and Laboratory Characteristics, Treatment and Outcome. Front Pediatr 2022; 10:896252. [PMID: 35757128 PMCID: PMC9227661 DOI: 10.3389/fped.2022.896252] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 05/06/2022] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Pediatric inflammatory multisystem syndrome - temporally associated with SARS-CoV-2 infection (PIMS -TS) comprises a new disease entity having emerged after the COVID-19 outbreak in 2019. MATERIALS AND METHODS For this multicenter, retrospective study children between 0 and 18 years with PIMS-TS between March 2020 and May 2021 were included, before availability of vaccination for children. Frequent SARS-CoV-2 variants at that period were the wildtype virus, alpha, beta and delta variants. Inclusion criteria were according to the PIMS-TS criteria, proposed by the Royal College of Pediatrics and WHO. Study aim was to review their clinical, laboratory and echocardiographic data with a focus on cardiac involvement. RESULTS We report 45 patients, median age 9 years, 64% male. SARS-CoV-2 antibodies were positive in 35/41 (85%). PIMS occurrence followed local COVID-19 peak incidence periods with a time lag. The most common symptoms at presentation were fever (98%), abdominal pain (89%) and rash (80%). Fever history of > 5 days was associated with decreased left ventricular function (p = 0.056). Arterial hypotension and cardiac dysfunction were documented in 72% patients, increased brain natriuretic peptide in 96% and increased cardiac troponin in 64% of the children. Echocardiography revealed mitral valve regurgitation (64%), coronary abnormalities (36%) and pericardial effusions (40%). Increased NT-proBNP was significantly associated with the need of inotropics (p < 0.05), which were necessary in 40% of the patients. Treatment comprised intravenous immunoglobulin (93%), systemic steroids (84%) and acetylsalicylic acid (100%; 26/45 started with high dosages). For insufficient response to this treatment, five (11%) children received the interleukin-1 receptor antagonist anakinra. All patients were discharged with almost resolved cardiac signs. CONCLUSION Our analysis of non-vaccinated children with PIMS-TS demonstrates that a considerable number have associated myocarditis requiring intensive care and inotropic support. Most children showed adequate response to intravenous immunoglobulin and steroids and good recovery. Further evaluation of pediatric patients with COVID-19 associated diseases is required to evaluate the impact of new virus variants.
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Affiliation(s)
- Katharina Thom
- Department of Pediatrics, Division of Pediatric Cardiology, Pediatric Heart Centre, Medical University of Vienna, Vienna, Austria
| | - Beatrice Kahl
- Department of Pediatrics, Division of Pediatric Cardiology, Pediatric Heart Centre, Medical University of Vienna, Vienna, Austria
| | - Thomas Wagner
- Department of Pediatrics and Adolescent Medicine, Clinic Donaustadt, Vienna, Austria
| | | | - Mathias Krainz
- St. Anna Children's Hospital, Center for Children and Adolescent Medicine, Medical University Vienna, Vienna, Austria
| | - Thomas Frischer
- Department of Pediatrics and Adolescent Medicine, Clinic Ottakring, Sigmund Freud Private University, Vienna, Austria
| | - Iris Leeb
- Department of Pediatrics and Adolescent Medicine, State Hospital Mödling, Mödling, Austria
| | - Christine Schuster
- Department of Pediatrics and Adolescent Medicine, State Hospital Mistelbach-Gänserndorf, Mistelbach, Austria
| | - Doris Ehringer-Schetitska
- Department of Pediatrics and Adolescent Medicine, State Hospital Wiener Neustadt, Wiener Neustadt, Austria
| | - Milen Minkov
- Department of Pediatrics and Adolescent Medicine, Clinic Floridsdorf, Vienna, Austria
| | - Christoph Male
- Department of Pediatrics, Division of Pediatric Cardiology, Pediatric Heart Centre, Medical University of Vienna, Vienna, Austria
| | - Ina Michel-Behnke
- Department of Pediatrics, Division of Pediatric Cardiology, Pediatric Heart Centre, Medical University of Vienna, Vienna, Austria
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Fremed MA, Farooqi KM. Longitudinal Outcomes and Monitoring of Patients With Multisystem Inflammatory Syndrome in Children. Front Pediatr 2022; 10:820229. [PMID: 35433557 PMCID: PMC9010503 DOI: 10.3389/fped.2022.820229] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 02/28/2022] [Indexed: 12/15/2022] Open
Abstract
The acute manifestations and short-term outcomes of multisystem inflammatory syndrome (MIS-C) have been extensively described; however, our understanding of the longitudinal outcomes associated with this condition continue to evolve. Here we review the existing literature on outcomes of MIS-C up to 1 year following diagnosis and summarize current published expert recommendations for management and follow up of these patients.
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Affiliation(s)
- Michael A Fremed
- Division of Pediatric Cardiology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian-Morgan Stanley Children's Hospital, New York, NY, United States
| | - Kanwal M Farooqi
- Division of Pediatric Cardiology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian-Morgan Stanley Children's Hospital, New York, NY, United States
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