Heart Involvement in Multisystem Inflammatory Syndrome, Associated With COVID-19 in Children: The Retrospective Multicenter Cohort Data

Cardiac Manifestations and Emerging Biomarkers in Multisystem Inflammatory Syndrome in Children (MIS-C): A Systematic Review and Meta-Analysis

BACKGROUND

Cardiac involvement is a key prognostic factor in multisystem inflammatory syndrome in children (MIS-C), a rare but serious inflammatory condition that typically occurs 2-6 weeks after SARS-CoV-2 infection and is characterized by fever, systemic inflammation, and multiorgan involvement. Biomarkers may aid in early detection, severity assessment, and treatment stratification.

OBJECTIVE

To evaluate the diagnostic utility of established and emerging serum biomarkers in MIS-C, with an emphasis on cardiac dysfunction and disease severity.

METHODS

A systematic search was conducted in PubMed, Scopus, and Web of Science up to April 2025. Eligible studies included pediatric MIS-C cases with reported serum biomarkers. Meta-analyses were performed for NT-proBNP and troponin using random-effects models. Descriptive profiling was applied to emerging biomarkers. Subgroup comparisons were explored between severe and moderate MIS-C. Quality assessment followed the Newcastle-Ottawa Scale, and publication bias was assessed via funnel plots and Egger's test.

RESULTS

A total of 67 studies were included, comprising >4000 pediatric MIS-C cases. NT-proBNP and troponin were consistently elevated (pooled means: 9697 pg/mL and 0.384 ng/mL, respectively), with a low risk of publication bias. Emerging biomarkers such as CXCL9, angiopoietin-2, and vitamin D revealed high inter-study variability but potential prognostic value. Subgroup analyses for selected studies (n = 5) suggested higher biomarker levels in severe MIS-C.

CONCLUSIONS

NT-proBNP and troponin are robust indicators of cardiac injury in MIS-C. Emerging biomarkers show promise but require validation. Future studies should include copeptin and adopt standardized reporting to refine biomarker-guided management.

Clinical and laboratory markers defining MIS-C and hyperinflammation in COVID-19: a cross-sectional study in a tertiary hospital

BACKGROUND

Numerous inflammatory complications related to COVID are described, including the Multisystem inflammatory Syndrome in Children (MIS-C) and Hyperinflammation. There is a scarcity of studies comparing these two groups.

METHODS

Retrospective longitudinal outcome-conditioned study. Demographic, clinical, and laboratory variables are analyzed. Patients with history of COVID contact or infection with at least 24 h of fever, two or more systems involved and up to 21 years were included. Patients with no laboratory signal of inflammation or with other diagnoses for the condition were excluded. Demographic and laboratory data are presented as medians with interquartile ranges. Dichotomous variables and prevalences are reported as percentages. A ROC curve analysis was conducted to assess the discriminatory ability of these tests in relation to the MIS-C and hyperinflammation groups.

RESULTS

We present fifty-four patients, thirty-one with MIS-C and twenty-three with hyperinflammation. The most frequent symptom in the MIS-C group was altered mental status in 61% vs. 46% (p = 0.014) and conjunctival hyperemia in 29% vs. 4% (p = 0.032). The most frequent laboratory findings were hypoalbuminemia in 68% vs. 26% (p = 0.002), increased serum troponin in 42% vs. 26% (p = 0.034), increased d-dimers in 94% vs. 76% (p = 0.015), as well as increased BNP in 55% vs. 17% (p = 0.02). On the other hand, the hyperinflammation group more frequently presented respiratory dysfunction in 57% vs. 13% (p = < 0.001) and serum ferritin equal or greater than 500 ng/mL in 94% vs. 77% (p = 0.046).

CONCLUSIONS

This is an original study comparing clinical and laboratory findings between MIS-C and hyperinflammation due to COVID. Altered mental status is more frequently associated with MIS-C while respiratory symptoms are associated with hyperinflammation. In addition, regarding laboratory tests, there is hypoalbuminemia, increase in serum troponin, BNP, and D-dimers specially in the MIS-C group and hyperferritinemia in the hyperinflammation group. Further studies are needed to assess the cutoff point of biological markers such as BNP, troponin, and d-dimers for diagnosis and/or prognosis in the pediatric population with MIS-C.

Cardiovascular involvement in multisystem inflammatory syndrome in children and midterm follow-up from a pediatric tertiary center in India

BACKGROUND

In multisystem inflammatory syndrome in children (MIS-C) with coronavirus disease 2019, there was paucity of data from low-income and middle-income countries on cardiovascular involvement and its longitudinal outcomes. We planned to estimate the pattern of cardiovascular involvement among children with MIS-C and its mid-term outcomes.

AIM

To determine association between cardiovascular abnormalities and clinical and laboratory parameters. To study the time-line for resolution of various abnormalities.

METHODS

In this prospective study done in a tertiary care hospital, 270 were recruited from June 2020 to January 2022. Baseline demographic data and clinical presentation were recorded. Laboratory parameters and echocardiography were done at admission. Follow-up was done at 2 weeks, 3 months, 6 months and 1 year after diagnosis. Descriptive statistics were used for parametric and non-parametric data. Risk factors were identified by multivariate regression analysis.

RESULTS

The 211 (78.2%) had cardiac involvement and 102 needed intensive care unit (ICU) admission. Cardiovascular abnormalities observed were shock 123 (45.6%), coronary dilatation 28 (10.4%), coronary aneurysm 77 (28.5%), left ventricular (LV) dysfunction 78 (29.3%), mitral regurgitation (MR) 77 (28.5%) and pericardial effusion 98 (36.3%). Coronary artery aneurysm/dilatation during follow-up at 2 weeks and 1 year were 25.7% and 0.9% respectively. Multivariate regression analysis revealed breathlessness [odds ratio (OR) = 3.91, 95%CI: 1.25-12.21, P = 0.019] and hi-flow nasal cannula (HFNC) support (OR = 8.5, 95%CI: 1.06-68.38, P = 0.044) as predictors of cardiovascular involvement. Higher mean age (OR = 1.16, 95%CI: 1.02-1.32, P = 0.026), breathlessness (OR = 4.99, 95%CI: 2.05-12.20, P < 0.001), gallop (OR = 4.45, 95%CI: 0.41-2.52, P = 0.016), MR (OR = 3.61, 95%CI: 1.53-8.53, P = 0.004) and invasive ventilation (OR = 4.01, 95%CI: 1.28-12.58, P = 0.017) were predictive of LV dysfunction. Altered sensorium (OR = 4.96, 95%CI: 2.23-11.02, P < 0.001), headache (OR = 6.61, 95%CI: 1.46-29.92, P = 0.014), HFNC (OR = 7.03, 95%CI: 2.04-24.29, P = 0.002), non-rebreathing mask usage (OR = 21.13, 95%CI: 9.00-49.61, P < 0.001) and invasive ventilation (OR = 5.64, 95%CI: 1.42-22.45, P = 0.014) were risk factors for shock. Anemia was a risk factor for coronary involvement (OR = 3.09, 95%CI: 1.79- 5.34, P < 0.001).

CONCLUSION

Significant number of children with MIS-C had cardiovascular involvement contributing to higher ICU management. Although shock resolved quickly, resolution of ventricular function and coronary abnormalities were slower, and hence warrants a structured long-term follow-up protocol.

Coronary artery dilation in children with MIS-C: prevalence, risk factor, and progression

Cardiac injury is the critical issue in children with MIS-C, particularly coronary artery dilation. This study aimed to describe the prevalence, risk factors associated with coronary artery abnormalities, and their progression after 3 months of follow-up in MIS-C children in Vietnam. A prospective multicenter case series study was conducted on MIS-C patients diagnosed per WHO criteria from September 2021 to February 2023 at the two largest pediatric hospitals in southern Vietnam. Data on demographics, clinical features, laboratory findings, and treatments during the acute phase of MIS-C were collected. Patients were followed for 3 months post-discharge and categorized into normal and abnormal coronary artery groups for comparative analysis. Among 195 patients (mean age 6.3 years; male to female ratio 1.5:1), 33.3% exhibited coronary artery abnormalities at admission. Treatment included a combination of intravenous immunoglobulin (IVIG) and corticosteroids (53.3%), corticosteroids alone (42.6%), and IVIG alone (4.1%). After 3 months, only 3.6% of patients had persistent coronary artery abnormalities. Independent risk factors for coronary artery dilation included male sex (OR 4.59; 95% CI 1.62-12.94; p = 0.004), Kawasaki-like phenotype (OR 6.42; 95% CI 2.25-18.33; p = 0.001), and mesenteric lymphadenitis (OR 8.79; 95% CI 1.74-44.31; p = 0.008).

CONCLUSION

Coronary artery dilation in MIS-C patients shows a favorable recovery trajectory after a 3-month follow-up. Male sex, Kawasaki-like MIS-C, and mesenteric lymphadenitis are independent risk factors for coronary artery dilation in MIS-C patients.

WHAT IS KNOWN

• Multisystem inflammatory syndrome in children (MIS-C) is a severe inflammatory syndrome following SARS-CoV-2 infection, often leading to cardiac complications, particularly coronary artery dilation.

WHAT IS NEW

• Coronary artery dilation in MIS-C patients mostly resolves within three months of follow-up. Factors associated with coronary artery dilation in MIS-C patients include: male sex, Kawasaki-like phenotype and mesenteric lymphadenitis.

Speckle-tracking and conventional echocardiography in MIS-C: tracking cardiac involvement and recovery

BACKGROUND

Multisystem inflammatory syndrome in children (MIS-C), a complication of COVID-19, is frequently associated with cardiac involvement. Although most affected children recover, the extent and duration of myocardial abnormalities remain uncertain. This study evaluates mid-term cardiac function in MIS-C patients, with and without cardiac involvement, using transthoracic echocardiography (TTE) and speckle-tracking echocardiography (STE).

METHODS

This case-control study (2022-2023) included 90 children: 30 with MIS-C and cardiac involvement, 30 with MIS-C without cardiac involvement, and 30 healthy controls. TTE and STE were used to assess left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) at diagnosis and at three months, comparing outcomes across groups.

RESULTS

The cardiac involvement group exhibited significantly elevated ferritin and C-reactive protein levels (P = 0.006 and P = 0.017, respectively) and a higher prevalence of troponin positivity (56.67% vs. 20%, P = 0.009). At baseline, these patients had markedly reduced LVEF (56.5 ± 4.3) and GLS (-21.6 ± 3.21) compared to healthy controls (LVEF: 68.2 ± 5.21; GLS: -24.8 ± 1.48; both P < 0.001). Notably, the basal segment showed significant longitudinal strain reduction (-18.75 ± 3.89 vs. -23.58 ± 0.27, P = 0.027), while differences in the apical and mid segments were not significant. By three months, LVEF (69 ± 4.21, P = 0.53) and GLS (-24.13 ± 2.39, P = 0.17) normalized. Heart failure and coronary artery brightness resolved in all affected patients, and most structural abnormalities improved; only two cases exhibited persistent mild left ventricular dilation. Regional strain analysis at follow-up revealed values comparable to those of healthy controls across all segments.

CONCLUSION

Cardiac dysfunction in MIS-C largely resolves within three months, with LVEF and GLS returning to normal. However, persistent myocardial abnormalities in a few cases highlight the need for long-term cardiac monitoring to detect and manage potential sequelae.

Development of Preliminary Criteria of Macrophage Activation Syndrome in Multisystem Inflammatory Syndrome Associated with COVID-19 in Children

Background: Macrophage activation syndrome (MAS) can be regarded as a key factor determining the severity of multisystem inflammatory syndrome associated with COVID-19 in children (MIS-C), and often requires treatment in the intensive care unit (ICU) to avoid life-threatening complications. No reputable specific criteria for the diagnosis of MAS in MIS-C patients have yet been identified, and criteria currently used for the diagnosis of hemophagocytic syndromes, such as HLH-2004, MAS-2005, and MAS-2016, are not sufficient for MAS in MIS-C. Our goal in this study was to work out the criteria for the early diagnosis of MAS in MIS-C. Methods: One hundred and sixty-six (166) patients with MIS-C were assessed retrospectively. The two most experienced experts independently identified patients with MAS. The patients were divided into three cohorts: MAS (n = 19), without MAS (n = 78), and probable MAS (n = 67). The latter included patients diagnosed with MAS by only one expert, and it was excluded from the analysis. Results: The age of patients with MAS was much higher, and they more frequently had edematous syndrome, hypotension and/or shock, splenomegaly, and CNS involvement. In their blood tests, thrombocytopenia, hypoalbuminemia, and hypertriglyceridemia occurred more often. The level of biomarkers of inflammation, such as ferritin, CRP, troponin, AST, and ALT, was also higher in this group. Increased fibrinogen and D-dimer were also found, demonstrating hypercoagulation in the MAS-MIS-C group. We chose 21 continuous and categorical variables with statistical significance, out of which 2-ferritin > 469 μg/L or platelets < 114 × 109/L-allowed us to discriminate MAS patients. Conclusions: Ferritin > 469 μg/L or platelets < 114 × 109/L can be regarded as key signs to differentiate MAS in MIS-C patients with a sensitivity of 100% and specificity of 94.9%, and they can be used along with other diagnostic methods.

In-hospital unfavorable outcomes of MIS-C during 2020-2022: a systematic review

Studies on the severity in multisystem inflammatory syndrome in children (MIS-C) show heterogeneous results and may not reflect a global perspective. This systematic review aims to estimate the frequency of in-hospital unfavorable outcomes in patients with MIS-C over the 3 years since the onset of the SARS-CoV-2 pandemic. A systematic search was conducted in Medline, Scopus, Embase, Cochrane, Web of Science, Scielo, and preprint repositories until December 15, 2022. Study selection and data extraction were evaluated independently. The primary outcomes were intensive care unit (ICU) admission, invasive mechanical ventilation (IMV), and death. Additionally, we evaluated cardiovascular-related outcomes. We performed a random-effects model meta-analysis and assessed the certainty of the evidence. Fifty-seven studies (n = 13 254) were included. The frequency of ICU admission was 44.7% (95% CI 38.8-50.7), 11.9% for IMV (95% CI 9.6-14.4), and 2.0% for death (95% CI 1.3-3.0). The requirement of vasoactive/inotropic drugs was 40.1% (95% CI 35.9-44.4), 7.9% for coronary aneurysm (95% CI 4.1-12.7), 30.7% for decreased left ventricle ejection fraction (LVEF) (95% CI 26.3-35.4), and 29.7% for myocarditis (95% CI 18.4-42.4). We assess the included evidence as being of very low certainty. Finally, excess COVID-19 mortality by country and the diagnostic criteria for MIS-C (CDC compared to WHO) were associated with a higher frequency of ICU admissions. The year of study conduction (2022 compared to 2020) was associated with a lower frequency of IMV.

CONCLUSION

The frequency of in-hospital unfavorable outcomes in patients with MIS-C was high. Well-designed studies are needed to explore other heterogeneity sources.

PROTOCOL REGISTRATION

CRD42021284878.

WHAT IS KNOWN

• Multisystem inflammatory syndrome in children (MIS-C) is a serious post-infectious condition linked to SARS-CoV-2. Studies on the severity of MIS-C show heterogeneous results. These findings may not be representative of the reality in other regions, making it challenging to draw generalizable conclusions.

WHAT IS NEW

• Over the 3 years since the onset of the SARS-CoV-2 pandemic, our systematic review has shown that the frequency of in-hospital unfavorable outcomes in patients with MIS-C is high, with a very low certainty of the evidence. Our results reflect the reality from a global perspective, across different countries with varying income levels. • The main sources of heterogeneity in the frequency of severe outcomes could be explained by the excess mortality due to COVID-19 in each country, the type of diagnostic criteria for MIS-C, and the year the study was conducted.

Pediatric endocarditis - a stone left after the pandemic cascade

Infective endocarditis is a rare disease in children. The etiology is mainly bacterial. However, viral infective endocarditis, possibly related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has also been reported. The pathophysiological principle of the connection between the two entities seems to be attributed to the transient immune deficiency of the body during the infection. Additionally, SARS-CoV-2 is reported in the literature as a direct cardiopathic virus. Therefore, the new coronavirus seems to have the ability to affect both the intact cardiac tissue and the previously damaged one both during the acute episode and at a distance from it. Consequently, we propose to review the main pathophysiological aspects of pediatric cardiac damage caused by SARS-CoV-2. The ultimate goal is to deepen existing knowledge, broaden the horizon of understanding and analysis regarding the systemic damage induced by viral infections, and strengthen an information base from which to start a meta-analysis. Next, we performed a non-systematized screening of the specialized literature with reference to cases of endocarditis in the pediatric population, reported in the period 2020-2023. From the total of articles found, we chose to include in the review a number of 6 case reports, including a number of 7 patients (5 children and 2 adolescents). Analysis of reports suggests that SARS-CoV-2 infection could play a role in the development of endocarditis, either directly through active infection or indirectly through a post-infectious immune response. Also, pre-existing conditions and complex medical history predispose to an increased risk of developing a severe, complicated form of endocarditis. Also, the lack of data on the vaccination history and the failure to categorize the infection depending on the type of antibodies (IgM or IgG) in some studies represent a major bias in the reports. The latter make it difficult to evaluate the influence of vaccination and the impact of acute versus chronic infection on the course of cases.

Relationship between gastrointestinal symptoms and COVID-19 infection in the pediatric population: a scoping review

OBJECTIVE

To map the evidence in the literature about the relationship between gastrointestinal symptoms and COVID-19 in the pediatric population.

METHOD

This is a scoping review following the recommendations of the Joanna Briggs Institute and PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. The search was carried out on the following bases: Embase, Google Scholar, PubMed, Scopus, LILACS, CINAHL, Scielo, Web of Science and Virtual Health Library Portal, between July and August 2023. Original studies available in full, in any language, were included.

RESULTS

Ten studies were chosen that pointed to three premises: (1) the ACE2 receptor is found in the epithelial cells of the gastrointestinal tract; (2) gastrointestinal symptoms are mediated by stress and infection is justified by the gut-brain axis; (3) it develops the process of Multisystem Inflammatory Syndrome in children, affecting the gastrointestinal tract.

CONCLUSION

The synthesis of evidence provided three assumptions which guide the origin of gastrointestinal symptoms. The identification of gastrointestinal symptoms in children affected by COVID-19 can assist in the clinical approach and management of care and treatments.

Multisystem Inflammatory Syndrome in Children and Cardiac Involvement: A Quaternary Center Experience

We prospectively analyzed clinical and laboratory characteristics associated with cardiac involvement and severe presentation in multisystem inflammatory syndrome in children. Of 146 patients, 66 (45.2%) had cardiac dysfunction and 26 (17.8%) had coronary artery abnormalities. Lower serum albumin levels, absolute lymphocyte and platelet counts, and elevated ferritin, fibrinogen, d-dimer and interleukin-6 levels were associated with cardiac dysfunction. Possible treatment complications were identified.

Cardiovascular Manifestations of Multisystem Inflammatory Syndrome in Children: A Single-Center Bulgarian Study

Background and objectives: Multisystem inflammatory syndrome in children (MIS-C) poses challenges to the healthcare system, especially with frequent heart involvement. The current retrospective observational study aims to summarize the type and degree of cardiovascular involvement in children with MISC and to find possible associations between laboratory, inflammatory, and imaging abnormalities and the predominant clinical phenotype using a cluster analysis. Material and methods: We present a retrospective observational single-center study including 51 children meeting the MIS-C criteria. Results: Fifty-three percent of subjects presented with at least one sign of cardiovascular involvement (i.e., arterial hypotension, heart failure, pericardial effusion, myocardial dysfunction, pericarditis without effusion, myocarditis, coronaritis, palpitations, and ECG abnormalities). Acute pericarditis was found in 30/41 of the children (73%) assessed using imaging: 14/30 (46.7%) with small pericardial effusion and 16/30 (53.3%) without pericardial effusion. The levels of CRP were significantly elevated in the children with pericarditis (21.6 ± 13 mg/dL vs. 13.9 ± 11 mg/dL, p = 0.035), and the serum levels of IL-6 were higher in the children with small pericardial effusion compared to those without (191 ± 53 ng/L vs. 88 ± 27 ng/L, p = 0.041). Pericarditis with detectable pericardial effusion was significantly more frequent in the female vs. male subjects, 72% vs. 30% (p = 0.007). The hierarchical clustering analysis showed two clusters: Cluster 1 includes the children without cardiovascular symptoms, and Cluster 2 generalizes the MIS-C children with mild and severe cardiovascular involvement, combining pericarditis, myocarditis, heart failure, and low blood pressure. Also, subjects from Cluster 2 displayed significantly elevated levels of fibrinogen (5.7 ± 0.3 vs. 4.6 ± 0.3, p = 0.03) and IL-6 (158 ± 36 ng/mL vs. 66 ± 22 ng/mL, p = 0.032), inflammatory markers suggestive of a cytokine storm. Conclusions: Our results confirm that children with oligosymptomatic MIS-C or those suspected of long COVID-19 should be screened for possible cardiological involvement.

Determination of Risk Factors for Severe Life-Threatening Course of Multisystem Inflammatory Syndrome Associated with COVID-19 in Children

Multisystem inflammatory syndrome associated with COVID-19 in children (MIS-C) is a life-threatening condition that often requires intensive care unit (ICU) admission. The aim of this study was to determine risk factors for severe/life-threatening course of MIS-C. The study included 166 patients (99 boys, 67 girls) aged 4 months-17 years (median 8.2 years). The criterion of severity was the fact of ICU admission. To conduct a comparative analysis, MIS-C patients were divided into two groups: patients hospitalized in the ICU (n = 84, 50.6%) and those who did not need ICU admission (n = 82, 49.4%). Patients with a more severe course of MIS-C were significantly older. They had a higher frequency of signs such as rash, swelling, hepatomegaly, splenomegaly, and neurological and respiratory symptoms. Hypotension/shock and myocardial involvement were much more common in patients with severe MIS-C. These patients had a more significant increase in CRP, creatinine, troponin, and D-dimer levels. Additionally, the presence of macrophage activation syndrome was higher in patients admitted to the ICU. Conclusion: Nineteen predictors of severe course of MIS-C were found, out of which hepatomegaly, splenomegaly, D-dimer > 2568 ng/mL, troponin > 10 pg/mL were mainly associated with the probability of being classified as early predictors of severe MIS-C requiring ICU admission.

Pediatric multisystem inflammatory syndrome associated with COVID-19: Insights in pathogenesis and clinical management

The pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been a major challenge to be faced in recent years. While adults suffered the highest morbidity and mortality rates of coronavirus disease 2019, children were thought to be exclusively asymptomatic or to present with mild conditions. However, around April 2020, there was an outbreak of a new clinical syndrome related to SARS-CoV-2 in children - multisystemic inflammatory syndrome in children (MIS-C) - which comprises a severe and uncon-trolled hyperinflammatory response with multiorgan involvement. The Centers for Disease Control and Prevention considers a suspected case of MIS-C an individual aged < 21 years presenting with fever, high inflammatory markers levels, and evidence of clinically severe illness, with multisystem (> 2) organ involvement, no alternative plausible diagnoses, and positive for recent SARS-CoV-2 infection. Despite its severity, there are no definitive disease management guidelines for this condition. Conversely, the complex pathogenesis of MIS-C is still not completely understood, although it seems to rely upon immune dysregulation. Hence, in this study, we aim to bring together current evidence regarding the pathogenic mechanisms of MIS-C, clinical picture and management, in order to provide insights for clinical practice and implications for future research directions.

Epidemiologic and clinical characteristics of human bocavirus infection in children hospitalized for acute respiratory tract infection in Qingdao, China

Persistent infection and prolonged shedding of human bocavirus 1 (HBoV1) in children have been reported, and the role of HBoV1 as a sole causative pathogen in acute respiratory infection (ARI) is yet to be established. While the reported prevalence of HBoV infection varies due to different detection methods and sampling criteria, determining the viral and bacterial etiology of HBoV infection using multiplex real-time PCR is yet to be reported. Herein, we aimed to further explore the pathogenicity of HBoV in patients with ARI by screening the viral and bacterial infections in children with ARI in Qingdao and comparing the epidemiological, clinical characteristics, and etiological results. Human bocavirus was identified in 28.1% of the samples, and further sequencing analysis of the detected HBoV confirmed 96.4% as HBoV1. The rate of HBoV as a single viral infection was 75%, and the rate of coinfection with bacteria was 66.1%, suggesting the need for continued monitoring of HBoV in children with ARIs. Clinical characterization suggested that HBoV infection may affect the function of organs, such as the liver, kidney, and heart, and the blood acid–base balance. Additionally, it is essential to promote awareness about the importance of disinfection and sterilization of the hospital environment and standardizing operations. The interactions between HBoV and other pathogens remain to be investigated in further detail in the future.