Kawasaki Disease-Like Features in 10 Pediatric COVID-19 Cases: A Retrospective Study

Acute kidney injury following multisystem inflammatory syndrome associated with SARS-CoV-2 infection in children: a systematic review and meta-analysis

INTRODUCTION

Multisystem inflammatory syndrome (MIS-C) is a rare paediatric hyper-inflammatory disorder that occurs following SARS-CoV-2 infection. Acute kidney injury (AKI) occurs in approximately one-quarter to one-third of the patients with MIS-C and is associated with poor prognosis in critically ill children. This systematic review is aimed to evaluate the incidence of AKI, mortality, and the need for kidney replacement therapy (KRT) in patients with MIS-C.

METHODS

We searched databases from Medline, EMBASE, Cochrane Register, and Google Scholar from December 2019 to December 2021 with our search strategy. Studies meeting the following criteria were included in this systematic review: (1) articles on AKI in MIS-C; (2) studies providing AKI in MIS-C and COVID-19 infection separately; (3) studies reporting outcomes such as mortality, KRT, serum creatinine; length of hospital/ICU stay.

QUALITY ASSESSMENT

The quality of the included studies was independently assessed by using the National Heart Lung and Blood Institute (NHLBI) quality assessment tool for cohort studies and case series.

STATISTICAL ANALYSIS

Outcomes and their 95% confidence intervals (CI) were reported if a meta-analysis of these outcomes was conducted. Heterogeneity was reported using I² statistics, and heterogeneity ≥ 50% was considered high. We used Baujat's plot for the contribution of each study toward overall heterogeneity. In sensitivity analysis, the summary estimates were assessed by repeating meta-analysis after omitting one study at a time. Forest plots were used for reporting outcomes in each study and with their 95% CI. All statistical tests were performed using R software version 4.0.3.

RESULTS

A total of 24 studies were included in this systematic review and of these, 11 were included in the meta-analysis. The pooled proportion of patients with MIS-C developing AKI was 20% (95% CI: 14-28%, I² = 80%). Pooled proportion of death in children with MIS-C was 4% (95% CI: 1-14%; I² = 93%). The odds of death in patients with AKI were 4.68 times higher than in patients without AKI (95% CI: 1.06-20.7%; I² = 17%). The overall pooled proportion of MIS-C-induced AKI patients requiring KRT was 15% (95% CI: 4-42%; I² = 91%).

CONCLUSION

Approximately one-fifth of children with MIS-C develop AKI which is associated with higher odds of death. PROSPERO registration: CRD42022306170 A higher resolution version of the Graphical abstract is available as Supplementary information.

Oral Lesions Associated with COVID-19 and the Participation of the Buccal Cavity as a Key Player for Establishment of Immunity against SARS-CoV-2

BACKGROUND

Some oral lesions have been described in patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); the possibility has been raised that the buccal lesions observed in patients with the coronavirus disease 2019 (COVID-19) are due to this virus and the patient's systemic condition. The aim of this review was to integrate the knowledge related to the oral lesions associated with COVID-19 and the participation of the buccal cavity in the establishment of immunity against SARS-CoV-2.

METHODS

A literature search on the manifestations of buccal lesions from the beginning of the pandemic until October 2021 was carried out by using the PubMed database. A total of 157 scientific articles were selected from the library, which included case reports and reports of lesions appearing in patients with COVID-19.

RESULTS

Oral lesions included erosions, ulcers, vesicles, pustules, plaques, depapillated tongue, and pigmentations, among others. The oral cavity is a conducive environment for the interaction of SARS-CoV-2 with the mucosal immune system and target cells; direct effects of the virus in this cavity worsen the antiviral inflammatory response of underlying oral disorders, immunodeficiencies, and autoimmunity primarily.

CONCLUSIONS

The oral cavity is an accessible and privileged environment for the interaction of SARS-CoV-2 with the mucosal immune system and target cells; the direct effects of the virus in this cavity worsen the antiviral inflammatory response of underlying oral disorders, in particular those related to immunodeficiencies and autoimmunity.

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

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

Acute and sub-acute ocular manifestations in pediatric patients with COVID-19: A systematic review

Background

The coronavirus disease 2019 (COVID-19) pandemic has been the most challenging health problem in the last 2 years. Post-COVID-19 multisystem inflammatory syndrome of children (MIS-C) is a severe post-COVID-19 complication in pediatric patients. Ocular manifestations may be the first presentation of MIS-C, wherein prompt treatment may improve outcomes. In this systematic review, we aimed to summarize the acute and sub-acute ocular manifestations in pediatric patients with laboratory-confirmed COVID-19.

Methods

We included all online primary studies, with no language restriction and published between January 1, 2019 and November 18, 2020, reporting any acute or sub-acute ocular manifestations in children with laboratory-confirmed COVID-19. PubMed/MEDLINE was searched using the following MeSH and Emtree terms: "eye," "ophthalmologic," "ocular," "vision," "conjunctivitis," "severe acute respiratory syndrome coronavirus 2," "SARS-CoV-2," "corona," "2019-nCoV," "COVID19," and "COVID." The eligibility and quality of the selected records were assessed by two independent reviewers as per the Cochrane Handbook for Systematic Review.

Results

A total of 1,192 records were identified electronically. Seven papers were extracted from the reference lists of the eligible records. Thirty-six papers met the inclusion criteria and were categorized into two subgroups according to acute or sub-acute presentation of ocular manifestations. Among 463 pediatric patients with COVID-19, 72 (15.5%) had acute ocular manifestations. There was one patient with central retinal vein occlusion and another with photophobia and diplopia associated with meningoencephalitis. Among 895 pediatric patients with post-COVID-19 MIS-C, 469 (52.4%) had ocular manifestations, which only included non-purulent conjunctivitis.

Conclusions

Ocular manifestations have been reported in less than one-fifth of pediatric patients with acute COVID-19. Furthermore, conjunctivitis was the only ocular manifestation reported in half of the patients with MIS-C, and it may be missed easily due to its non-purulent nature. During the COVID-19 pandemic, pediatricians and health workers must remain vigilant for early detection of signs of this potentially fatal post-COVID-19 inflammatory syndrome.

Post-COVID-19 Acute Transverse Myelitis: A Case Report and Literature Review

Acute transverse myelitis (ATM) following coronavirus disease 19 (COVID-19) is rarely reported in the literature. We report a case of ATM after COVID-19 infection in a female who presented with sudden onset bilateral lower limb weakness, paresthesia, and urinary retention. She developed fever, cough, dyspnea two weeks ago, and her COVID-19 test was positive one week later. After a complete physical examination and detailed investigations, including cerebrospinal fluid analysis, autoimmune screening, and infectious workup, a diagnosis of ATM due to COVID-19 was made. Magnetic resonance imaging of the whole spine confirmed the diagnosis of ATM. She was managed with intravenous methylprednisolone, physical therapy, and bladder training and her condition improved gradually.

Multisystem inflammatory syndrome in children: A complication of COVID-19

ABSTRACT

Multisystem inflammatory syndrome in children is a previously unrecognized and potentially catastrophic illness that appears in children who have been exposed to or diagnosed with COVID-19. As healthcare agents and members of the community, nurses are positioned to assist in identifying children who may experience previously unrecognized complications of infection from the SARS-CoV-2 virus.

Multiple Sclerosis Following SARS-CoV-2 Infection: A Case Report and Literature Review

Coronavirus disease 19 (COVID-19) is caused by severe acute respiratory coronavirus 2 (SARS-CoV-2). Apart from respiratory manifestations, COVID-19 can affect the nervous system due to its neurotropic features. Neurological manifestations and complications include headache, polyneuropathies, cerebrovascular accidents, seizures, encephalopathy, and demyelinating disease. We describe a case of multiple sclerosis, a demyelinating disease following COVID-19 infection, rarely reported in the literature. A 47-year-old female presented with fatigue, blurry vision, numbness, and signs of upper motor neuron lesions that had occurred three weeks after COVID-19 infection. Magnetic resonance imaging of the brain revealed demyelinating lesions in the periventricular area of both hemispheres, suggesting a demyelinating disease. A provisional diagnosis of multiple sclerosis was made. Her condition improved after the commencement of methylprednisolone.

A Case of Acute Encephalitis in COVID-19 Patient: A Rare Complication

Coronavirus disease 19 (COVID-19) is a respiratory disease, has a variable presentation, and neurological involvement in COVID-19 is not widely reported. We report a rare case of acute encephalitis in a COVID-19 patient presented with fever, dry cough, and dyspnea. She had a fever, tachypnea, and tachycardia. On auscultation, she had scattered wheezing in both lung fiends. Chest X-ray revealed small infiltrates in the lower lobe of both lungs. A nasopharyngeal swab for the COVID-19 polymerase chain reaction was positive. Later on, she developed sudden onset confusion accompanied by restlessness and visual hallucinations. Neurological examination revealed an altered level of consciousness, slight trembling of the limbs, psychomotor restlessness, and poor speech with no signs of meningeal irritation. Magnetic resonance imaging of the brain revealed diffuse hyperintense signals. A possible diagnosis of acute encephalitis was made due to concurrent COVID-19 infection and lack of other findings suggesting a diagnosis other than COVID-19. She was treated with azithromycin, tocilizumab, and methylprednisolone. Her condition started improving gradually.

Coronavirus Disease 2019-Related Multisystem Inflammatory Syndrome in Children: A Systematic Review and Meta-Analysis

Background

This study aimed to describe the clinical symptoms, laboratory findings, treatment, and outcomes of coronavirus disease 2019-related multisystem inflammatory syndrome in children to provide a reference for clinical practice.

Methods

We employed a literature search of databases such as PubMed, Web of Science, EMBASE, and Johns Hopkins University for articles on COVID-19-related multisystem inflammatory syndrome in children published between April 1, 2020, and January 15, 2021. High-quality articles were selected for analysis on the basis of their quality standard scores. Using R3.6.3 software, meta-analyses of random- or fixed-effects models were used to determine the prevalence of comorbidities. Subgroup analysis was also performed to determine heterogeneity.

Results

A total of 57 articles (2,290 pediatric patients) were included in the study. Clinical Manifestations. :ncidences of fever, gastrointestinal symptoms, respiratory symptoms, and musculoskeletal symptoms (myalgias or arthralgias) were 99.91% (95% CI: 99.67–100%), 82.72% (95% CI: 78.19–86.81%), 53.02% (45.28–60.68%), and 14.16% (95% CI: 8.4–21.12%), respectively. The incidences of rash, conjunctival injection, lymphadenopathy, dry cracked lips, neurologic symptoms (headache, altered mental status, or confusion), swollen hands and feet, typical Kawasaki disease, and atypical Kawasaki disease were 59.34% (95% CI: 54.73–63.87%), 55.23% (95% CI: 50.22–60.19%), 27.07% (95% CI: 19.87–34.93%), 46.37% (95% CI: 39.97–52.83%), 28.87% (95% CI: 22.76–35.40%), 28.75% (95% CI: 21.46–36.64%), 17.32% (95% CI: 15.44–19.29%), and 36.19% (95% CI: 21.90–51.86%), respectively. The incidences of coronary artery dilation, aneurysm, pericardial effusion, myocarditis, myocardial dysfunction, high troponin, and N-terminal pro-B-type natriuretic peptide were 17.83%, 6.85%, 20.97%, 35.97%, 56.32%, 76.34%, and 86.65%, respectively. The incidences of reduced lymphocytes, thrombocytopenia, hypoalbuminemia, elevated C-reactive protein, ferritin, LDH, interleukin-6, PCT, and FIB were 61.51%, 26.42%, 77.92%, 98.5%, 86.79%, 80.59%, 89.30%, 85.10%, and 87.01%, respectively. PICU Hospitalization Rate and Mortality. The incidences of PICU hospitalization or with shock were 72.79% and 55.68%, respectively. The mortality rate was 1.00%. Conclusion and Relevance. PICU hospitalization and shock rates of multisystem inflammatory syndrome in children associated with COVID-19 were high, and its cumulative multiorgans and inflammatory indicators are increased, but if treated in time, the mortality rate was low.

Current Understanding of Multisystem Inflammatory Syndrome (MIS-C) Following COVID-19 and Its Distinction from Kawasaki Disease

PURPOSE OF REVIEW

In this article, I have reviewed current reports that explore differences and similarities between multisystem inflammatory syndrome in children (MIS-C) and other known multisystem inflammatory diseases seen in children, particularly Kawasaki disease.

RECENT FINDINGS

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a human coronavirus causing the COVID-19 disease which emerged in China in December 2019 and spread rapidly to the entire country and quickly to other countries. Currently, there is a pandemic of SARS-CoV-2 infection that results in 20% of patients admitted to hospital with illness, with 3% developing intractable acute respiratory distress syndrome (ARDS) with high mortality. However, pediatric COVID-19 is still reported to be a mild disease, affecting only 8% of children. Pathogenesis in children is comparable to adults. There are suggested impaired activation of IFN-alpha and IFN regulator 3, decreased cell response causing impaired viral defense, yet the clinical course is mild, and almost all children recover from the infection without major complications. Interestingly, there is a subset of patients that develop a late but marked immunogenic response to COVID-19 and develop MIS-C. Clinical features of MIS-C resemble certain pediatric rheumatologic diseases, such as Kawasaki disease (mucocutaneous lymph node syndrome) which affects small-medium vessels. Other features of MIS-C resemble those of macrophage activation syndrome (MAS). However, recent research suggests distinct clinical and laboratory differences between MIS-C, Kawasaki disease, and MAS. Since the start of the SARS-CoV-2 pandemic, MIS-C has become the candidate for the most common cause of acquired heart disease in children.

SARS-CoV-2-related MIS-C: A key to the viral and genetic causes of Kawasaki disease?

Multisystem inflammatory syndrome in children (MIS-C) emerged in April 2020 in communities with high COVID-19 rates. This new condition is heterogenous but resembles Kawasaki disease (KD), a well-known but poorly understood and clinically heterogenous pediatric inflammatory condition for which weak associations have been found with a myriad of viral illnesses. Epidemiological data clearly indicate that SARS-CoV-2 is the trigger for MIS-C, which typically occurs about 1 mo after infection. These findings support the hypothesis of viral triggers for the various forms of classic KD. We further suggest that rare inborn errors of immunity (IEIs) altering the immune response to SARS-CoV-2 may underlie the pathogenesis of MIS-C in some children. The discovery of monogenic IEIs underlying MIS-C would shed light on its pathogenesis, paving the way for a new genetic approach to classic KD, revisited as a heterogeneous collection of IEIs to viruses.

Future Challenges of Covid-19 and Oral Manifestations in Daily Dental Practice: A Literature Review

OBJECTIVE

Some patients reportedly present with oral manifestations of coronavirus disease 2019 (Covid-19). It is unknown if this is due to the virus itself or a side effect of treatment; however, severe acute respiratory syndrome coronavirus 2 has been shown to have a predilection for angiotensin-converting enzyme receptors that are present in the respiratory tract, oral mucosa, tongue, and salivary glands, causing alterations in taste and smell. Therefore, the objective of this review was to present the future challenges of Covid-19 and oral manifestations in daily dental practice through a literature review.

MATERIALS AND METHODS

Scientific evidence in the databases Scopus and PubMed was searched using the Boolean operators. Articles published in Spanish and English between January and December 2020 were included.

RESULTS

Of the 89 articles found in Scopus, 69 were of the open access type and 20 were in the "others" category; only 22 scientific articles were found in PubMed.

CONCLUSION

It is important to take into account these clinical manifestations such as loss of taste and smell in order to detect the disease. Good oral hygiene is also recommended as a preventive measure to reduce viral load, which considerably reduces the probability of infecting other people who are in contact with the infected patient.

Acute Coronary Syndrome and COVID-19: A Case Report of Refractory Hypercoagulability

Novel coronavirus disease 2019 (COVID-19) is known to cause severe bilateral pneumonia and acute respiratory distress syndrome (ARDS), leading to difficulty breathing requiring mechanical ventilation and ICU management. In many patients, it has been found to cause severe hypercoagulability. We present a case of COVID-19 positive patient who developed myocardial infarction (MI) despite being on multiple anticoagulants. A 51-year-old, Middle-Eastern male diabetic patient presented to the emergency room with complaints of sudden onset left leg pain, paresthesias, and swelling for one day. On physical examination, the left leg was cool to touch from forefoot to mid-calf, with noticeable mottling over the forefoot and a nonpalpable dorsalis pedis. The patient was started on therapeutic enoxaparin and diltiazem in ED. Chest X-ray showed bilateral pulmonary infiltrates beginning peripherally and COVID-19 pneumonitis. The patient underwent a mechanical thrombectomy and was loaded with aspirin/clopidogrel, heparin drip, and enoxaparin. Despite being on triple anticoagulation, the patient had new-onset STEMI and elevated troponin levels. On angiography, the patient was found to have occluded mid-left anterior descending, most likely from acute on chronic thrombosis related to the patient’s COVID-19 status. As flow could not be re-established, the patient was kept on long-term protective anticoagulation-triple therapy (an oral anticoagulant and dual antiplatelet therapy) and received pulmonary care for COVID-19 infection. The patient was discharged on long-term triple anticoagulation and COVID-19 precautions with scheduled retesting and follow-up.

Clinical characteristics, treatment and outcomes of paediatric COVID-19: a systematic review and meta-analysis

OBJECTIVE

Compare paediatric COVID-19 disease characteristics, management and outcomes according to World Bank country income level and disease severity.

DESIGN

Systematic review and meta-analysis.

SETTING

Between 1 December 2019 and 8 January 2021, 3350 articles were identified. Two reviewers conducted study screening, data abstraction and quality assessment independently and in duplicate. Observational studies describing laboratory-confirmed paediatric (0-19 years old) COVID-19 were considered for inclusion.

MAIN OUTCOMES AND MEASURES

The pooled proportions of clinical findings, treatment and outcomes were compared according to World Bank country income level and reported disease severity.

RESULTS

129 studies were included from 31 countries comprising 10 251 children of which 57.4% were hospitalised. Mean age was 7.0 years (SD 3.6), and 27.1% had a comorbidity. Fever (63.3%) and cough (33.7%) were common. Of 3670 cases, 44.1% had radiographic abnormalities. The majority of cases recovered (88.9%); however, 96 hospitalised children died. Compared with high-income countries, in low-income and middle-income countries, a lower proportion of cases were admitted to intensive care units (ICUs) (9.9% vs 26.0%) yet pooled proportion of deaths among hospitalised children was higher (relative risk 2.14, 95% CI 1.43 to 3.20). Children with severe disease received antimicrobials, inotropes and anti-inflammatory agents more frequently than those with non-severe disease. Subgroup analyses showed that a higher proportion of children with multisystem inflammatory syndrome (MIS-C) were admitted to ICU (47.1% vs 22.9%) and a higher proportion of hospitalised children with MIS-C died (4.8% vs 3.6%) compared with the overall sample.

CONCLUSION

Paediatric COVID-19 has a favourable prognosis. Further severe disease characterisation in children is needed globally.

Severe SARS-CoV-2 Infection: A Multisystem Inflammatory Syndrome in Moroccan Children

Until October 2020, children seem to have a mild form of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in Morocco. Since April 2020, a new entity of multisystem inflammatory syndrome in children associated with SARS-CoV-2 infection was reported in England, Italy, France, and the United States. This syndrome has similarities with the most frequent vasculitis in children, Kawasaki disease. Here, we describe the features and outcome of the first five cases of Kawasaki-like multisystem inflammatory syndrome in Moroccan children triggered by the SARS-CoV-2. The median age of the children was 7.8 years; three of them were boys. Criteria for Kawasaki disease were met in all of them with a complete presentation. Three patients required admission to a critical care unit with multi-organ failure in one of them, but no mortality occurred. They all received intravenous immunoglobulin (IVIG), a high dose of aspirin, methylprednisolone, and supportive therapy. Coronavirus 2019 disease (COVID-19) infection in children may be life-threatening; rigorous monitoring for several weeks is required in any positive child or living in a family cluster.