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Reis BCSD, Soares Faccion R, de Carvalho FAA, Moore DCBC, Zuma MCC, Plaça DR, Salerno Filgueiras I, Leandro Mathias Fonseca D, Cabral-Marques O, Bonomo AC, Savino W, Freitas FCDP, Faoro H, Passetti F, Robaina JR, de Oliveira FRC, Novaes Bellinat AP, Zeitel RDS, Salú MDS, de Oliveira MBG, Rodrigues-Santos G, Prata-Barbosa A, de Vasconcelos ZFM. Rare genetic variants involved in multisystem inflammatory syndrome in children: a multicenter Brazilian cohort study. Front Cell Infect Microbiol 2023; 13:1182257. [PMID: 37588055 PMCID: PMC10426286 DOI: 10.3389/fcimb.2023.1182257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 06/23/2023] [Indexed: 08/18/2023] Open
Abstract
Introduction Despite the existing data on the Multisystem Inflammatory Syndrome in Children (MIS-C), the factors that determine these patients evolution remain elusive. Answers may lie, at least in part, in genetics. It is currently under investigation that MIS-C patients may have an underlying innate error of immunity (IEI), whether of monogenic, digenic, or even oligogenic origin. Methods To further investigate this hypothesis, 30 patients with MIS-C were submitted to whole exome sequencing. Results Analyses of genes associated with MIS-C, MIS-A, severe covid-19, and Kawasaki disease identified twenty-nine patients with rare potentially damaging variants (50 variants were identified in 38 different genes), including those previously described in IFNA21 and IFIH1 genes, new variants in genes previously described in MIS-C patients (KMT2D, CFB, and PRF1), and variants in genes newly associated to MIS-C such as APOL1, TNFRSF13B, and G6PD. In addition, gene ontology enrichment pointed to the involvement of thirteen major pathways, including complement system, hematopoiesis, immune system development, and type II interferon signaling, that were not yet reported in MIS-C. Discussion These data strongly indicate that different gene families may favor MIS- C development. Larger cohort studies with healthy controls and other omics approaches, such as proteomics and RNAseq, will be precious to better understanding the disease dynamics.
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Affiliation(s)
- Bárbara Carvalho Santos Dos Reis
- Programa de Pós Graduação em Pesquisa Aplicada à Saúde da Criança e da Mulher, Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira (IFF), Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, RJ, Brazil
- Laboratório de Alta Complexidade (LACIFF), Unidade de Pesquisa Clínica, IFF, FIOCRUZ, Rio de Janeiro, RJ, Brazil
- Departamento de Imunologia, IFF, FIOCRUZ, Rio de Janeiro, RJ, Brazil
| | - Roberta Soares Faccion
- Programa de Pós Graduação em Pesquisa Aplicada à Saúde da Criança e da Mulher, Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira (IFF), Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, RJ, Brazil
- Laboratório de Alta Complexidade (LACIFF), Unidade de Pesquisa Clínica, IFF, FIOCRUZ, Rio de Janeiro, RJ, Brazil
| | - Flavia Amendola Anisio de Carvalho
- Programa de Pós Graduação em Pesquisa Aplicada à Saúde da Criança e da Mulher, Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira (IFF), Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, RJ, Brazil
- Departamento de Imunologia, IFF, FIOCRUZ, Rio de Janeiro, RJ, Brazil
| | - Daniella Campelo Batalha Cox Moore
- Unidade de Pacientes Graves, Departamento de Pediatria, IFF, FIOCRUZ, Rio de Janeiro, RJ, Brazil
- Faculdade de Medicina, Universidade Federal Fluminense, Niterói, Rio de Janeiro, RJ, Brazil
| | - Maria Celia Chaves Zuma
- Programa de Pós Graduação em Pesquisa Aplicada à Saúde da Criança e da Mulher, Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira (IFF), Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, RJ, Brazil
- Laboratório de Alta Complexidade (LACIFF), Unidade de Pesquisa Clínica, IFF, FIOCRUZ, Rio de Janeiro, RJ, Brazil
| | - Desirée Rodrigues Plaça
- Departamento de Análises Clínicas e Toxicológicas, Faculdade de Ciências Farmacêuticas (FCF), Universidade de São Paulo (USP), São Paulo, SP, Brazil
- Programa de Pós-Graduação em Farmácia (Fisiopatologia e Toxicologia), FCF, USP, São Paulo, SP, Brazil
| | - Igor Salerno Filgueiras
- Departamento de Imunologia, Instituto de Ciências Biomédicas (ICB), USP, São Paulo, SP, Brazil
| | - Dennyson Leandro Mathias Fonseca
- Programa Interunidades de Pós-graduação em Bioinformática, Instituto de Matemática e Estatística (IME), USP, São Paulo, SP, Brazil
| | - Otavio Cabral-Marques
- Departamento de Análises Clínicas e Toxicológicas, Faculdade de Ciências Farmacêuticas (FCF), Universidade de São Paulo (USP), São Paulo, SP, Brazil
- Departamento de Imunologia, Instituto de Ciências Biomédicas (ICB), USP, São Paulo, SP, Brazil
- Programa Interunidades de Pós-graduação em Bioinformática, Instituto de Matemática e Estatística (IME), USP, São Paulo, SP, Brazil
- Network of Immunity in Infection, Malignancy, and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), São Paulo, Brazil
- Department of Medicine, Division of Molecular Medicine, University of São Paulo School of Medicine, São Paulo, SP, Brazil
- Laboratory of Medical Investigation 29, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Adriana Cesar Bonomo
- Laboratoírio de Pesquisas Sobre o Timo, Instituto Oswaldo Cruz (IOC), FIOCRUZ, Rio de Janeiro, RJ, Brazil
- Instituto National de Ciencia e Tecnologia em Neuroimunomodulação (INCT/NIM), IOC, FIOCRUZ, Rio de Janeiro, RJ, Brazil
- Rede FAPERJ de Pesquisa em Neuroinflamação, IOC, FIOCRUZ, Rio de Janeiro, RJ, Brazil
- Rede INOVA-IOC em Neuroimunomodulação, IOC, FIOCRUZ, Rio de Janeiro, RJ, Brazil
| | - Wilson Savino
- Laboratoírio de Pesquisas Sobre o Timo, Instituto Oswaldo Cruz (IOC), FIOCRUZ, Rio de Janeiro, RJ, Brazil
- Instituto National de Ciencia e Tecnologia em Neuroimunomodulação (INCT/NIM), IOC, FIOCRUZ, Rio de Janeiro, RJ, Brazil
- Rede FAPERJ de Pesquisa em Neuroinflamação, IOC, FIOCRUZ, Rio de Janeiro, RJ, Brazil
- Rede INOVA-IOC em Neuroimunomodulação, IOC, FIOCRUZ, Rio de Janeiro, RJ, Brazil
| | | | - Helisson Faoro
- Laboratório de Regulação da Expressão Gênica, Instituto Carlos Chagas (ICC), FIOCRUZ, Curitiba, PR, Brazil
| | - Fabio Passetti
- Laboratório de Regulação da Expressão Gênica, Instituto Carlos Chagas (ICC), FIOCRUZ, Curitiba, PR, Brazil
| | | | | | | | - Raquel de Seixas Zeitel
- Pediatric Intensive Care Unit, Hospital Universitário Pedro Ernesto (HUPE), Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
| | - Margarida dos Santos Salú
- Programa de Pós Graduação em Pesquisa Aplicada à Saúde da Criança e da Mulher, Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira (IFF), Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, RJ, Brazil
- Laboratório de Alta Complexidade (LACIFF), Unidade de Pesquisa Clínica, IFF, FIOCRUZ, Rio de Janeiro, RJ, Brazil
- Pediatric Intensive Care Unit, Hospital Martagão Gesteira, Salvador, BA, Brazil
| | | | | | - Arnaldo Prata-Barbosa
- Instituto D’Or de Pesquisa e Ensino (IDOR), Rio de Janeiro, Brazil
- Pediatric Intensive Care Unit, Instituto de Puericultura e Pediatria Martagão Gesteira (IPPMG), Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
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Minoia F, Lucioni F, Heshin-Bekenstein M, Vastert S, Kessel C, Uziel Y, Lamot L, Ruperto N, Gattorno M, Bracaglia C, Toplak N. Approaches to SARS-CoV-2 and other vaccinations in children with a history of multisystem inflammatory syndrome (MIS-C): An international survey. Front Pediatr 2022; 10:1030083. [PMID: 36440337 PMCID: PMC9682234 DOI: 10.3389/fped.2022.1030083] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 10/21/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Following the Coronavirus Disease-19 (COVID-19) pandemic outbreaks, the hyperinflammatory condition termed Multisystem Inflammatory Syndrome in Children (MIS-C) became a healthcare issue worldwide. Since December 2020 the mRNA vaccine against SARS-CoV-2 has become available with a good safety profile. However, evidence regarding safety and vaccination strategies in children with previous MIS-C is still lacking. The aim of our study was to investigate the current approach of international centers to anti-SARS-CoV-2 and other vaccinations in children with a history of MIS-C. METHODS Physicians who care for patients with MIS-C were invited to anonymously complete a 15-question, web-based survey. The survey was open from October 6 to December 31, 2021. RESULTS A total of 290 replies from 236 centers in 61 countries were collected. Most respondents (86%) were pediatric rheumatologists. The anti-SARS-CoV-2 vaccine was available in 85% of the countries. Sixty-seven centers (28%) in 22 countries already vaccinated MIS-C patients without adverse reactions in most cases (89%). Six reported complications: 2 not specified, 3 mild symptoms and 1 reported a MIS-C-like reaction. Most centers (84%) favored vaccinating MIS-C patients against SARS-CoV-2, after 3-6 months (40%), 6-12 months (52%) or >12 months (8%). The survey revealed broad heterogeneity of responses among healthcare providers within the same country and within the same center. The variable with the greatest impact on the decision not to vaccinate MIS-C patients was the current lack of evidence (51%), followed by patient/parent objection (40%). The most relevant parameters in the vaccination strategy were time from MIS-C episode (78%), immunosuppressive treatment (35%), SARS-CoV-2 serologic status (32%), and MIS-C features (31%). Almost all centers favored continuing regular vaccination with non-live (99%) and live (93%) vaccines; however, with high variability in suggested timelines. CONCLUSION To date, the experience of the international pediatric rheumatology community in vaccinating MIS-C patients against SARS-CoV-2 is overall reassuring. However, lack of evidence causes broad heterogeneity in vaccination strategy worldwide.
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Affiliation(s)
- Francesca Minoia
- Pediatric Immuno-Rheumatology Unit, Fondazione IRCSS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Federica Lucioni
- Pediatric Immuno-Rheumatology Unit, Fondazione IRCSS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Merav Heshin-Bekenstein
- Dana Dwek Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Sebastiaan Vastert
- Division of Pediatric Rheumatology and Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Christoph Kessel
- Department of Pediatric Rheumatology and Immunology, University Children's Hospital Muenster, Muenster, Germany
| | - Yosef Uziel
- Meir Medical Center, Sackler School of Medicine, Tel Aviv University, Kfar Saba, Israel
| | - Lovro Lamot
- University Hospital Center Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Nicolino Ruperto
- UOSID Centro Trial, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Marco Gattorno
- Center for Autoinflammatory Diseases and Immunodeficiencies, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Claudia Bracaglia
- Division of Rheumatology and Laboratory of Immuno Rheumatology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Natasa Toplak
- Department of Pediatric Allergology, Rheumatology and Clinical Immunology, University Children's Hospital, University Medical Centre, MF, UL, Ljubljana, Slovenia
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Jaramillo-Esparza CM, Vázquez-Frias R. Risk of pediatric inflammatory multi-system syndrome (PIMS or MIS-C) in pediatric patients with COVID-19 presenting with gastrointestinal symptoms. Front Pediatr 2022; 10:904793. [PMID: 35911826 PMCID: PMC9334698 DOI: 10.3389/fped.2022.904793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 06/27/2022] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION AND OBJECTIVES Pediatric inflammatory multisystem syndrome (PIMS) is a life-threatening complication in pediatric patients with SARS-CoV-2 infection. An increase in the association of gastrointestinal symptoms and the presence of PIMS has been observed. The objective of this study was to analyze whether pediatric patients with COVID-19, who debut with gastrointestinal symptoms, have a higher risk of developing PIMS. MATERIAL AND METHODS An observational, analytical and retrolective study was carried out with a review of the records of patients diagnosed with COVID-19. Demographic, clinical and laboratory variables were recorded. RESULTS A total of 248 patients who met the selection criteria were included. Of Those 40% were female, with a mean age of 7 +/- 5.8 years. Gastrointestinal symptoms were the initial presentation in 103 patients, with vomiting being the most frequent symptom, followed by abdominal pain and diarrhea. In total 52 patients developed PIMS, 30 of whom presented with gastrointestinal symptoms. A RR of 1.57 (97% CI of 1.17-2.11) was found for the presentation of PIMS in patients positive for SARS-CoV-2 who present with gastrointestinal symptoms. CONCLUSIONS There is an increased risk of developing pediatric multisystem inflammatory syndrome when there are gastrointestinal symptoms in pediatric patients with COVID-19.
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Affiliation(s)
- Carlos Mauricio Jaramillo-Esparza
- Pediatric COVID-19 Care Unit, National Institute of Health Children's Hospital Infantil de México Federico Gómez, Mexico City, Mexico
| | - Rodrigo Vázquez-Frias
- Department of Gastroenterology and Nutrition, National Institute of Health Hospital Infantil de México Federico Gómez, Mexico City, Mexico
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Jurkiewicz B, Szymanek-Szwed M, Hartmann P, Samotyjek J, Brędowska E, Kaczorowska J, Wajszczuk E, Twardowska-Merecka M, Cybulska J. Pediatric Multisystem Inflammatory Syndrome in Children as a Challenging Problem for Pediatric Surgeons in the COVID 19 Pandemic-A Case Report. Front Pediatr 2021; 9:677822. [PMID: 34178893 PMCID: PMC8225948 DOI: 10.3389/fped.2021.677822] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/17/2021] [Indexed: 01/29/2023] Open
Abstract
The first cases of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection were identified at the end of 2019 and, in the next few months, coronavirus disease (COVID-19) spread throughout the world. Initially, it was believed that this disease mainly affected elderly individuals with comorbidities, in whom respiratory failure often occurs. It was believed that children fell ill from the infection more often, although the course of infection in the vast majority of pediatric cases has been asymptomatic or mildly symptomatic. In April and May 2020, the first report of a rapidly progressing disease, similar to Kawasaki syndrome, was found in children who had been infected with SARS-CoV-2. Shortly thereafter, children with symptoms of pediatric inflammatory multisystem syndrome (PIMS-ST [temporally associated with SARS-CoV-2 infection]) began presenting to pediatric hospitals around the world. The syndrome has a mortality rate of up to 2%. Symptoms of PIMS-TS include those that may suggest the need for surgical treatment (severe abdominal pain with the presence of peritoneal symptoms, ascites, high levels of inflammatory markers, intestinal inflammation, and appendages revealed on ultrasound examination). However, there are few reports addressing surgical cases associated with this condition. The authors present a case involving an 11-year-old boy who was admitted to hospital with severe abdominal pain and underwent surgery for symptoms of peritonitis and was diagnosed with PIMS in the post-operative period. Due to the large number of illnesses caused by SARS-CoV-2 infection in recent months, the diagnosis of PIMS-TS/MISC should be considered in the differential diagnosis of acute abdominal symptoms, especially in atypical courses and interviews indicating exposure to SARS-CoV-2.
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Affiliation(s)
- Beata Jurkiewicz
- Department of Pediatric Surgery and Pediatric Urology, Medical Center of Postgraduate Education, Dziekanów Leśny, Poland
| | - Magdalena Szymanek-Szwed
- Department of Pediatric Surgery and Pediatric Urology, Medical Center of Postgraduate Education, Dziekanów Leśny, Poland
| | - Piotr Hartmann
- Department of Pediatrics, Children's Hospital, Dziekanów Leśny, Poland
| | - Joanna Samotyjek
- Department of Pediatric Surgery and Pediatric Urology, Medical Center of Postgraduate Education, Dziekanów Leśny, Poland
| | - Eliza Brędowska
- Department of Pediatrics, Children's Hospital, Dziekanów Leśny, Poland
| | | | - Ewa Wajszczuk
- Department of Pediatric Surgery and Pediatric Urology, Medical Center of Postgraduate Education, Dziekanów Leśny, Poland
| | - Martyna Twardowska-Merecka
- Department of Pediatric Surgery and Pediatric Urology, Medical Center of Postgraduate Education, Dziekanów Leśny, Poland
| | - Joanna Cybulska
- Department of Pediatric Surgery and Pediatric Urology, Medical Center of Postgraduate Education, Dziekanów Leśny, Poland
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Crivelenti LRDMP, Frazão MMN, Maia MPDM, Gomes FHR, de Carvalho LM. Chronic arthritis related to SARS-CoV-2 infection in a pediatric patient: A case report. Braz J Infect Dis 2021; 25:101585. [PMID: 34043944 PMCID: PMC8120484 DOI: 10.1016/j.bjid.2021.101585] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/07/2021] [Accepted: 04/10/2021] [Indexed: 02/07/2023] Open
Abstract
Although the pattern of proinflammatory cytokines induced in COVID-2019 is similar to that of rheumatoid arthritis, the association of arthritis with SARS-CoV-2 infection is extremely rare and the symptoms are generally acute and self-limited. Herein we present the clinical case of a child who developed chronic arthritis after SARS-CoV-2 infection. An 11-year-old girl started with symptoms of multisystem inflammatory syndrome temporally associated with COVID-19 infection and subsequently developed chronic arthritis. After six weeks of arthritis, corticosteroids were started which resulted in clinical improvement after two weeks of use. Serology for SARS-CoV-2 was positive in the fifth week after symptom onset. Currently, the patient has no clinical complaints but continues to experience morning stiffness, high erythrocyte sedimentation rate, and synovial hypertrophy with no power Doppler signal on ultrasound. We alert to the possibility that SARS-CoV-2 may be a trigger of chronic arthritis.
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Affiliation(s)
- Luísa Rosa de Morais Palma Crivelenti
- Department of Pediatrics, University of São Paulo, Clinical Hospital of the Ribeirão Preto Medical School, São Paulo, SP, Brazil; Division of Pediatric Rheumatology, University of São Paulo, Clinical Hospital of the Ribeirão Preto Medical School, São Paulo, SP, Brazil
| | - Marina Martins Nascimento Frazão
- Department of Pediatrics, University of São Paulo, Clinical Hospital of the Ribeirão Preto Medical School, São Paulo, SP, Brazil
| | - Marina Paiva de Melo Maia
- Department of Pediatrics, University of São Paulo, Clinical Hospital of the Ribeirão Preto Medical School, São Paulo, SP, Brazil
| | - Francisco Hugo Rodrigues Gomes
- Department of Pediatrics, University of São Paulo, Clinical Hospital of the Ribeirão Preto Medical School, São Paulo, SP, Brazil; Division of Pediatric Rheumatology, University of São Paulo, Clinical Hospital of the Ribeirão Preto Medical School, São Paulo, SP, Brazil
| | - Luciana Martins de Carvalho
- Department of Pediatrics, University of São Paulo, Clinical Hospital of the Ribeirão Preto Medical School, São Paulo, SP, Brazil; Division of Pediatric Rheumatology, University of São Paulo, Clinical Hospital of the Ribeirão Preto Medical School, São Paulo, SP, Brazil.
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Schlapbach LJ, Andre MC, Grazioli S, Schöbi N, Ritz N, Aebi C, Agyeman P, Albisetti M, Bailey DGN, Berger C, Blanchard-Rohner G, Bressieux-Degueldre S, Hofer M, L'Huillier AG, Marston M, Meyer Sauteur PM, Pachlopnik Schmid J, Perez MH, Rogdo B, Trück J, Woerner A, Wütz D, Zimmermann P, Levin M, Whittaker E, Rimensberger PC. Best Practice Recommendations for the Diagnosis and Management of Children With Pediatric Inflammatory Multisystem Syndrome Temporally Associated With SARS-CoV-2 (PIMS-TS; Multisystem Inflammatory Syndrome in Children, MIS-C) in Switzerland. Front Pediatr 2021; 9:667507. [PMID: 34123970 PMCID: PMC8187755 DOI: 10.3389/fped.2021.667507] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 04/12/2021] [Indexed: 12/19/2022] Open
Abstract
Background: Following the spread of the coronavirus disease 2019 (COVID-19) pandemic a new disease entity emerged, defined as Pediatric Inflammatory Multisystem Syndrome temporally associated with COVID-19 (PIMS-TS), or Multisystem Inflammatory Syndrome in Children (MIS-C). In the absence of trials, evidence for treatment remains scarce. Purpose: To develop best practice recommendations for the diagnosis and treatment of children with PIMS-TS in Switzerland. It is acknowledged that the field is changing rapidly, and regular revisions in the coming months are pre-planned as evidence is increasing. Methods: Consensus guidelines for best practice were established by a multidisciplinary group of Swiss pediatric clinicians with expertise in intensive care, immunology/rheumatology, infectious diseases, hematology, and cardiology. Subsequent to literature review, four working groups established draft recommendations which were subsequently adapted in a modified Delphi process. Recommendations had to reach >80% agreement for acceptance. Results: The group achieved agreement on 26 recommendations, which specify diagnostic approaches and interventions across anti-inflammatory, anti-infectious, and support therapies, and follow-up for children with suspected PIMS-TS. A management algorithm was derived to guide treatment depending on the phenotype of presentation, categorized into PIMS-TS with (a) shock, (b) Kawasaki-disease like, and (c) undifferentiated inflammatory presentation. Conclusion: Available literature on PIMS-TS is limited to retrospective or prospective observational studies. Informed by these cohort studies and indirect evidence from other inflammatory conditions in children and adults, as well as guidelines from international health authorities, the Swiss PIMS-TS recommendations represent best practice guidelines based on currently available knowledge to standardize treatment of children with suspected PIMS-TS. Given the absence of high-grade evidence, regular updates of the recommendations will be warranted, and participation of patients in trials should be encouraged.
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Affiliation(s)
- Luregn J. Schlapbach
- Pediatric and Neonatal Intensive Care Unit, Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
- Paediatric Intensive Care Unit, Child Health Research Centre, Queensland Children's Hospital, The University of Queensland, Brisbane, QLD, Australia
| | - Maya C. Andre
- Division of Respiratory and Critical Care Medicine, University of Basel Children's Hospital, Basel, Switzerland
- Department of Pediatric Hematology and Oncology, University Children's Hospital, Eberhard Karls University, Tübingen, Germany
| | - Serge Grazioli
- Division of Neonatal and Pediatric Intensive Care, Department of Child, Woman, and Adolescent Medicine, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Nina Schöbi
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Alder Hey Children's Hospital, National Health System Foundation Trust, Liverpool, United Kingdom
| | - Nicole Ritz
- Department of Infectiology and Vaccinology, University Children's Hospital Basel, Basel, Switzerland
| | - Christoph Aebi
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Philipp Agyeman
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Manuela Albisetti
- Department of Haematology, Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Douggl G. N. Bailey
- Pediatric and Neonatal Intensive Care Unit, Children's Hospital St. Gallen, St. Gallen, Switzerland
| | - Christoph Berger
- Division of Infectious Diseases, Hospital Epidemiology, University Children's Hospital Zurich, Zurich, Switzerland
| | - Géraldine Blanchard-Rohner
- Unit of Immunology and Vaccinology, Division of General Pediatrics, Department of Pediatrics, Gynecology and Obstetrics, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | | | - Michael Hofer
- Unit of Immunology and Vaccinology, Division of General Pediatrics, Department of Pediatrics, Gynecology and Obstetrics, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
- Pediatric Immuno-Rheumatology of Western Switzerland, Department Women-Mother-Child, Lausanne University Hospital, Lausanne, and University Hospitals of Geneva, Geneva, Switzerland
| | - Arnaud G. L'Huillier
- Unit of Immunology and Vaccinology, Division of General Pediatrics, Department of Pediatrics, Gynecology and Obstetrics, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Mark Marston
- Division of Respiratory and Critical Care Medicine, University of Basel Children's Hospital, Basel, Switzerland
| | - Patrick M. Meyer Sauteur
- Division of Infectious Diseases, Hospital Epidemiology, University Children's Hospital Zurich, Zurich, Switzerland
| | - Jana Pachlopnik Schmid
- Division of Immunology, Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Marie-Helene Perez
- Pediatric Intensive Care Unit, University Hospital Lausanne, Lausanne, Switzerland
| | - Bjarte Rogdo
- Pediatric and Neonatal Intensive Care Unit, Children's Hospital St. Gallen, St. Gallen, Switzerland
| | - Johannes Trück
- Division of Infectious Diseases, Hospital Epidemiology, University Children's Hospital Zurich, Zurich, Switzerland
- Division of Immunology, Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Andreas Woerner
- Department of Rheumatology, University Children's Hospital Basel, Basel, Switzerland
| | - Daniela Wütz
- Division of Pediatric Cardiology, Pediatric Heart Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Petra Zimmermann
- Department of Paediatrics, Faculty of Science and Medicine, Fribourg Hospital, University of Fribourg, Fribourg, Switzerland
- Infectious Diseases Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Michael Levin
- Section of Paediatric Infectious Diseases, Imperial College London, London, United Kingdom
- Paediatric Infectious Diseases, Imperial College Healthcare National Health System Trust, London, United Kingdom
| | - Elizabeth Whittaker
- Section of Paediatric Infectious Diseases, Imperial College London, London, United Kingdom
- Paediatric Infectious Diseases, Imperial College Healthcare National Health System Trust, London, United Kingdom
| | - Peter C. Rimensberger
- Division of Neonatal and Pediatric Intensive Care, Department of Child, Woman, and Adolescent Medicine, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
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Uda K, Okita K, Soneda K, Taniguchi K, Horikoshi Y. Kawasaki disease following coronavirus disease 2019 with prolonged fecal viral shedding. Pediatr Int 2021; 63:597-599. [PMID: 33278321 DOI: 10.1111/ped.14452] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 08/14/2020] [Accepted: 08/20/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Kazuhiro Uda
- Division of Infectious Diseases, Department of Pediatrics, Tokyo Metropolitan Children's Medical Center, Fuchu, Tokyo, Japan
| | - Keiko Okita
- Division of Infectious Diseases, Department of Pediatrics, Tokyo Metropolitan Children's Medical Center, Fuchu, Tokyo, Japan
| | - Keiko Soneda
- Division of Infectious Diseases, Department of Pediatrics, Tokyo Metropolitan Children's Medical Center, Fuchu, Tokyo, Japan
| | - Kimihiro Taniguchi
- Division of Infectious Diseases, Department of Pediatrics, Tokyo Metropolitan Children's Medical Center, Fuchu, Tokyo, Japan
| | - Yuho Horikoshi
- Division of Infectious Diseases, Department of Pediatrics, Tokyo Metropolitan Children's Medical Center, Fuchu, Tokyo, Japan.,Western Pacific Regional Office, World Health Organization, Kuala Lumpur, Malaysia
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8
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Mărginean CO, Meliţ LE, Săsăran MO. Pediatric Obesity-A Potential Risk Factor for Systemic Inflammatory Syndrome Associated to COVID-19, a Case Report. Front Pediatr 2021; 9:681626. [PMID: 34123977 PMCID: PMC8192702 DOI: 10.3389/fped.2021.681626] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 04/30/2021] [Indexed: 12/14/2022] Open
Abstract
The well-documented systemic inflammation associated to pediatric obesity might act as an augmenting factor for other inflammatory conditions, such as pediatric inflammatory multisystem syndrome (PIMS) associated to COVID-19. We report the case of 9-year-old boy admitted in our clinic for fever, anorexia, and fatigability. The clinical exam revealed influenced general status, palpebral edema, non-exudative conjunctivitis, and abdominal tenderness. The patient weighed 45 kg. The laboratory tests at the time of admission pointed out anemia, lymphopenia; elevated inflammatory biomarkers, NT-proBNP, D-dimers, and troponin; high liver enzymes and lactate dehydrogenase levels, as well as hypoalbuminemia. The patient tested positive for both RT-PCR and serology for SARS-CoV-2 infection. We initiated intravenous immunoglobulin and methylprednisolone, associated with empirical antibiotic, anticoagulation therapy, and symptomatic treatment. The patient was discharged on the 7th day of admission with the recommendation to continue enoxaparin and methylprednisolone at home tapering the dose for the next week. The subclinical inflammatory status associated to obesity might serve as an unfortunate trigger factor for the development of COVID-19 severe forms in children. Therefore, clinicians should be aware that children with obesity and COVID-19 represent a peculiar group that should be closely monitored and thoroughly assessed in order to preempt life-threatening complications, such as PIMS.
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Affiliation(s)
- Cristina Oana Mărginean
- Department of Pediatrics I, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureş, Târgu Mureş, Romania
| | - Lorena Elena Meliţ
- Department of Pediatrics I, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureş, Târgu Mureş, Romania
| | - Maria Oana Săsăran
- Department of Pediatrics III, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Târgu Mureş, Târgu Mureş, Romania
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9
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Plouffe B, Van Hooren T, Barton M, Nashid N, Demirkaya E, Norozi K, Rachinsky I, Delport J, Knauer M, Tole S, Filler G. Renal Infarcts-A Perplexing Case in the Middle of the COVID-19 Pandemic. Front Pediatr 2021; 9:669453. [PMID: 34055700 PMCID: PMC8160427 DOI: 10.3389/fped.2021.669453] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 04/15/2021] [Indexed: 11/15/2022] Open
Abstract
Renal infarction is a rare finding in children. Associations between SARS-CoV-2 infections and thromboembolic events including renal infarcts have been described in adults. Although a similar association in children has not yet been described with this pandemic, the pediatric literature is still evolving with the recognition of new manifestations including the post-infectious Multisystem Inflammatory Syndrome in Children (MIS-C). We report the rare event of multiple renal infarcts in a 6-year-old boy manifesting several features of MIS-C 9 weeks following a self-limiting febrile illness characteristic of COVID-19. An underlying Factor V Leiden mutation was identified in this child but felt to be insufficient on its own to explain his clinical presentation. As SARS-CoV-2 testing was delayed, the failure to identify viral RNA or antibodies may not exclude the virus' potential role in precipitating the infarct in this host. Given that renal infarcts have been described in adult patients with COVID-19, reporting this perplexing case where SARS-CoV-2 may have played a role, may help identify this potential complication.
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Affiliation(s)
- Brett Plouffe
- Department of Pediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
| | - Tamara Van Hooren
- Department of Pediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
| | - Michelle Barton
- Department of Pediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada.,Children's Health Research Institute, Lawson Health Research Institute, University of Western Ontario, London, ON, Canada
| | - Nancy Nashid
- Department of Pediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
| | - Erkan Demirkaya
- Department of Pediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada.,Children's Health Research Institute, Lawson Health Research Institute, University of Western Ontario, London, ON, Canada
| | - Kambiz Norozi
- Department of Pediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada.,Children's Health Research Institute, Lawson Health Research Institute, University of Western Ontario, London, ON, Canada.,Department of Pediatric Cardiology, Medical School Hannover, Hannover, Germany
| | - Irina Rachinsky
- Department of Imaging, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
| | - Johan Delport
- Departments of Medicine Pathology and Laboratory Medicine, University of Western Ontario, London, ON, Canada
| | - Michael Knauer
- Departments of Medicine Pathology and Laboratory Medicine, University of Western Ontario, London, ON, Canada
| | - Soumitra Tole
- Department of Pediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
| | - Guido Filler
- Department of Pediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada.,Children's Health Research Institute, Lawson Health Research Institute, University of Western Ontario, London, ON, Canada.,Departments of Medicine Pathology and Laboratory Medicine, University of Western Ontario, London, ON, Canada.,Lilibeth Caberto Kidney Clinical Research Unit, Lawson Health Research Institute, University of Western Ontario, London, ON, Canada
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10
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Schvartz A, Belot A, Kone-Paut I. Pediatric Inflammatory Multisystem Syndrome and Rheumatic Diseases During SARS-CoV-2 Pandemic. Front Pediatr 2020; 8:605807. [PMID: 33344389 PMCID: PMC7746854 DOI: 10.3389/fped.2020.605807] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 11/13/2020] [Indexed: 12/12/2022] Open
Abstract
Globally, the coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), appeared to have a milder clinical course in children compared to adults. As severe forms of COVID-19 in adults included an aberrant systemic immune response, children with chronic systemic inflammatory diseases were cautiously followed. No evidence for a specific susceptibility was identified in this pediatric population. European and US Pediatricians started to notice cases of myocarditis, sharing some features with toxic shock syndrome, Kawasaki disease, and macrophage activation syndrome in otherwise healthy patients. Multisystem Inflammatory Syndrome in Children (MIS-C) and Pediatric Inflammatory Multisystem Syndrome (PIMS) have designated this new entity in the US and Europe, respectively. The spectrum of severity ranged from standard hospitalization to pediatric intensive care unit management. Most patients had a clinical history of exposure to COVID-19 patients and/or SARS-COV2 biological diagnosis. Clinical presentations include fever, cardiac involvement, gastro-intestinal symptoms, mucocutaneous manifestations, hematological features, or other organ dysfunctions. The temporal association between the pandemic peaks and outbreaks of PIMS seems to be in favor of a post-infectious, immune-mediated mechanism. Thus, SARS-CoV2 can rarely be associated with severe systemic inflammatory manifestations in previously healthy children differently from adults highlighting the specific need for COVID-19 research in the pediatric population.
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Affiliation(s)
- Adrien Schvartz
- Service De Rhumatologie Pédiatrique, Centre De Référence Des Maladies Auto-Inflammatoires et de l'Amylose Inflammatoire, Hospital Bicêtre, Assistance Publique des Hôpitaux de Paris, Université Paris Sud Saclay, Le Kremlin-Bicêtre, France
| | - Alexandre Belot
- Service de Néphrologie, Rhumatologie, Dermatologie Pédiatriques, Centre de Référence des Rhumatismes Inflammatoires et Maladies Auto-Immunes Rares de l'Enfant (RAISE), Hôpital Femme-Mère-Enfant, Hospices Civils de Lyon, Bron, France
| | - Isabelle Kone-Paut
- Service De Rhumatologie Pédiatrique, Centre De Référence Des Maladies Auto-Inflammatoires et de l'Amylose Inflammatoire, Hospital Bicêtre, Assistance Publique des Hôpitaux de Paris, Université Paris Sud Saclay, Le Kremlin-Bicêtre, France
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11
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Abstract
We describe a 46-year-old male with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection who presented as a Kawasaki-like syndrome with features including prolonged fever, bilateral conjunctivitis, oral mucosal swelling, diffuse erythematous rash, cervical and hilar lymphadenopathy, as well as cardiovascular complications and multi-organ failure. There are several reports of a similar clinical entity mimicking Kawasaki disease (KD) in the pediatric population, which has been termed Pediatric Inflammatory Multisystem Syndrome Temporally Associated with SARS-CoV-2 (PIMS-TS) by the Royal College of Pediatric and Child Health. To our knowledge, to date, there has been only one case report of COVID-19 presenting as KD in an adult patient.
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Affiliation(s)
- Boniface Malangu
- Internal Medicine, Rutgers New Jersey Medical School, Newark, USA
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12
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Nelson C, Ishimine P, Hayden SR, Correia M, Wardi G. Multisystem Inflammatory Syndrome in Children (MIS-C) in an Adolescent that Developed Coronary Aneurysms: A Case Report and Review of the Literature. J Emerg Med 2020; 59:699-704. [PMID: 33011038 PMCID: PMC7527793 DOI: 10.1016/j.jemermed.2020.09.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 09/02/2020] [Indexed: 12/13/2022]
Abstract
Background A small subset of pediatric patients develop a rare syndrome associated with Coronavirus Disease 2019 (COVID-19) infection called multisystem inflammatory syndrome in children (MIS-C). This syndrome shares characteristics with Kawasaki disease. Case Report A 15-year-old girl presented to our Emergency Department (ED) with fevers and malaise. She was diagnosed on her initial visit with an acute viral syndrome and discharged with a COVID polymerase chain reaction test pending, which was subsequently negative. She returned 3 days later with persistent fever, conjunctivitis, and a symmetric targetoid rash over her palms. She had no adenopathy, but her erythrocyte sedimentation rate and C-reactive protein were both significantly elevated at 90 mm/h and 19.61 mg/dL, respectively. The patient was then transferred to the regional children's hospital due to a clinical suspicion for MIS-C, and subsequent COVID-19 immunoglobulin G testing was positive. She had been empirically started on intravenous immunoglobulin in addition to 81 mg aspirin daily. Initial echocardiograms showed mild dilatation of the left main coronary artery, and on repeat echocardiogram, a right coronary artery aneurysm was also identified. Oral prednisone therapy (5 mg) was initiated and the patient was discharged on a continued prednisone taper. Why Should an Emergency Physician Be Aware of This? We present a case of a 15-year-old girl who presented to the ED with MIS-C who developed coronary aneurysms despite early therapy, to increase awareness among emergency physicians of this emerging condition.
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Affiliation(s)
- Cole Nelson
- Department of Emergency Medicine, University of California at San Diego, San Diego, California
| | - Paul Ishimine
- Department of Emergency Medicine, University of California at San Diego, San Diego, California; Division of Emergency Medicine, Rady Children's Hospital, San Diego, California
| | - Stephen R Hayden
- Department of Emergency Medicine, University of California at San Diego, San Diego, California
| | - Matthew Correia
- Department of Emergency Medicine, University of California at San Diego, San Diego, California
| | - Gabriel Wardi
- Department of Emergency Medicine, University of California at San Diego, San Diego, California; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California at San Diego, San Diego, California
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13
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Loomba RS, Villarreal EG, Flores S. COVID-19 and Hyperinflammatory Syndrome in Children: Kawasaki Disease with Macrophage Activation Syndrome in Disguise? Cureus 2020; 12:e9515. [PMID: 32884871 PMCID: PMC7462650 DOI: 10.7759/cureus.9515] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
A hyperinflammatory syndrome has been described in times of COVID-19 in children. In the setting of uncertainty due to a new virus, the so-called hyperinflammatory syndrome has been coined as a novel entity by some and is being referred to as pediatric inflammatory multisystem syndrome (PIMS). However, the characteristics of the syndrome resemble those of Kawasaki disease (KD), an inflammatory syndrome in children that can lead to coronary artery abnormalities due to a subsequent vasculitis. Furthermore, Kawasaki disease may occasionally trigger macrophage activation syndrome (MAS), a condition in which there is uncontrolled activation and proliferation of macrophages and other cell types, and could lead to multiorgan system dysfunction. This study provides a review of the data regarding COVID-19, Kawasaki disease, and macrophage activation syndrome to demonstrate the similarities and differences between the inflammatory syndrome seen with COVID-19 and KD. In addition, a framework for diagnosis and evaluation is provided that focuses on the pathway previously established for KD and MAS. The authors believe that based on current knowledge, KD treatment delays may carry deleterious effects in the near future for children with COVID-19-related Kawasaki disease.
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Affiliation(s)
| | - Enrique G Villarreal
- Pediatrics, Tecnologico De Monterrey, Escuela De Medicina Y Ciencias De La Salud, Monterrey, MEX
| | - Saul Flores
- Cardiology, Texas Children's Hospital, Houston, USA
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