Kawasaki disease from COVID-19 in children: how common is it?

Some pediatric cardiologists may even be underestimated even in the classic case, as health authorities began to warn about abnormal symptoms of inflammatory syndromes such as Kawasaki disease associated with COVID-19. I pointed out that there is.

First known published case of classic Kawasaki disease associated with COVID-19 Reported in Hospital pediatrics Late April. A 6-month-old patient found in Stanford, California was screened for COVID-19 positivity after showing fever, an itchy rash, and minimal respiratory symptoms. She first came home from emergency care.

New York City Department of Health this week Announcement of 15 findings “The full spectrum of illnesses is unknown,” it noted. “At present, only serious cases may be recognized.”

On Wednesday, the New York Department of Health 64 cases throughout the state He then issued a recommendation on what is known as “the childhood multisystem inflammatory syndrome that is temporarily associated with COVID-19”.

Italy, Spain, United Kingdom With the outbreak of COVID-19 among children, an increase in diseases such as Kawasaki disease was observed.

British health officials have warned about a slight increase in children with features consistent with severe COVID-19 and toxic shock syndrome and atypical Kawasaki disease. “Abdominal pain and gastrointestinal symptoms are as common a feature as heart inflammation.”

Unusual features

Dr. Michael Portman of the Seattle Children’s Hospital, a member of the American College of Cardiology at the Seattle Children’s Hospital, has not confirmed blood tests to distinguish Kawasaki disease from other pediatric disorders that cause similar symptoms under normal circumstances. It can be difficult to do. A committee that sets benchmarks for the care of Kawasaki disease.

“What really changes this particular presentation is old age,” said Deepika Thacker, MD, MD, Medical Director of the Heart Unit at Nemours Children’s Health System in Wilmington, Delaware. Kawasaki disease usually affects children under the age of five, but she noted that many of these reported cases were in their teens.

Another atypical feature is the high prevalence of abdominal and digestive symptoms.

The NYC Department of Health reported that 15 children between the ages of 2 and 15 were hospitalized with typical or incomplete Kawasaki disease and some were shocked. All had fever and more than half had rash, abdominal pain, vomiting, or diarrhea. However, less than half have respiratory symptoms.

Even a few cases of severe abdominal pain sending these children to surgery were described, nothing was found, Thacker noted in an interview monitored by media relations at her institution. Blood tests also follow a “very different pattern”, which usually contains higher markers of heart damage than seen in Kawasaki disease.

“It’s too early to say with confidence, but the features seem to include high CRP [C-reactive protein], High ESR [erythrocyte sedimentation rate] And high ferritin “. statement.

New York alerts also point to myocarditis and other cardiovascular changes. “In addition, some patients develop cardiogenic or angiogenic shock and require intensive care. This inflammatory syndrome can occur days to weeks after acute COVID-19 disease. . “

A press release from the American Heart Association (AHA) Reassure parents In a very rare situation, “ some children get sick very quickly, so children with these symptoms should be assessed quickly and, if necessary, cared for in a hospital with a pediatric cardiac intensive care unit. is needed.”

“As the number of children with fever and evidence of non-severe inflammation increases, it is necessary to carefully monitor all children with unexplained fever and elevated C-reactive protein (CRP) or white blood cell count. There is. “

The New York State warning agrees and demands that doctors do not delay seeking advice from inpatient specialists while trying to eliminate the causes of other microbes.

AHA’s Young Hearts Council is a member of Royal College of Pediatrics and Child Health. Case definition not requiring a positive PCR test for SARS-CoV-2.

The guideline for frontline providers developed by Thacker’s group recommends repeating the COVID-19 PCR test after a few days as it can be negative initially. She said the antibody test was also not very reliable.

Aside from test sensitivity issues, “this may be slow to respond to the virus,” Portman said. During that interim period, active virus may not be found, but the antibody under test may not yet be fully produced.

Repeated echocardiography of the coronary arteries may also be required. This could lead to inflammation and aneurysms during hospitalization for young people with Kawasaki shock syndrome, similar to those described in the case of “pediatric multisystem inflammatory syndrome temporarily associated with COVID”. Because of. 19, ”Portman pointed out.

Thacker said the recommended treatment for inpatients is to support shock (at least 75% need pressor) and to administer steroids and IV immunoglobulin.

Missed case

Most children who develop Kawasaki disease recover without problems, but “25% of the chances of having a serious illness with delayed treatment are still high, and some children walk around with the fever disappearing. It’s a coronary aneurysm, and they don’t know it, “Portman said.

“One of the concerns about the COVID pandemic is that everyone is told to leave the hospital because people are worried about their exposure and exposure to it,” he said. “But in reality, there are children we believe to be there. They have a fever for 4-5 days. They call and they say,” That’s heat and nothing else. If your child isn’t really sick, you don’t have one and they’re evaluated, some of those children may actually have Kawasaki disease and may have coronary artery disease. May be at risk. “

His group saw fewer cases at that Kawasaki disease clinic during a pandemic than would normally be expected in the same period.

“Looking back a month ago, this one child seemed to have Kawasaki disease, but was eventually seen because of low inflammation and fever,” he said. He said the child did not develop an aneurysm, but colleagues in other parts of the country are referring to a child who did not get hospitalized or was delayed in treatment and developed an aneurysm.

Thacker believes the number of missed cases leading to sustained harm is small.

Still, Portman urged general practitioners, pediatricians, family doctors, and emergency physicians to keep an eye on Kawasaki disease and not to think the child was fine because he had no respiratory symptoms.

Open question

Tucker has long believed that Kawasaki disease is an immune response caused by an infection, but its etiology is not yet clear and not all viruses predispose to Kawasaki disease.

Despite the chronological relationship between COVID-19 and these cases, “at this time, there is no clear evidence that COVID-19-induced shock is associated with Kawasaki disease,” studying Kawasaki disease. Dr. Unlory, MD, an infectious disease specialist, has warned Northwestern University in Chicago.

“Several clinical manifestations of both of these diseases-Kawasaki disease and COVID-19-like fever, rashes, and red blood cells (conjunctival injections) are present in many pediatric diseases. But these two Laboratory tests of the children in the group are quite specific, with children with COVID-19 infection developing myocardial inflammation rather than the characteristic swelling of the coronary arteries observed in Kawasaki disease. ”

To better understand what is happening, the AHA Council has asked affected children to enroll in the COVID-19 study, which collects serum or plasma samples.

The Portman group is following up on Kawasaki disease patients to determine if they are exposed to COVID-19, their genetic susceptibility, and what happens to their immunity to coronaviruses.

Portman may not be able to get complete immunity to the virus with IV immunoglobulin treatment, pointing out the American Academy of Pediatrics’ recommendation for live vaccination for 11 months after use.

On a broader scale, one community-based study is the National Institute of Allergy and Infectious Diseases (NIAID) HEROS study Examine SARS-CoV-2 prevalence in US children and their families, who collect nasal swabs and blood samples from participants every two weeks.

“One of the interesting features of this pandemic of this new coronavirus is that fewer children are ill with COVID-19 compared to adults,” said NIAID director Anthony Fauci in a statement. “Is this because my child is resistant to SARS-CoV-2 or is infected but does not have symptoms? The HEROS study answers these and other important questions. It will help you get started. “

Tucker believes that if all attention to COVID-19 for Kawasaki disease facilitates data collection, it will be more likely to be understood and treated.