Correspondence e36classic Kawasaki disease. Two of these six patients (patients 7 and 8) had sufficient criteria for typical Kawasaki disease. None of these six children showed evidence of myocardial dysfunction, although pericardial effusion was observed in 3 of 6 children.Coronary artery dilatation was seen in five (62•5%) patients. A z-score of more than 2•5 in the left anterior descending or right coronary artery was reported in three and 2•0-2•5 in two patients (mean 2•94, SD ± 0•97, 95%CI 1•7 -4•16, SE ± 0•44, median 2•6, range +2•06 to +4•27, spread range +2•2). Both children with shocklike pre sentation had coronary artery involve ment, but two patients who fulfilled the Kawasaki disease criteria showed healthy coronary arteries. All children except one (7 of 8, 87•5%) received intra venous immuno globulin (2 g/kg body weight) within the first 2 days of their stay. Three patients received thera peutic anticoagulation (enoxaparin) on the basis of the high risk of thrombo embolism and amount of D-dimers. With the exception of the one death discussed already, the other seven children have been discharged home.Other children with PIMS-TS reported in the literature have presented with acute heart failure and features of acute myocarditis. 3,5,7 This feature has a special notability in our country, because viral myocarditis is a common presentation all year long, and there would be background cases with dilated cardiomyopathy or myocarditis. All children presenting with acute myocarditis in the study period were screened for exposure to SARS-CoV-2 and underwent COVID-19 antibody testing. Only one of six patients admitted with myocarditis during the study period tested positive for COVID-19 antibodies. This child, however, did not show evidence of raised inflammatory markers and is not included in the series.Our data, although restricted by numbers, show some differences For data on COVID-19 cases in Pakistan see www.covid.gov.pk

Objectives: We aim to describe the early and upto 16 months follow-up of post-coronavirus disease (COVID), multi-system inflammatory syndrome in children (MIS-C), with special reference to cardiac involvement. Study design: This cohort non-interventional descriptive study included patients <18 years admitted between May, 2020 and April, 2021. Based on underlying similarities, children were classified as post-COVID MIS-C with overlapping Kawasaki Disease, MIS-C with no overlapping Kawasaki Disease, and MIS-C with shock. Post-discharge, patients were followed at 1, 3, 6, 12, and 16 months. Results: Forty-one patients predominantly males (73%), at median age of 7 years (range 0.2–16 years) fulfilled the World Health Organisation criteria for MIS-C. Cardiac involvement was seen in 15 (36.5%); impaired left ventricle (LV) function in 5 (12.2%), coronary artery involvement in 10 (24.4%), pericardial effusion in 6 (14.6%) patients, and no arrhythmias. There were two hospital deaths (4.9%), both in MIS-C shock subgroup (2/10, 20%). At 1 month, there was persistent LV dysfunction in 2/5, coronary artery abnormalities in 7/10, and pericardial effusion resolved completely in all patients. By 6 months, LV function returned to normal in all but coronary abnormalities persisted in two patients. At last follow-up (median 9.8 months, interquartile range 2–16 months), in 36/38 (94.7%) patients, coronary artery dilatation was persistent in 2 (20%) patients. Conclusions: Children with MIS-C have a good early outcome, though MIS-C with shock can be life-threatening subgroup in a resource-constrained country setting. On midterm follow-up, there is normalisation of LV function in all and recovery of coronary abnormalities in 80% of patients.

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