Atypical presentation of complete heart block in children with pediatric inflammatory multisystem syndrome: A case series of two patients

Abstract

In the midst of the COVID-19 pandemic, we report two cases of children presenting with typical diagnosis of pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) who suffered from complete heart block requiring pacemaker placement which is an unusual presentation of PIMS-TS. We also compared it with the already existing data with similar manifestations. PIMS-TS is reported to occur in children with predominantly gastrointestinal symptoms, hemodynamic instability, and myocardial dysfunction. The implications of development of atrioventricular block during critical illness in PIMS-TS are yet unknown. Both patients had an otherwise normal cardiac structure and had no gastrointestinal symptoms but suffered complete heart block without any other identifiable etiology, both requiring temporary pacemaker placement. While one child recovered completely with medical management, the other child required permanent pacemaker placement. While we cannot be certain that COVID-19 was the cause, complete heart block appeared to be temporally related to COVID-19 infection in both patients, and hence, it is important for pediatricians to be aware of the potential manifestation of this disease.

Arrhythmia and COVID-19 in children

“…56,59,63) In rare instances, some children required permanent pacemaker implantation, and the first-degree AV block persisted at the time of discharge in some, suggesting the possibility of irreversible damage to the conduction tissue. 59,64) Therefore, patients with conduction abnormalities require intensive electrocardiogram monitoring during hospitalization and long-term follow-up after discharge. 56,60,61) The therapeutic effect of anti-inflammatory drugs on AV block or the preventive effect on the progression to a complete AV block remains unknown because all related studies were retrospective.…”

“…However, some patients who developed a first-degree AV block progressed to a second- or third-degree AV block [ 56 , 59 , 63 ]. In rare instances, some children required permanent pacemaker implantation, and the first-degree AV block persisted at the time of discharge in some, suggesting the possibility of irreversible damage to the conduction tissue [ 59 , 64 ]. Therefore, patients with conduction abnormalities require intensive electrocardiogram monitoring during hospitalization and long-term follow-up after discharge [ 56 , 60 , 61 ].…”

COVID-19 and heart disease in children: What have we learned?

“…Mehta et al . [ 38 ] reported the rare occurrence of complete heart block in two children, of whom one recovered and one needed pacemaker implantation. The authors have summarized all the uncommon electrophysiology abnormalities seen in association with MIS-C.…”

COVID‐19 infection as a possible cause of complete heart block: What do we know so far?

“…Other causes of cardiac injury with subsequent development of CHB in patients with COVID‐19 have been reported (Figure 1 ). Cardiac injury leading to temporary CHB could happen as a consequence of pediatrics multisystem inflammatory syndrome (Kawasaki‐like reaction) in patients with COVID‐19 (Mehta et al, 2021 ). In addition, myocardial injury and CHB following COVID‐19 has been attributed to systemic inflammatory response, such as cytokine storm (Gyawali et al, 2021 ).…”