Cardiac manifestations in SARS-CoV-2-associated multisystem inflammatory syndrome in children: a comprehensive review and proposed clinical approach

Abstract

Initial reports on COVID-19 described children as largely spared from severe manifestations, with only 2-6% of children requiring intensive care treatment. However, since mid-April 2020, clusters of pediatric cases of severe systemic hyperinflammation and shock epidemiologically linked with COVID-19 have been reported. This condition was named as SARS-Cov-2-associated multisystem inflammatory syndrome in children and showed similarities to Kawasaki disease. Here, we present a narrative review of cases reported in literature and we discuss the clinical acute and follow-up management of these patients. Patients with SARS-Cov-2-associated multisystem inflammatory syndrome frequently presented with persistent fever, gastrointestinal symptoms, polymorphic rash, conjunctivitis, and mucosal changes. Elevated inflammatory markers and evidence of cytokine storm were frequently observed. A subset of these patients also presented with hypotension and shock (20-100%) from either acute myocardial dysfunction or systemic hyperinflammation/vasodilation. Coronary artery dilation or aneurysms have been described in 6-24%, and arrhythmias in 7-60%. Cardiac support, immunomodulation, and anticoagulation are the key aspects for the management of the acute phase. Long-term structured follow-up of these patients is required due to the unclear prognosis and risk of progression of cardiac manifestations. Conclusion: Multisystem inflammatory syndrome is a novel syndrome related to SARS-CoV-2 infection. Evidence is still scarce but rapidly emerging in the literature. Cardiac manifestations are frequent, including myocardial and coronary involvement, and need to be carefully identified and monitored over time.

Paediatric Inflammatory Multisystem Syndrome Temporally-Associated with SARS-CoV-2 Infection: An Overview

“…In our experience, immediate and serial assessment of electro-and echocardiograms are required given the breadth of cardiac involvement, variable trajectory of disease and exquisite sensitivity to volume loading in some patients. Cardiac dysfunction requires vasoactive support in the majority of children, with mechanical ventilation instituted in approximately one third of children, and a small number requiring mechanical circulatory support [13].…”

“…The multisystem nature of PIMS-TS has invited a multidisciplinary approach to management, including intensivists, infectious disease paediatricians, rheumatologists, cardiologists and haematologists, surgeons (where acute abdominal conditions are suspected) and specialist nurses. Prompt administration of pooled intravenous immunoglobulins is advocated by many institutions [13], and is an evidence-based therapy for KD [14] and TSS [15]. As an epicentre for the UK epidemic of PIMS-TS, we also advocate transfer to a specialist paediatric cardiac centre capable of providing mechanical circulatory support.…”

“…Aspirin (as anti-inflammatory or prophylaxis of thrombosis) or heparins are administered to children with acute PIMS-TS. Convalescent follow-up may involve cardiac computed tomography or magnetic resonance imaging if concerns of coronary artery aneurysms or ventricular dysfunction persist [13].…”

“…Sharing of data across institutions will be crucial to understanding the best treatment and outcomes for this novel disease [13]. Globally, the Best Available Treatment Study for PIMS-TS (ISRCTN69546370) will detail retrospectively the trajectory of disease following immunomodulation in PIMS-TS.…”

COVID-19 Infection in a Child Presenting With Functional Intestinal Obstruction

“…The first confirmed COVID-19 case in the US was recorded in January 2020 [3]. While COVID-19 infection affects all age groups and most children seem to be asymptomatic, the infection may also cause lifethreatening illnesses, especially in infants aged less than one year and in children with underlying health problems [4,5,6]. COVID-19 infection in children manifests as diverse clinical findings among which fever and cough are the most commonly reported symptoms [5,6].…”