Shock and Myocardial Injury in Children With Multisystem Inflammatory Syndrome Associated With SARS-CoV-2 Infection: What We Know. Case Series and Review of the Literature

Abstract

Background: Multisystem inflammatory syndrome associated with SARS-CoV-2 infection can lead to myocardial injury and shock in children, likely the result of a severe inflammatory state, and can mimic Kawasaki disease. Objective: To describe the characteristics of shock and myocardial injury in children with confirmed or suspeted COVID-19 during the SARS-CoV-2 pandemic in Spain, including clinical presentation, laboratory and imaging findings, treatment, disease course, and outcome. An extensive literature review is provided. Methods: Retrospective case series including all children (age 1 month–18 years) admitted to a pediatric intensive care unit in Madrid, Spain, between March 15 and April 30, 2020 with suspected or confirmed SARS-CoV-2 infection and shock. Results: Twelve previously healthy patients with shock, age 5 to 14 years, were included. All required volume resuscitation and 75% required vasoactive/inotropic support. Distributive shock was present on admission in 67% (n = 8), and 4 patients (33%) showed features of cardiogenic shock. Myocardial injury was diagnosed in 67% (n = 8) and ventricular dysfunction in 33% (n = 4). The most common symptoms on presentation were fever (100%), anorexia (100%), diarrhea (75%), and vomiting (75%). Five patients showed signs of Kawasaki disease but none met the criteria for the classic form. Laboratory findings revealed lymphopenia (83%), thrombocytopenia (83%), and increased inflammatory markers (100%). Respiratory status was not significantly impacted. Chest X-ray showed bilateral alveolar infiltrates in 7 (58%) and bilateral pneumonia in 3 (25%). COVID-19 was confirmed in 11 cases (92%). All received empirical therapy against COVID-19, thromboprophylaxis and immunomodulation. Median stay in the PICU and inpatient ward was 4.5 and 10 days, respectively. No patients died. Conclusion: Multisystem inflammatory syndrome in children with COVID-19 can mimic Kawasaki disease and lead to a combination of distributive and cardiogenic shock, probably secondary to a hyperinflammatory state that remains to be precisely defined. Treatment strategies include hemodynamic support, empirical therapies against COVID-19, thromboprophylaxis, and immunomodulation.

Short-term Cardiovascular Complications of Multi-system Inflammatory Syndrome in Children (MIS-C) in Adolescents and Children

“…In some cohorts, cardiac complications persisted at time of last follow-up [21, 33••]. One study found that, at the time of discharge, cardiac complications persisted in 3 (25%) patients [15]. One patient had persistent LAD prominence [17].…”

An 11-Year-Old Saudi Arabian Girl Who Presented with Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with SARS-CoV-2 Infection with Coronary Artery Aneurysm and Cardiac Involvement: A Case Report

“…This is the first case report of multisystem inflammatory syndrome in children (MIS-C) in Saudi Arabia involving coronary artery aneurysm, left ventricular dysfunction, hyperinflammation, and multiorgan damage associated with SARS-CoV-2 infection. Rapid clinical deterioration has been shown in most studies as a cardinal feature, associated with shock, poor capillary refilling times, and skin rashes, and necessitating fluid bolus administration followed by inotrope support, as in our case [ 15 – 17 , 24 ] In fact, shock is either cardiogenic or distributive in nature [ 28 , 29 ]. de Lama Caro-Paton published a case series in a pediatric intensive care unit in Madrid, Spain, with 12 patients with MIS-C ages 5–14 years old.…”

“…de Lama Caro-Paton published a case series in a pediatric intensive care unit in Madrid, Spain, with 12 patients with MIS-C ages 5–14 years old. All patients presented with shock and received volume resuscitation, 75% required vasoactive/inotropic support, 67% had a high hs-cT-nI, and 33% demonstrated left ventricular dysfunction [ 29 ].…”

“…Various theories suggest that SARS-CoV-2 spike proteins, infecting cardiomyocytes through the angiotensin converting enzyme 2 (ACE2) receptor, caused myocardial damage and deregulated immune function, and the subsequent cytokine storm leads to multiorgan failure and severe cardiotoxicity [ 31 ]. Further, due to prolonged hypoxia and ischemia, microvascular thrombosis, coronary artery disease, right heart strain, and stress cardiomyopathy, a consequence of oxygen demand and supply imbalance, all contribute to cardiac muscle damage [ 29 ]. Medications like lopinavir/ritonavir, hydroxychloroquine, and tocilizumab, whose safety margins are less clear, could worsen cardiac dysfunction in pediatric patients with COVID-19 infection [ 31 ].…”

Consenso sobre el tratamiento del síndrome inflamatorio multisistémico asociado a COVID-19

“…Por último, siempre debe descartarse la presencia de trombos y de signos de pericarditis. [36][37][38]…”