Now it is showing up in adults too. Autoimmune type inflammation, must be some antigenic part of the virus that is similar to some antigen throughout the human body, the problem is it hits the heart too. cf Rheumatic Fever before the copious use of penicillin. 📷COVID-19

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Your comment has been posted.JULY 14, 2020

Gary Joseph Ordog, MD.

Case reports detail adult presentations of Kawasaki-like disease related to SARS-CoV-2 infection

Two case reports were published in The Lancet journals describing a case of an adult with Kawasaki-like multisystem inflammatory syndrome associated with COVID-19, and an adult presentation consistent with paediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (PIMS-TS), respectively.

In the first case report published in The Lancet, Sheila Shaigany, New York University Grossman School of Medicine, New York, and colleagues reported a case of an adult male who presented to NYU Langone Health in New York City with a Kawasaki-like multisystem inflammatory syndrome in the setting of SARS-CoV-2 infection, similar to what has been reported in children.

The 45-year-old patient presented to the emergency department with 6 days of fever, sore throat, diarrhoea, bilateral lower extremity pain, conjunctivitis, and diffuse exanthem after having cared for his wife with SARS-CoV-2 infection 2 weeks earlier. The patient denied respiratory symptoms on presentation, although his respiratory rate was elevated (25–33 breaths per min), and he had not taken any medications before symptom onset. A SARS-CoV-2-specific RT-PCR was positive, and chest x-ray showed diffuse interstitial haziness typical of COVID-19. 

“Given the patient's constellation of signs (fever for more than 5 days, erythema multiforme-like rash, bilateral non-exudative conjunctivitis, erythema or cracking of the lips, unilateral cervical lymphadenopathy measuring more than 1.5 cm in diameter), he met American Heart Association (AHA) criteria for Kawasaki disease, and he was diagnosed with Kawasaki-like multisystem inflammatory syndrome associated with COVID-19,” the authors wrote.

Nonetheless, the authors noted that although the patient's presentation met AHA criteria for Kawasaki disease, he also exhibited many multisystem inflammatory syndrome in children (MIS-C)-related features such as a predominance of gastrointestinal symptoms, generalised extremity pain, and prominent cardiac dysfunction, and his cardiac findings (elevated cardiac enzymes and left ventricular hypokinesis with a reduction in ejection fraction) resemble findings of myocarditis recently described in MIS-C. 

Furthermore, they said the patient's palmar lesions were distinct from the acral erythema and swelling with subsequent desquamation typically seen in Kawasaki disease, and his diffuse conjunctivitis was not limbic-sparing. Biochemically, he demonstrated markedly elevated C-reactive protein (546.7 mg/L), neutrophilia (10100–15000 neutrophils per μL), and lymphopenia (0–700 lymphocytes per μL), which are more consistent with MIS-C than with classic Kawasaki disease.

The patient underwent therapy with therapeutic dose low molecular weight heparin, intravenous immunoglobulin (2 g/kg) over 2 days, and a single intravenous dose of the IL-6 inhibitor tocilizumab (400 mg). He did not require vasopressor support or an intensive care unit level of care and was maintained on minimal oxygen requirements. 

Following intravenous immunoglobulin and tocilizumab administration, he showed clinical improvement with defervescence, resolution of tachycardia and tachypnoea, improvement in rash, cheilitis, and conjunctivitis, and down-trending inflammatory markers. He was discharged 9 days after hospital admission. Upon outpatient follow-up, he had complete resolution of his diffuse cutaneous eruption and conjunctivitis as well as a normal repeat echocardiogram.

“With the exception of his age, our patient meets the current case definition for MIS-C according to both the CDC and WHO,” the authors wrote. 

“We highlight this case to draw attention to the presence of a Kawasaki-like multisystem hyperinflammatory syndrome in an adult with SARS-CoV-2 infection and note clinical improvement following administration of anticoagulation, intravenous immunoglobulin, and tocilizumab,” the authors noted. They also acknowledged that this isolated case may represent a spurious finding rather than an instance of a larger disease pattern although the patient's Kawasaki-like presentation bears a strong resemblance to MIS-C, adding that further investigation is warranted to better elucidate the possibility of an MIS-C analogue syndrome in adults.

Meanwhile, another case report published in The Lancet Rheumatology described a 21-year-old man with presentation consistent with PIMS-TS. 

The patient was admitted to University College London Hospitals with 6 days of fever and abdominal pain associated with constipation, anorexia, and headache. He described a transient maculopapular palmar rash 4 days into illness. Additionally, he had non-exudative conjunctivitis, cervical lymphadenopathy, cracked lips, and prominent lingual papillae. A CT scan showed mesenteric adenopathy and terminal ileitis. 

Further, the patient had neutrophilia, eosinophilia, lymphopenia, elevated inflammatory markers, and elevated troponin T with normal electrocardiogram, transthoracic echocardiogram, and CT coronary angiogram.

The patient had no previous history of COVID-19 symptoms or contact with known COVID-19 cases. Nasopharyngeal and stool samples were negative for SARS-CoV-2 by PCR. Other infective and inflammatory conditions were excluded. 

“Adult and paediatric specialists conferred and concluded that the most likely diagnosis was Kawasaki-like disease on the PIMS-TS spectrum,” Imogen Jones, Hospital for Tropical Diseases, University College London Hospitals, London, UK, and colleagues wrote. 

The patient was treated with intravenous immunoglobulin and methylprednisolone, which resulted in rapid resolution of symptoms and normalisation of blood parameters. 

The authors noted that the patient’s SARS-CoV-2 serology (checked before treatment with intravenous immunoglobulin) “was strongly positive, suggesting recent exposure to SARS-CoV-2”. 

The patient was discharged on low-dose aspirin 8 days after admission to hospital.

“To the best of our knowledge, this is the first reported case of adult Kawasaki-like disease related to SARS-CoV-2 infection,” the authors added . “There is an urgent need to recognise and fully characterise PIMS-TS in young adults to improve our understanding of pathogenesis, guide treatment decisions, and prevent sequelae in these patients.”

Reference: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31526-9/fulltextSOURCE: The Lancet; The Lancet Rheumatology

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J-Moncrief replied on Tue, 07/14/2020 - 13:17

Most interesting.

• Reply

G-Ordog replied on Tue, 07/14/2020 - 13:38

Reminiscent of Rheumatic Fever before the widespread use of penicillin.

Interesting

COVID-19: A Kawasaki-like disease and a multi-organ inflammatory syndrome in children.

This is an important aspect of the presentation of COVID-19, one can glean about it on links to these articles:

1. Article COVID-19 and Kawasaki Disease: Novel Virus and Novel Case

2. Presentation COVID19 in Children What we know so far?

3. Preprint COVID-19 and Kawasaki Like Disease: The Known-Known, the Unk...

4. Article Coronavirus Disease (COVID-19) in Children - What We Know So...

5. Article Kawasaki-like multisystem inflammatory syndrome in children ...

6. Article Multisystem Inflammatory Syndrome in Children in COVID-19 Pandemic

Very good, thank you for the additional references.

July 17, 2020: More evidence of major COVID-19 complications, even in children.

Intensive care admissions of children with paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) in the UK: a multi-centre observational study.

Patrick Davies, Claire Evans et al. Lancet Child Adolesc Health. 2020 Jul 9 [Epub ahead of print] In April, 2020, clinicians in the UK observed a cluster of children with unexplained inflammation requiring admission to paediatric intensive care units (PICUs). We aimed to describe the clinical characteristics, course, management, and outcomes of patients admitted to PICUs with this condition, which is now known as paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS).

METHODS We did a multicentre observational study of children (aged

August 28, 2020 Update

From British Columbia, Canada:

Eight children were hospitalized in B.C. with a rare inflammatory disorder that has been linked to COVID-19.

The provincial health officer said two of those children had been treated in intensive care — suffering from multi-system inflammatory syndrome — but all the children had survived. The average age of the children was four, Dr. Bonnie Henry said.

Henry said that previously the syndrome-C would only be reported if a child was COVID-19 positive or had been exposed to the disease.

“We will (now) be reporting, for the first time, a number of suspect cases of what we have called MIS-C,” Henry said. “That is the multi-system inflammatory syndrome in children and adolescents. And this is something that has arisen as being associated in some parts of the world with COVID-19.”

However, Henry said that none of the eight sick children had tested positive for COVID-19 or had antibodies in their blood showing that they had been exposed to the disease.

In May, B.C. Children’s Hospital reported that it had not seen any patients with the syndrome, adding “reports from Italy, the UK, and the U.S. have shown an increase in cases of the syndrome in children and they have found that this is occurring several weeks after a COVID-19 infection.

The hospital described the syndrome as “a newly recognized clinical syndrome being reported in children and adolescents. Physicians believe this syndrome could be triggered by a response to the coronavirus in some children because the cases are being recognized at the same time as the pandemic.”

August 31, 2020 Update:

COVID-19AUGUST 31, 2020

Study details clinical characteristics of UK paediatric cohort admitted to hospital with COVID-19

A study in the British Medical Journal confirms that children and young people have lower rates of severe coronavirus disease 2019 (COVID-19) than adults, with researchers noting that severe illness was "rare" and death "exceptionally rare" in a large prospective cohort in the UK. However, factors that raised the likelihood of a child being admitted to critical care with the condition included age under 1 month old, age between 10 to 14 years, and black ethnicity, while older age and non-white ethnicity were associated with multisystem inflammatory syndrome in children (MIS-C) temporarily related to COVID-19.

They also discussed the distinct cluster presenting with systemic mucocutaneous-enteric symptoms (rash, conjunctivitis, diarrhoea, vomiting, and abdominal pain) in addition to headache, myalgia, sore throat, fatigue, and lymphadenopathy, which overlapped closely with the WHO preliminary case definition. "The significant associations between MIS-C and fatigue, headache, myalgia, sore throat, and lymphadenopathy in our cohort may be useful in refining the [WHO preliminary] case definition. In addition, the association of MIS-C with platelet count less than 150 × 109/L and low lymphocyte counts agrees with previous reports. These important findings may assist in differentiating this syndrome from other illnesses, particularly Kawasaki disease in which platelet counts are typically elevated," they said.

Reference: https://www.bmj.com/content/370/bmj.m3249

Thank you and please stay safe; Gary Ordog, MD

FEBRUARY 4, 2021

IVIG plus methylprednisolone linked to more favourable fever course in children with multisystem inflammatory syndrome

Treatment with intravenous immunoglobulin (IVIG) and methylprednisolone, compared with IVIG alone, was associated with a more favourable fever course in multisystem inflammatory syndrome in children (MIS-C), according to a study published in the Journal of the American Medical Association. In addition, the combination therapy was also associated with less severe acute complications, including acute left ventricular dysfunction and hemodynamic support requirement. 

A total of 106 children, with a median age of 8.6 years, who fulfilled the World Health Organization definition of MIS-C were included in this retrospective cohort study which started on April 1, 2020, with follow-up ended on January 6, 2021. More than half (52%) of the children were female. The primary outcome was treatment failure, defined as persistence of fever for 2 days after the introduction of initial therapy or recrudescence of fever within 7 days after the initial therapy. Meanwhile, secondary outcomes included second-line therapy, hemodynamic support, acute left ventricular dysfunction after first-line therapy, and length of stay in the pediatric intensive care unit (PICU).

Of the children, 34 received IVIG and methylprednisolone while 72 received IVIG alone. The dosage of IVIG was 2 g/kg for all patients. Among children in the IVIG and methylprednisolone group, 30 received methylprednisolone at 0.8 to 1 mg/kg every 12 hours (maximum of 30 mg for 12 hours) for 5 days, while the 4 remaining children received a bolus of 15 to 30 mg/kg/d of methylprednisolone for 3 days.

Overall, 3 of 34 children (9%) in the IVIG and methylprednisolone group while 37 of 72 (51%) in the IVIG alone group did not respond to treatment. When 32 children in the IVIG and methylprednisolone group were propensity-score matched with 64 children in the IVIG alone group, the researchers found that treatment with IVIG and methylprednisolone was associated with a lower risk of treatment failure (absolute risk difference, −0.28 [95% confidence interval (CI), −0.48 to −0.08]; odds ratio [OR], 0.25 [95% CI, 0.09 to 0.70]; P = 0.008). 

Similarly, IVIG and methylprednisolone therapy, compared with IVIG alone, was also significantly associated with lower risk of use of second-line therapy (absolute risk difference, −0.22 [95% CI, −0.40 to −0.04]; OR, 0.19 [95% CI, 0.06 to 0.61]; P = 0.004), hemodynamic support (absolute risk difference, −0.17 [95% CI, −0.34 to −0.004]; OR, 0.21 [95% CI, 0.06 to 0.76]; P = 0.01), acute left ventricular dysfunction occurring after initial therapy (absolute risk difference, −0.18 [95% CI, −0.35 to −0.01]; OR, 0.20 [95% CI, 0.06 to 0.66]; P = 0.007). The duration of PICU stay was also significantly shorter among those treated with IVIG and methylprednisolone compared with those on IVIG alone (median, 4 vs 6 days; difference in days, −2.4 [95% CI, −4.0 to −0.7]; P = 0.005). 

“MIS-C is the most severe pediatric disease associated with severe acute respiratory syndrome coronavirus 2 infection, potentially life-threatening, but the optimal therapeutic strategy remains unknown,” wrote Naïm Ouldali, MD, Université de Paris, Paris, France, and colleagues. 

“Corticosteroid use is currently one of the few validated therapeutics in severe respiratory adult forms of COVID-19. The findings in the current study suggest that corticosteroids may also be beneficial in MIS-C, possibly acting systematically as a potent inhibitor of SARS-CoV-2–induced inflammation,” the authors noted. “Combined with findings of studies reporting MIS-C cases in young adults, there may be common pathways between severe respiratory adult forms of COVID-19 and MIS-C.”

“Additional studies are warranted to understand the mechanisms underlying a possible corticosteroid effect in MIS-C and in severe forms of COVID-19,” the authors added. 

Reference: https://jamanetwork.com/journals/jama/fullarticle/2776054SOURCE: Journal of the American Medical Association

(Finally some confirmation of 40 year old treatment) Thank you Gary Joseph Ordog, MD February 04, 2021.