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Acute myocarditis and multisystem inflammatory emerging disease following SARS-CoV-2 infection in critically ill children.
Ann Intensive Care. 2020 Jun 01; 10(1):69.AI

Abstract

BACKGROUND

A recent increase in children admitted with hypotensive shock and fever in the context of the COVID-19 outbreak requires an urgent characterization and assessment of the involvement of SARS-CoV-2 infection. This is a case series performed at 4 academic tertiary care centers in Paris of all the children admitted to the pediatric intensive care unit (PICU) with shock, fever and suspected SARS-CoV-2 infection between April 15th and April 27th, 2020.

RESULTS

20 critically ill children admitted for shock had an acute myocarditis (left ventricular ejection fraction, 35% (25-55); troponin, 269 ng/mL (31-4607)), and arterial hypotension with mainly vasoplegic clinical presentation. The first symptoms before PICU admission were intense abdominal pain and fever for 6 days (1-10). All children had highly elevated C-reactive protein (> 94 mg/L) and procalcitonin (> 1.6 ng/mL) without microbial cause. At least one feature of Kawasaki disease was found in all children (fever, n = 20, skin rash, n = 10; conjunctivitis, n = 6; cheilitis, n = 5; adenitis, n = 2), but none had the typical form. SARS-CoV-2 PCR and serology were positive for 10 and 15 children, respectively. One child had both negative SARS-CoV-2 PCR and serology, but had a typical SARS-CoV-2 chest tomography scan. All children but one needed an inotropic/vasoactive drug support (epinephrine, n = 12; milrinone, n = 10; dobutamine, n = 6, norepinephrine, n = 4) and 8 were intubated. All children received intravenous immunoglobulin (2 g per kilogram) with adjuvant corticosteroids (n = 2), IL 1 receptor antagonist (n = 1) or a monoclonal antibody against IL-6 receptor (n = 1). All children survived and were afebrile with a full left ventricular function recovery at PICU discharge.

CONCLUSIONS

Acute myocarditis with intense systemic inflammation and atypical Kawasaki disease is an emerging severe pediatric disease following SARS-CoV-2 infection. Early recognition of this disease is needed and referral to an expert center is recommended. A delayed and inappropriate host immunological response is suspected. While underlying mechanisms remain unclear, further investigations are required to target an optimal treatment.

Authors+Show Affiliations

Pediatric Intensive Care Unit, Necker-Enfants-Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.Pediatric and Neonatal Intensive Care Unit, Armand-Trousseau University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.Pediatric Intensive Care Unit, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France.Pediatric and Neonatal Intensive Care Unit, Kremlin-Bicêtre University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.Pediatric Intensive Care Unit, Necker-Enfants-Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.M3C-Necker, Congenital and Pediatric Cardiology, Necker-Enfants-Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.Laboratoire de Virologie, Paris University, EA 7328, Paris, France.Paediatric Hematology-Immunology and Rheumatology Unit, Reference center for Rheumatic, AutoImmune and Systemic diseases in children (RAISE), Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris, IMAGINE Institute, Université de Paris, Paris, France.Pediatric and Neonatal Intensive Care unit, Armand-Trousseau University Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris, France.Pediatric Intensive Care Unit, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France.Pediatric and Neonatal Intensive Care Unit, Kremlin-Bicêtre University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.Pediatric Intensive Care Unit, Necker-Enfants-Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.Pediatric Intensive Care Unit, Necker-Enfants-Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.Pediatric and Neonatal Intensive Care Unit, Armand-Trousseau University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.Pediatric Intensive Care Unit, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France.Pediatric Intensive Care Unit, Necker-Enfants-Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris University, EA7323, 75006, Paris, France.Pediatric Intensive Care Unit, Necker-Enfants-Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris University, EA7323, 75006, Paris, France. mehdi.oualha@aphp.fr.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

32488505

Citation

Grimaud, Marion, et al. "Acute Myocarditis and Multisystem Inflammatory Emerging Disease Following SARS-CoV-2 Infection in Critically Ill Children." Annals of Intensive Care, vol. 10, no. 1, 2020, p. 69.
Grimaud M, Starck J, Levy M, et al. Acute myocarditis and multisystem inflammatory emerging disease following SARS-CoV-2 infection in critically ill children. Ann Intensive Care. 2020;10(1):69.
Grimaud, M., Starck, J., Levy, M., Marais, C., Chareyre, J., Khraiche, D., Leruez-Ville, M., Quartier, P., Léger, P. L., Geslain, G., Semaan, N., Moulin, F., Bendavid, M., Jean, S., Poncelet, G., Renolleau, S., & Oualha, M. (2020). Acute myocarditis and multisystem inflammatory emerging disease following SARS-CoV-2 infection in critically ill children. Annals of Intensive Care, 10(1), 69. https://doi.org/10.1186/s13613-020-00690-8
Grimaud M, et al. Acute Myocarditis and Multisystem Inflammatory Emerging Disease Following SARS-CoV-2 Infection in Critically Ill Children. Ann Intensive Care. 2020 Jun 1;10(1):69. PubMed PMID: 32488505.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Acute myocarditis and multisystem inflammatory emerging disease following SARS-CoV-2 infection in critically ill children. AU - Grimaud,Marion, AU - Starck,Julie, AU - Levy,Michael, AU - Marais,Clémence, AU - Chareyre,Judith, AU - Khraiche,Diala, AU - Leruez-Ville,Marianne, AU - Quartier,Pierre, AU - Léger,Pierre Louis, AU - Geslain,Guillaume, AU - Semaan,Nada, AU - Moulin,Florence, AU - Bendavid,Matthieu, AU - Jean,Sandrine, AU - Poncelet,Géraldine, AU - Renolleau,Sylvain, AU - Oualha,Mehdi, Y1 - 2020/06/01/ PY - 2020/05/07/received PY - 2020/05/25/accepted PY - 2020/6/4/entrez PY - 2020/6/4/pubmed PY - 2020/6/4/medline KW - Acute myocarditis KW - Children KW - Multisystem inflammatory syndrome KW - SARS-CoV-2 KW - Shock SP - 69 EP - 69 JF - Annals of intensive care JO - Ann Intensive Care VL - 10 IS - 1 N2 - BACKGROUND: A recent increase in children admitted with hypotensive shock and fever in the context of the COVID-19 outbreak requires an urgent characterization and assessment of the involvement of SARS-CoV-2 infection. This is a case series performed at 4 academic tertiary care centers in Paris of all the children admitted to the pediatric intensive care unit (PICU) with shock, fever and suspected SARS-CoV-2 infection between April 15th and April 27th, 2020. RESULTS: 20 critically ill children admitted for shock had an acute myocarditis (left ventricular ejection fraction, 35% (25-55); troponin, 269 ng/mL (31-4607)), and arterial hypotension with mainly vasoplegic clinical presentation. The first symptoms before PICU admission were intense abdominal pain and fever for 6 days (1-10). All children had highly elevated C-reactive protein (> 94 mg/L) and procalcitonin (> 1.6 ng/mL) without microbial cause. At least one feature of Kawasaki disease was found in all children (fever, n = 20, skin rash, n = 10; conjunctivitis, n = 6; cheilitis, n = 5; adenitis, n = 2), but none had the typical form. SARS-CoV-2 PCR and serology were positive for 10 and 15 children, respectively. One child had both negative SARS-CoV-2 PCR and serology, but had a typical SARS-CoV-2 chest tomography scan. All children but one needed an inotropic/vasoactive drug support (epinephrine, n = 12; milrinone, n = 10; dobutamine, n = 6, norepinephrine, n = 4) and 8 were intubated. All children received intravenous immunoglobulin (2 g per kilogram) with adjuvant corticosteroids (n = 2), IL 1 receptor antagonist (n = 1) or a monoclonal antibody against IL-6 receptor (n = 1). All children survived and were afebrile with a full left ventricular function recovery at PICU discharge. CONCLUSIONS: Acute myocarditis with intense systemic inflammation and atypical Kawasaki disease is an emerging severe pediatric disease following SARS-CoV-2 infection. Early recognition of this disease is needed and referral to an expert center is recommended. A delayed and inappropriate host immunological response is suspected. While underlying mechanisms remain unclear, further investigations are required to target an optimal treatment. SN - 2110-5820 UR - https://www.unboundmedicine.com/medline/citation/32488505/Acute_myocarditis_and_multisystem_inflammatory_emerging_disease_following_SARS-CoV-2_infection_in_critically_ill_children L2 - https://dx.doi.org/10.1186/s13613-020-00690-8 DB - PRIME DP - Unbound Medicine ER -
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