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Intensive care admissions of children with paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) in the UK: a multicentre observational study.
Lancet Child Adolesc Health. 2020 09; 4(9):669-677.LC

Abstract

BACKGROUND

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 <18 years), admitted to PICUs in the UK between April 1 and May 10, 2020, fulfilling the case definition of PIMS-TS published by the Royal College of Paediatrics and Child Health. We analysed routinely collected, de-identified data, including demographic details, presenting clinical features, underlying comorbidities, laboratory markers, echocardiographic findings, interventions, treatments, and outcomes; serology information was collected if available. PICU admission rates of PIMS-TS were compared with historical trends of PICU admissions for four similar inflammatory conditions (Kawasaki disease, toxic shock syndrome, haemophagocytic lymphohistiocytosis, and macrophage activation syndrome).

FINDINGS

78 cases of PIMS-TS were reported by 21 of 23 PICUs in the UK. Historical data for similar inflammatory conditions showed a mean of one (95% CI 0·85-1·22) admission per week, compared to an average of 14 admissions per week for PIMS-TS and a peak of 32 admissions per week during the study period. The median age of patients was 11 years (IQR 8-14). Male patients (52 [67%] of 78) and those from ethnic minority backgrounds (61 [78%] of 78) were over-represented. Fever (78 [100%] patients), shock (68 [87%]), abdominal pain (48 [62%]), vomiting (49 [63%]), and diarrhoea (50 [64%]) were common presenting features. Longitudinal data over the first 4 days of admission showed a serial reduction in C-reactive protein (from a median of 264 mg/L on day 1 to 96 mg/L on day 4), D-dimer (4030 μg/L to 1659 μg/L), and ferritin (1042 μg/L to 757 μg/L), whereas the lymphocyte count increased to more than 1·0 × 109 cells per L by day 3 and troponin increased over the 4 days (from a median of 157 ng/mL to 358 ng/mL). 36 (46%) of 78 patients were invasively ventilated and 65 (83%) needed vasoactive infusions; 57 (73%) received steroids, 59 (76%) received intravenous immunoglobulin, and 17 (22%) received biologic therapies. 28 (36%) had evidence of coronary artery abnormalities (18 aneurysms and ten echogenicity). Three children needed extracorporeal membrane oxygenation, and two children died.

INTERPRETATION

During the study period, the rate of PICU admissions for PIMS-TS was at least 11-fold higher than historical trends for similar inflammatory conditions. Clinical presentations and treatments varied. Coronary artery aneurysms appear to be an important complication. Although immediate survival is high, the long-term outcomes of children with PIMS-TS are unknown.

FUNDING

None.

Authors+Show Affiliations

Paediatric Critical Care Unit, Nottingham Children's Hospital, Nottingham, UK. Electronic address: patrick.davies@nuh.nhs.uk.Paediatric Critical Care Unit, Nottingham Children's Hospital, Nottingham, UK.Paediatric Intensive Care Unit, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK.Paediatric Intensive Care Unit, Evelina Children's Hospital, London, UK.Paediatric Intensive Care Unit, Great Ormond Street Hospital, London, UK.Paediatric Intensive Care Unit, Evelina Children's Hospital, London, UK.Paediatric Intensive Care Unit, Great Ormond Street Hospital, London, UK.Paediatric Intensive Care Unit, Evelina Children's Hospital, London, UK.Paediatric Intensive Care Unit, Great Ormond Street Hospital, London, UK.Paediatric Intensive Care Unit, Leicester Royal Infirmary, Leicester, UK.Paediatric Intensive Care Unit, King's College Hospital, London, UK.Paediatric Intensive Care Unit, Royal Manchester Children's Hospital, Manchester, UK.Paediatric Intensive Care Unit, Leeds Royal Infirmary, Leeds, UK.Paediatric Intensive Care Unit, Addenbrooke's Hospital, Cambridge, UK.Paediatric Critical Care Unit, Children's Hospital for Wales, Cardiff, UK.Paediatric Intensive Care Unit, Southampton Children's Hospital, Southampton, UK.Paediatric Intensive Care Unit, Alder Hey Children's Hospital, Liverpool, UK.Paediatric Intensive Care Unit, Royal Hospital for Children, Glasgow, UK.Paediatric Intensive Care Unit, St Mary's Hospital, London, UK.Paediatric Critical Care Unit, John Radcliffe Hospital, Oxford, UK.Paediatric Infectious Diseases Department, Imperial College Healthcare NHS Trust, London, UK.Paediatric Critical Care Unit, Nottingham Children's Hospital, Nottingham, UK.Paediatric Intensive Care Unit, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK; Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.Paediatric Intensive Care Unit, St Mary's Hospital, London, UK; Children's Acute Transport Service, Great Ormond Street Hospital NHS Foundation Trust and NIHR Biomedical Research Centre, London, UK.

Pub Type(s)

Journal Article
Multicenter Study

Language

eng

PubMed ID

32653054

Citation

Davies, Patrick, et al. "Intensive Care Admissions of Children With Paediatric Inflammatory Multisystem Syndrome Temporally Associated With SARS-CoV-2 (PIMS-TS) in the UK: a Multicentre Observational Study." The Lancet. Child & Adolescent Health, vol. 4, no. 9, 2020, pp. 669-677.
Davies P, Evans C, Kanthimathinathan HK, et al. Intensive care admissions of children with paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) in the UK: a multicentre observational study. Lancet Child Adolesc Health. 2020;4(9):669-677.
Davies, P., Evans, C., Kanthimathinathan, H. K., Lillie, J., Brierley, J., Waters, G., Johnson, M., Griffiths, B., du Pré, P., Mohammad, Z., Deep, A., Playfor, S., Singh, D., Inwald, D., Jardine, M., Ross, O., Shetty, N., Worrall, M., Sinha, R., ... Ramnarayan, P. (2020). Intensive care admissions of children with paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) in the UK: a multicentre observational study. The Lancet. Child & Adolescent Health, 4(9), 669-677. https://doi.org/10.1016/S2352-4642(20)30215-7
Davies P, et al. Intensive Care Admissions of Children With Paediatric Inflammatory Multisystem Syndrome Temporally Associated With SARS-CoV-2 (PIMS-TS) in the UK: a Multicentre Observational Study. Lancet Child Adolesc Health. 2020;4(9):669-677. PubMed PMID: 32653054.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Intensive care admissions of children with paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) in the UK: a multicentre observational study. AU - Davies,Patrick, AU - Evans,Claire, AU - Kanthimathinathan,Hari Krishnan, AU - Lillie,Jon, AU - Brierley,Joseph, AU - Waters,Gareth, AU - Johnson,Mae, AU - Griffiths,Benedict, AU - du Pré,Pascale, AU - Mohammad,Zoha, AU - Deep,Akash, AU - Playfor,Stephen, AU - Singh,Davinder, AU - Inwald,David, AU - Jardine,Michelle, AU - Ross,Oliver, AU - Shetty,Nayan, AU - Worrall,Mark, AU - Sinha,Ruchi, AU - Koul,Ashwani, AU - Whittaker,Elizabeth, AU - Vyas,Harish, AU - Scholefield,Barnaby R, AU - Ramnarayan,Padmanabhan, Y1 - 2020/07/09/ PY - 2020/06/17/received PY - 2020/06/19/revised PY - 2020/06/23/accepted PY - 2020/7/13/pubmed PY - 2020/9/2/medline PY - 2020/7/13/entrez SP - 669 EP - 677 JF - The Lancet. Child & adolescent health JO - Lancet Child Adolesc Health VL - 4 IS - 9 N2 - BACKGROUND: 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 <18 years), admitted to PICUs in the UK between April 1 and May 10, 2020, fulfilling the case definition of PIMS-TS published by the Royal College of Paediatrics and Child Health. We analysed routinely collected, de-identified data, including demographic details, presenting clinical features, underlying comorbidities, laboratory markers, echocardiographic findings, interventions, treatments, and outcomes; serology information was collected if available. PICU admission rates of PIMS-TS were compared with historical trends of PICU admissions for four similar inflammatory conditions (Kawasaki disease, toxic shock syndrome, haemophagocytic lymphohistiocytosis, and macrophage activation syndrome). FINDINGS: 78 cases of PIMS-TS were reported by 21 of 23 PICUs in the UK. Historical data for similar inflammatory conditions showed a mean of one (95% CI 0·85-1·22) admission per week, compared to an average of 14 admissions per week for PIMS-TS and a peak of 32 admissions per week during the study period. The median age of patients was 11 years (IQR 8-14). Male patients (52 [67%] of 78) and those from ethnic minority backgrounds (61 [78%] of 78) were over-represented. Fever (78 [100%] patients), shock (68 [87%]), abdominal pain (48 [62%]), vomiting (49 [63%]), and diarrhoea (50 [64%]) were common presenting features. Longitudinal data over the first 4 days of admission showed a serial reduction in C-reactive protein (from a median of 264 mg/L on day 1 to 96 mg/L on day 4), D-dimer (4030 μg/L to 1659 μg/L), and ferritin (1042 μg/L to 757 μg/L), whereas the lymphocyte count increased to more than 1·0 × 109 cells per L by day 3 and troponin increased over the 4 days (from a median of 157 ng/mL to 358 ng/mL). 36 (46%) of 78 patients were invasively ventilated and 65 (83%) needed vasoactive infusions; 57 (73%) received steroids, 59 (76%) received intravenous immunoglobulin, and 17 (22%) received biologic therapies. 28 (36%) had evidence of coronary artery abnormalities (18 aneurysms and ten echogenicity). Three children needed extracorporeal membrane oxygenation, and two children died. INTERPRETATION: During the study period, the rate of PICU admissions for PIMS-TS was at least 11-fold higher than historical trends for similar inflammatory conditions. Clinical presentations and treatments varied. Coronary artery aneurysms appear to be an important complication. Although immediate survival is high, the long-term outcomes of children with PIMS-TS are unknown. FUNDING: None. SN - 2352-4650 UR - https://www.unboundmedicine.com/medline/citation/32653054/Intensive_care_admissions_of_children_with_paediatric_inflammatory_multisystem_syndrome_temporally_associated_with_SARS_CoV_2__PIMS_TS__in_the_UK:_a_multicentre_observational_study_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S2352-4642(20)30215-7 DB - PRIME DP - Unbound Medicine ER -