The use of immune globulin therapy appears to benefit children who experience acute heart failure caused by coronavirus disease 2019 (COVID-19)-related multisystem inflammatory syndrome, according to the findings of a case series recently published in Circulation. 

After observing that a small number of children developed symptoms consistent with both toxic shock syndrome and Kawasaki disease following COVID-19 exposure, a small study was conducted to determine more about this “emerging condition.” Symptoms of multisystem inflammatory syndrome in children (MIS-C) include high-spiking fever for approximately 2 days, asthenia, severe abdominal pain, vomiting, diarrhea, adenopathy, and skin rash.

“Over a 2-month period contemporary with the SARS-CoV-2 pandemic in France and Switzerland, we retrospectively collected clinical, biological, therapeutic, and early outcomes data in children who were admitted to pediatric intensive care units in 14 centers for cardiogenic shock, left ventricular dysfunction and severe inflammatory state,” the study authors explained.

The small study included a total of 35 pediatric patients, of which, 88.5% (31/35) tested positive for COVID-19. The median age of patients in the study was 10 years old (range, 2-16) and 28% had comorbidities (asthma, overweight). It was noted that underlying cardiovascular disease was not present in any patient included in the study.

At presentation, all patients had left ventricular systolic dysfunction in association with low systolic blood pressure and one-third of patients had a left ventricular ejection fraction of <30%. The authors stated that the inflammatory markers of the patients indicated cytokine storm as well as macrophage activation; elevated mean brain natriuretic peptide value was also observed. 

Nearly all patients (33/35) required respiratory assistance. Of the total patients, 80% (28/35) required inotropic support; extracorporeal membrane oxygenation (ECMO) was used to treat 10 patients and was successfully weaned after 3 to 6 days of therapy. 

The majority of patients (25/35) were treated with intravenous immune globulin and one-third of high-risk patients (12/35) received steroid therapy. A therapeutic dose of heparin was administered to 23 patients and 3 patients were treated with an interleukin 1 receptor antagonist (anakinra) due to a continuous inflammatory state.

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Complete left ventricular function recovery was observed in the majority of patients (25/35) discharged from the intensive care unit.  The median stay in the hospital was 10 days, with a median 7 days spent in intensive care.

“The pediatric and cardiology communities should be acutely aware of this new disease probably related to SARS-CoV-2 infection (MIS-C), that shares similarities with Kawasaki disease but has specificities in its presentation,” the study authors concluded. They added, “Early diagnosis and management appear to lead to favorable outcome using classical therapies.”

Reference

Belhadjer Z, Méot M, Bajolle F, et al.  Acute heart failure in multisystem inflammatory syndrome in children (MIS-C) in the context of global SARS-CoV-2 pandemic [published online May 17, 2020]. Circulation. doi: 10.1161/CIRCULATIONAHA.120.048360.