Acute Heart Failure Associated with COVID-19 , Multisystem Inflammatory Syndrome in Children

Initially during the global pandemic, relatively few confirmed Covid-19 cases of infants have been reported with mild illness. However, recently children have been reported to experience acute heart failure as a secondary condition to multisystem inflammatory syndrome in children – MIS-C due to SARS-CoV-2 infection, say a study published in the AHA Journals.

Recently, in Europe and North America, clusters of cases have been reported of children and adolescents with a multisystem inflammatory condition.  Initially the news was encouraging that virus is sparing the children. However, the parents and doctors were devasted when several cases of children with serious multi-system inflammatory condition was reported as a secondary complication of COVID-19 infection that can considerably damage the heart and other organs in children.

On April 26, physicians in UK recognized the upsurge in cases of children with a severe inflammatory syndrome with Kawasaki disease-like features and tested positive for Covid-19 by RT-PCR or serologic assay.  The common symptoms were persistent fever, hypotension, multiple organ damage including kidneys, brain, stomach, skin, and heart with elevated inflammatory cells that delays the recovery process. However, there were no prominent respiratory symptoms. All 8 cases tested positive for virus. In UK, there was one death reported of a child with this condition out of eight, where 75% were from Afro-Caribbean Descent with 62.5% effected boys.

Symptoms of multisystem inflammatory syndrome in children – MIS-C due to SARS-CoV-2 infection Source: The Lancet

Therefore, on May 14, the Centers for Disease Control and Prevention (CDC) issued a health advisory to provide the background on a few recently reported cases, draw the case definition and recommend to health care providers to report cases to health departments.

Source: CDC.

However, on May 15, WHO has outlined a preliminary case definition for the multisystem inflammatory disorder in children and adolescents which will be revised respectively with the new developments in cases and scientific data.

WHO released a scientific brief on Multisystem Inflammatory Syndrome in Children with COVID-19:“I call on all clinicians worldwide to work with your national authorities and WHO to be on the alert and better understand this syndrome in children”- Tedros Adhanom Ghebreyesus

Posted by World Health Organization (WHO) on Saturday, May 16, 2020

The pediatric Covid-19 study

In France and Switzerland, the conducted study speculates that treatment with immune globulin, a protein present in serum and cells of immune system functioning as antibodies, can recover the left chamber of heart. A retrospective two months period study collected the therapeutic and biological outcomes in children who were hospitalized in pediatric intensive care units at 14 centers for the cardiac shock and left dysfunctional heart ventricle along with severe inflammatory condition. The study included 35 children with median age of10 years ranging from 2 to 16 years.

The results revealed that over 28% children who had heart failure as a result of inflammatory disease had co-morbidities including asthma and overweight with prominent gastrointestinal symptoms. Left ventricle ejects maximum portion of blood to the rest of the body including lungs.  Study showed that one third of children has less than 30% of blood pumping from left ventricle per contraction, which is far less than normal level. Over 80% of the children required short-term ECMO life support to deliver oxygen into the child’s blood. Moreover, the immune system molecular indicating inflammation were drastically high indicating presence of inflammatory disease MIS-C in infected children. However, 31 out of 35 children tested positive for the virus.

The study showed that children were injected with immunoglobulin antibody therapy with steroid therapy. Subsequently, all patients showed recovery with maximum functionality in left ventricle.

We want to reassure families that this complication is very rare. Even though this is rare, and we don’t want parents to become alarmed, it’s wise for them to know what to watch for, said Roshni Mathew, MD, clinical assistant professor of infectious disease, Stanford Children’s Health.

It is critical to understand the characteristic of this syndrome and potential risk factors like heart failure to completely understand the casualties and develop new interventions. Yet the exact underlying cause and the spectrum of the disease is not confirming and needs further elucidation, whether the disease pattern is due to geographical distribution.

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