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Less than two weeks ago (Apr 27th) the NHS issued the first alert (see PICS: NHS Alert On Possible Severe Pediatric COVID-19 Complication) in the UK on children with a severe inflammatory syndrome similar to Kawasaki Disease, suspected to be linked to COVID-19 infection.
Since then, other European countries - particularly Italy - have reported a small, but growing number of similar cases.Late last week the Royal College of Paediatrics and Child Health published a case definition and preliminary guidance on the treatment of this condition (see RCPCH: Case Definition For Pediatric Inflammatory Syndrome).
On Tuesday of this week, the New York City Health department issued a HAN Alert On Pediatric Multi-System Inflammatory Syndrome, announcing 15 hospitalized cases in NYC, and calling for immediate reporting of similar cases by physicians.
A little over 24 hours later (Apr 6th), the State of New York followed up with a Health Advisory, which increased the number of hospitalized cases in New York State (including NYC) to 64.While this appears to be a rare complication in children, the rapid reporting of 64 cases in New York State suggests we are likely only seeing the tip of the iceberg. It is also unknown what the severity range of this syndrome is, meaning there may be many mild (non-hospitalized) cases going unnoticed as well.
Since this syndrome can cause serious heart inflammation, The American Heart Association issued a statement last night (see Kids with Kawasaki disease symptoms possibly linked to COVID-19; coronavirus infection leading to critical illness in children remains very infrequent).
The New York Health Advisory follows, after which I'll return with a brief postscript.
Most children appear to have a relatively mild (often asymptomatic) course of illness with COVID-19 - but this is another reminder that we are dealing with a novel virus - and that we are still far from fully understanding its impact on human health.
HEALTH ADVISORY: PEDIATRIC MULTI-SYSTEM INFLAMMATORY SYNDROME POTENTIALLY ASSOCIATED WITH CORONAVIRUS DISEASE (COVID-19) IN CHILDREN
SUMMARYADVISORY
- Recently, the Novel Coronavirus (COVID-19) has been reported as possibly linked with a pediatric multi-system inflammatory syndrome disease – “Pediatric Multi-System Inflammatory Syndrome Potentially Associated with COVID-19.”
- As of May 5, 2020, sixty-four (64) suspected pediatric clinical cases compatible with multi-system inflammatory syndrome associated with COVID-19 have been reported in children in New York State hospitals, including New York City.
- Hospitals must immediately report cases of pediatric multi-system inflammatory syndrome potentially associated with COVID-19 in patients who are under 21 years of age to NYS DOH through the Health Emergency Response Data System (HERDS) application on the health commerce system (HCS) and perform a diagnostic and serological test to detect the presence of SARS-COV-2, the virus that causes COVID-19, or corresponding antibodies in the patient.
- The purpose of this health advisory is to (1) ensure providers are aware of the pediatric multi-system inflammatory syndrome potentially associated with COVID-19 and (2) provide guidance on reporting of cases to NYS DOH and testing of patients who present with this disease.
- Please note that while older adults are at risk for severe COVID-19 illness, children can still get sick with COVID-19, most often presenting with mild symptoms, but rarely becoming severely ill.
PEDIATRIC MULTI-SYSTEM INFLAMMATORY SYNDROME POTENTIALLY ASSOCIATED WITH COVID-19
In the United Kingdom and Europe, a possible link has been reported between COVID-19 and a serious inflammatory disease recently termed “Pediatric Multi-System Inflammatory Syndrome Temporally Associated with COVID-19.”
As of May 5, 2020, sixty-four (64) suspected pediatric clinical cases compatible with multisystem inflammatory syndrome have been reported in children in New York State hospitals, including New York City.
This syndrome has features which overlap with Kawasaki Disease and Toxic Shock Syndrome. Inflammatory markers may be elevated, and fever and abdominal symptoms may be prominent.
Rash also may be present. Myocarditis and other cardiovascular changes may be seen.
Additionally, some patients have developed cardiogenic or vasogenic shock and required intensive care. This inflammatory syndrome may occur days to weeks after acute COVID-19 illness.
The syndrome may include:
- A child presenting with persistent fever, inflammation (e.g. neutrophilia, elevated C-reactive protein and lymphopenia) and evidence of single or multi-organ dysfunction (shock, cardiac, respiratory, renal, gastrointestinal or neurological disorder). This may include children meeting full or partial criteria for Kawasaki disease.
- Exclusion of any other microbial cause, including bacterial sepsis, staphylococcal or streptococcal shock syndromes, and infections associated with myocarditis such as enterovirus. Clinicians should not delay seeking expert advice while waiting for results of these investigations.
Early recognition by pediatricians and prompt referral to an in-patient specialist, including to critical care is essential.
This syndrome should be considered by pediatricians and specialists, particularly when other microbial etiologies have not been identified.
Pediatricians and specialists should elicit any recent history of illness with COVID-19 or close contact with individuals who are known to have COVID-19 in children presenting with symptoms that are compatible with pediatric multi-system inflammatory syndrome potentially associated with COVID-19.
The majority of patients who have presented with this syndrome have tested positive for SARS-COV-2 or corresponding antibodies. Some tested positive on diagnostic, molecular testing for SARS-COV-2, others were positive on serological testing for corresponding antibodies.
REPORTING AND TESTING
Hospitals must immediately report cases of pediatric multi-system inflammatory syndrome potentially associated with COVID-19 in patients who are under 21 years of age to NYS DOH through the Health Emergency Response Data System (HERDS) application on the health commerce system (HCS)
Hospitals must perform a diagnostic and serological test to detect the presence of SARS-COV-2, the virus that causes COVID-19, or corresponding antibodies in patients who are under 21 years of age and present with symptoms compatible with pediatric multi-system inflammatory syndrome potentially associated with COVID-19.
For questions about HERDS, providers can send an e-mail to hospinfo@health.ny.gov.
For other questions, providers can contact their local health department (LHD) at the link below or NYS DOH BCDC at 518-473-4439 during business hours or 1-866-881-2809 during evenings, weekends, and holidays.
RESOURCES
Most children appear to have a relatively mild (often asymptomatic) course of illness with COVID-19 - but this is another reminder that we are dealing with a novel virus - and that we are still far from fully understanding its impact on human health.
Even though we know this is not pandemic flu, many continue to view it as an influenza-like illness, and expect it to act accordingly.But as we've seen (see EID Journal: Pulmonary Embolism and Increased Levels of d-Dimer in COVID-19 Patients and Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young), this is clearly not your father's influenza.
All of which means we need to be prepared for even more surprises and challenges going forward.
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