Multisystem Inflammatory Syndrome in Children Associated with COVID-19 in a Tertiary Level Hospital in Portugal

Joana Vieira de Melo; Rita Valsassina; Ana Margarida Garcia; Tiago Silva; Catarina Gouveia; Maria João Brito

doi:10.20344/amp.17797

Autores

Joana Vieira de Melo Unidade de Infecciologia Pediátrica. Hospital Dona Estefânia. Centro Hospitalar Universitário Lisboa Central. Lisboa. https://orcid.org/0000-0002-1656-8878
Rita Valsassina Unidade de Infecciologia Pediátrica. Hospital Dona Estefânia. Centro Hospitalar Universitário Lisboa Central. Lisboa.
Ana Margarida Garcia Unidade de Infecciologia Pediátrica. Hospital Dona Estefânia. Centro Hospitalar Universitário Lisboa Central. Lisboa.
Tiago Silva Unidade de Infecciologia Pediátrica. Hospital Dona Estefânia. Centro Hospitalar Universitário Lisboa Central. Lisboa.
Catarina Gouveia Unidade de Infecciologia Pediátrica. Hospital Dona Estefânia. Centro Hospitalar Universitário Lisboa Central. Lisboa.
Maria João Brito Unidade de Infecciologia Pediátrica. Hospital Dona Estefânia. Centro Hospitalar Universitário Lisboa Central. Lisboa.

DOI:

https://doi.org/10.20344/amp.17797

Palavras-chave:

COVID-19/complications, Criança, SARS-CoV-2, Síndrome de Resposta Inflamatória Sistémica

Resumo

Introdução: A síndrome inflamatória multissistémica em crianças (MIS-C) é uma manifestação rara, mas grave da doença por coronavírus 2019 (COVID-19). Este estudo teve como objetivo descrever as características de crianças com MIS-C internadas num hospital pediátrico terciário em Portugal.
Material e Métodos: Estudo observacional e descritivo de doentes com MIS-C internados de abril de 2020 a abril de 2021. Analisaram-se dados demográficos, clínicos, exames de diagnóstico e terapêutica. O diagnóstico baseou-se nos critérios da Organização Mundial de Saúde e Centers for Disease Control and Prevention.
Resultados: Foram identificadas 45 crianças, com mediana de idades de sete anos (AIQ 4 - 10 anos) sendo 60,0% previamente saudáveis. A infeção por SARS-CoV-2 foi confirmada por RT-PCR ou serologia em 77,8% dos doentes e 73,3% tinham link epidemiológico. Todos os casos cursaram com febre e envolvimento multiorgânico: hematológico (100%), cardiovascular (97,8%), gastrointestinal (97,8%), mucocutâneo (86,7%), respiratório (26,7%), neurológico (15,6%) e renal (13,3%). O envolvimento neurológico (p = 0,035) e respiratório (p = 0,035) ocorreu nos doentes mais graves. Houve uma diferença significativa das medianas quando comparados grupos de gravidade da doença, nomeadamente nos valores de hemoglobina (p = 0,015), linfócitos (p = 0,030), D-dímeros (p = 0,019), albumina (p < 0,001), NT-proBNP (p = 0,005), ferritina (p = 0,048), pCr (p = 0,006), procalcitonina (p = 0,005) e IL-6 (p = 0,002). Destas crianças, 93,3% realizaram imunoglobulina intravenosa, 91% metilprednisolona e um (2,2%) realizou anakinra. Treze doentes (28,8%) necessitaram de cuidados intensivos e não se registaram óbitos. Dos 21 doentes avaliados seis meses após a alta, 90,4% apresentaram diminuição da tolerância ao esforço e 8/15 (53,3%) lesão cardíaca persistente.
Conclusão: Observámos um amplo espectro de apresentação da doença num grupo de doentes previamente saudável, na sua maioria. Uma pequena percentagem de pacientes (28,9%) teve uma apresentação grave da doença. O diagnóstico da MIS-C é um desafio na prática clínica atual e requer um elevado nível de suspeição pois o início atempado de terapêutica é fundamental para prevenir complicações. No entanto, não existe ainda consenso científico sobre a melhor terapêutica e seguimento destes doentes.

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Referências

World Health Organization. WHO Coronavirus Disease (COVID-19) Dashboard. [cited 2020 Oct 1]. Available from: http://covid19.who.int.

Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med. 2020;382:727-33.

Direção-Geral da Saúde. COVID-19. [cited 2020 Oct 1]. Available from: https://covid19.min-saude.pt/.

Riphagen S, Gomez X, Gonzalez-Martinez C, Wilkinson N, Theocharis P. Hyperinflammatory shock in children during COVID-19 pandemic. Lancet. 2020;395:1607-8.

Ludvigsson JF. Systematic review of COVID-19 in children shows milder cases and a better prognosis than adults. Acta Paediatr. 2020;109:1088-95.

Royal College of Paediatrics and Child Health. Guidance: Paediatric multisystem inflammatory syndrome temporallly associated with COVID-19. [cited 2020 Oct 1]. Available from: https://www.rcpch.ac.uk/resources/guidance-paediatric-multisystem-inflammatory-syndrometemporally-associated-covid-19.

Verdoni L, Mazza A, Gervasoni A, Martelli L, Ruggeri M, Ciuffreda M, et al. An outbreak of severe Kawasaki-like disease at the Italian epicentre of the SARS-CoV-2 epidemic: an observational cohort study. Lancet. 2020;395:1771-8.

Riollano-Cruz M, Akkoyun E, Briceno-Brito E, Kowalsky S, Posada R, Sordillo EM, et al. Multisystem inflammatory syndrome in children (MIS-C) related to COVID-19: a New York City experience. J Med Virol. 2021;93:424-33.

Centers for Disease Control and Prevention. Multisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease 2019 (COVID-19). [cited on 2020 Oct 1]. Available from: https://emergency.cdc.gov/han/2020/han00432.asp.

World Health Organization. Multisystem inflammatory syndrome in children and adolescents with COVID-19; [cited on 2020 Oct 1]. Available from: https://www.who.int/publications/multisystem-inflammatorysyndrome-in-children-and-adolescents-with-covid-19.

Centers for Disease Control and Prevention. Health Department - Reported cases of multisystem inflammatory syndrome in children (MIS-C) in the United States; [cited 2020 May 1]. Available from: http://cdc.gov/mis-c/cases/index.html.

Dufort EM, Koumans EH, Chow EJ, Rosenthal EM, Muse A, Rowlands J, et al. Multisystem inflammatory syndrome in children in New York State. N Engl J Med. 2020;383:347-58.

Belhadjer Z, Méot M, Bajolle F, Khraiche D, Legendre A, Abakka S, et al. Acute heart failure in multisystem inflammatory syndrome in children (MIS-C) in the context of global SARS-CoV-2 pandemic. Circulation. 2020;142:429-36.

Whittaker E, Bamford A, Kenny J, Kaforou M, Jones CE, Shah P, et al. Clinical characteristics of 58 children with a pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2. JAMA. 2020;324:259-69.

Capone CA, Subramony A, Sweberg T, Schneider J, Shah S, Rubin L, et al. Characteristics, cardiac involvement, and outcomes of multisystem inflammatory disease of childhood (MIS-C) associated with SARS-CoV-2 infection. J Pediatr. 2020;224:141-5.

Rowley AH. Understanding SARS-CoV-2-related multisystem inflammatory syndrome in children. Nat Rev Immunol. 2020;20:453-4.

Penner J, Abdel-Mannan O, Grant K, Maillard S, Kucera F, Hassell J, et al. 6-month multidisciplinary follow-up and outcomes of patients with paediatric inflammatory multisystem syndrome (PIMS-TS) at a UK tertiary paediatric hospital: a retrospective cohort study. Lancet Child Adolesc Health. 2021;5:473-82.

Kaushik S, Aydin SI, Derespina KR, Bansal PB, Kowalsky S, Trachtman R, et al. Multisystem inflammatory syndrome in children (MIS-C) associated with SARS-CoV-2 infection: a multi-institutional study from New York City. J Pediatr. 2020;224:24-9.

Feldstein LR, Rose EB, Horwitz SM, Collins JP, Newhams MM, Son MB, et al. Multisystem inflammatory syndrome in U.S. children and adolescents. N Engl J Med. 2020;383:334-46.

Toubiana J, Poirault C, Corsia A, Bajolle F, Fourgeaud J, Angoulvant F, et al. Kawasaki-like multisystem inflammatory syndrome in children during the covid-19 pandemic in Paris, France: prospective observational study. BMJ. 2020;369:m2094.

Kaushik A, Gupta S, Sood M, Sharma S, Verma S. A systematic review of multisystem inflammatory syndrome in children associated With SARS-CoV-2 infection. Pediatr Infect Dis J. 2020;39:e340–6.

Ahmed M, Advani S, Moreira A, Zoretic S, Martinez J, Chorath K, et al. Multisystem inflammatory syndrome in children: a systematic review. EClinicalMedicine. 2020;26:100527.

Jiang L, Tang K, Levin M, Irfan O, Morris SK, Wilson K, et al. COVID-19 and multisystem inflammatory syndrome in children and adolescents. Lancet Infect Dis. 2020;20:e276–88.

Rafferty MS, Burrows H, Joseph JP, Leveille J, Nihtianova S, Amirian ES. Multisystem inflammatory syndrome in children (MIS-C) and the coronavirus pandemic: current knowledge and implications for public health. J Infect Public Health. 2021;14:484-94.

Henderson LA, Canna SW, Friedman KG, Gorelik M, Lapidus SK, Bassiri H, et al. American college of rheumatology clinical guidance for multisystem inflammatory syndrome in children associated with SARS–CoV-2 and hyperinflammation in pediatric COVID-19: Version 1. Arthritis Rheumatol. 2020;72:1791–805.

Miller J, Cantor A, Zachariah P, Ahn D, Martinez M, Margolis KG. Gastrointestinal symptoms as a major presentation component of a novel multisystem inflammatory syndrome in children that is related to coronavirus disease 2019: a single center experience of 44 cases. Gastroenterology. 2020;159:1571-4.e2.

Morparia K, Park MJ, Kalyanaraman M, McQueen D, Bergel M, Phatak T. Abdominal imaging findings in critically Ill children with multisystem inflammatory syndrome associated with COVID-19. Pediatr Infect Dis J. 2021;40:e82–3.

Götzinger F, Santiago-García B, Noguera-Julián A, Lanaspa M, Lancella L, Calò Carducci FI, et al. COVID-19 in children and adolescents in Europe: a multinational, multicentre cohort study. Lancet Child Adolesc Heal. 2020;4:653-61.

Cheung EW, Zachariah P, Gorelik M, Boneparth A, Kernie SG, Orange JS, et al. Multisystem inflammatory syndrome related to COVID-19 in previously healthy children and adolescents in New York City. JAMA. 2020;324:294-6.

LaRovere KL, Riggs BJ, Poussaint TY, Young CC, Newhams MM, Maamari M, et al. Neurologic involvement in children and adolescents hospitalized in the United States for COVID-19 or multisystem inflammatory syndrome. JAMA Neurol. 2021;78:536–47.

Godfred-Cato S, Bryant B, Leung J, Oster ME, Conklin L, Abrams J, et al. COVID-19-associated multisystem inflammatory syndrome in children - United States, March July 2020. MMWR Morb Mortal Wkly Rep. 2020;69:1074-80.

Panaro S, Cattalini M. The spectrum of manifestations of severe acute respiratory syndrome-coronavirus 2 (SARS-CoV2) infection in children: what we can learn from multisystem inflammatory syndrome in children (MIS-C). Front Med. 2021;8:747190.

Goldenberg NA, Sochet A, Albisetti M, Biss T, Bonduel M, Jaffray J, et al. Consensus-based clinical recommendations and research priorities for anticoagulant thromboprophylaxis in children hospitalized for COVID-19-related illness. J Thromb Haemost. 2020;18:3099-105.

Feketea G, Vlacha V, Bocsan IC, Vassilopoulou E, Stanciu LA, Zdrenghea M. Vitamin D in coronavirus disease 2019 (COVID-19) related multisystem inflammatory syndrome in children (MIS-C). Front Immunol. 2021;12:648546.

Alsaied T, Tremoulet AH, Burns JC, Saidi A, Dionne A, Lang SM, et al. Review of cardiac involvement in multisystem inflammatory syndrome in children. Circulation. 2021;143:78-88.

American Academy of Pediatrics. COVID-19 Interim Guidance: return to sports and physical activity. [cited 2021 June 10]. Available from: https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-interim-guidance-return-to-sports/.

Nir A, Lindinger A, Rauh M, Bar-Oz B, Laer S, Schwachtgen L, et al. NTpro-B-type natriuretic peptide in infants and children: reference values based on combined data from four studies. Pediatr Cardiol. 2009;30:3–8.