Over the past two weeks, COVID took a back seat in the media to another public health crisis: Racial Inequalities and Disparities in the United States. (See this JAMA Article here on COVID-19 and Racial Disparities.) So that those important issues could be addressed, I only updated small parts of the website as to not deter attention from an equally important discussion and focus in the public health arena…..
Over the past week, we are beginning to see more MIS-C patients in our hospital, so I wanted to focus on the recent literature on MIS-C and COVID-19 in the Peds ICU that was released this week.
First, let’s dive into the recent numbers and projections of COVID-19. (Skip the numbers to go to straight to the literature by clicking here). According to the John Hopkins Dashboard, as of this afternoon, there are 7.4 million confirmed COVID-19 cases in the world with 2 million of those in the United States. The US reports 113,341 deaths due to COVID-19. At the beginning of this week, the US saw a lower number of deaths at about 400 new deaths reported on June 7th, and 500 deaths on June 8th.. However over the last two days of reporting we have seen 1,000 and 900 new deaths reported due to COVID-19.
In Wisconsin, we are down to about 200 to 300 new cases of COVID-19 reported daily and we are in the single digits to low teens for newly reported deaths, this number seems to have dropped off over the last week of May. See the DHS dashboard here.
It is difficult to anticipate how the reopening of states will see affect the number of fatalities from COVID-19, but we may see the case numbers increase following the demonstrations and state reopenings over the next week. See a link here for where states are in their new case trends. But, as we have learned over the last few weeks as pediatricians we are just starting to see the effects of COVID-19 in children. (Read our summaries here: PIMSTS #1, PIMSTS #2)
According to the VPS database, there have been 619 COVID-19 patients in the PICUs reporting to the database with 80% of those being under 18 years old. There were 32 confirmed deaths and 11,000 patients tested. A recent addition to the database was a diagnosis of MIS-C, and based on the 165 patients who had this data reported, 68 (41%) fit criteria for MIS-C/PIMS-TS.
Earlier this week, Pediatrics pre-published an article titled “Pediatric Critical Care and COVID19.”1
What was released was the data from the CAKE study. The CAKE study (Critical Coronavirus And Kids Epidemiologic) was a small case series of 17 children under 19 with severe or critical infection from COVID-19. The countries that collaborated were in Chile, Colombia, Italy, Spain, and USA. 6 patients were from Europe, 4 patients from North America, and 7 patients from South America.
They noted that 65% of patients were male with a median age of 4 years old and 14 did NOT have a known COVID exposure. Fever was the symptom most commonly found at admission, and the median time to presentation was about 3 days following symptom onset.
In looking at the break down by region reporting, patients in Europe and North America more commonly reported GI symptoms and patients in North and South America presented with a cough. It was also notable that patients in Europe reported a COVID-19 exposure when compared to the Americas.
- On admission, 50% of the patients had a leukocytosis and 76% had an elevated CRP. Elevated procalcitonin and D-dimer were also noted in a little over one-third of patients on presentation.
- 8 of the 17 patients (47%) required mechanical ventilation and 9 of the 17 patients (53%) required vasoactive infusions.
- All but 2 patients were treated with Antibiotics and over half received corticosteroids.
- 4 of the 17 patients (24%) received Remdesivir, all in North America
- 7 of the 17 patients (41%) were treated with Tocilizumab (Europe and North America)
- 8 of the 17 patients (47%) were treated with Hydroxychloroquine
- The most common diagnosis was Pneumonia (76% of patients)
- ARDs was reported in 8 of the patients with 3 of those meeting criteria for Severe ARDS
- 3 patients suffered cardiac arrest.
- For outcomes: only 1 patient, a 3yo F in South America died.
- The median ICU length of stay was 5.5 days.
I found this article to be extremely informative and it was quite interesting to see the different presentations throughout the different parts of the world. I highly recommend taking a look at the break down of patient presentations, treatments, and outcomes in the supplemental tables of the article.
This week we also saw publication of a larger case series regarding PIMS-TS or MIS-C here in the US. On June 8th JAMA published:
“Clinical Characteristics of 58 Children With a Pediatric Inflammatory Multisystem Syndrome Temporally Associated With SARS-CoV-2” 2
This article describes a case series of 58 children in 8 hospitals in England between the end of March and middle of May of 2020. They compared the clinical and laboratory findings of these 58 children with those who presented with Kawasaki Disease, Kawasaki Disease shock syndrome, and toxic shock syndrome between 2002 and 2019. They included any patients who met the UK, CDC, or WHO definition for PIMS-TS without requiring proof of exposure to COVID. (See Table 1 in the article for the differences in Definitions)
- The patients that met inclusion criteria had a median age of 9 years old. 33 of the 58 (57%) were female and 40 of the 58 (69%) were black or asian. In this group, comorbidities were not common and only present in 7 children.
- Presenting symptoms were persistent fever (>38 °C for >72 hours was an inclusion criteria), GI symptoms (vomiting, diarrhea, abdominal pain), conjunctival injection, and erythematous rash.
- 29 of the 58 patients were classified as developing shock and the same number of patients required admission to the Peds ICU
- Of those that developed shock, the median age of presentation was similar to the entire cohort: 10.5 years old. 55% were male. 48% were Black, 20% were Asian, and 20% were white.
- Presenting symptoms were similar in this group with again over half presenting with GI symptoms.
- 18 of the 29 patients (62%) who developed shock also had evidence of left ventricular dysfunction on echo and 19 (66%) had an elevation in troponin.
- Of the 11 patients who had a BNP measured, all 11 were elevated.
- Of these patients, 4 patients developed arrhythmias
- 11 of the 29 patients with shock also developed an acute Kidney injury
- Patients who developed shock has higher CRP and neutrophil counts, as well as lower albumin and lymphocyte counts.
- 27 of the 29 patients required inotropic support, 23 of the 29 patients with shock required intubation, and 3 patients required ECMO. 1 patient in the shock group died.
- IVIG and Steroids were the most commonly utilized therapy options for the 29 patients presenting with shock.
In comparing the cohort of PIMS-TS in this cohort with patients with Kawasaki Disease, Kawasaki Shock Syndrome, or toxic shock syndrome, it was noted that those with PIMS-TS tend to be older, show more signs of inflammation, and have higher markers of cardiac injury. The Figure on page E9 shows a great visual representation of the comparison of these groups.
Again, we are still learning more about how COVID-19 affects children, and each study published continues to supplement the little knowledge we have. Please feel free to contact here if you have any recommendations on articles or posts you would like to see summarized.
I also want to share a few quick articles on COVID-19 that are important to stay informed!
- The AAP recently released interim guidance for life support of COVID-19 confirmed or suspected neonates or children. Find that article here.3
- Testing continues to be one of the best ways to identify cases. However, we still can’t say for certain what every test result means for the virus. One article from the New England Journal of Medicine discusses False Negatives.4 Another piece from The New York Times is an op-ed which discusses COVID-19 Antibody testing.
- With the states opening up, we still have questions about the spread of the virus. Read this blog post written by biologist Erin Bromage and featured in the New York Times back in May.
Resources
1. González-Dambrauskas S, Vásquez-Hoyos P, Camporesi A, et al. Pediatric critical care and COVID19. Pediatrics. 2020; doi: 10.1542/peds.2020-1766
2. Whittaker E, Bamford A, Kenny J, et al. Clinical Characteristics of 58 Children With a Pediatric Inflammatory Multisystem Syndrome Temporally Associated With SARS-CoV-2. JAMA. Published online June 08, 2020. doi:10.1001/jama.2020.10369
3. Topjian A, Aziz K, Kamath-Rayne BD, et al. Interim Guidance for Basic and Advanced Life Support in Children and Neonates With Suspected or Confirmed COVID-19. Pediatrics. April 2020. doi:10.1542/peds.2020-1405.
4. Woloshin S, Patel N, Kesselheim AS. False Negative Tests for SARS-CoV-2 Infection — Challenges and Implications. New England Journal of Medicine. May 2020. doi:10.1056/nejmp2015897.
COVID-19 RESOURCE SITE FOR PEDS CRITICAL CARE AT MCW 