20.05.2020

Acute heart failure in multisystem inflammatory syndrome in children (MIS-C) in the context of global SARS-CoV-2 pandemic

Epidemiological Cardiology and metabolic diseasesPaediatricsAnesthesia-intensive care
Belhadjer Z et al
Circulation

Main result

Study on 35 children (median age of 10 years [2 to 16 years], 18 boys, comorbidities present in 28% of cases [3 asthmatics, 6 overweight patients]). Gastrointestinal symptoms were common (80% of patients). Clinical signs suggestive of Kawasaki disease were frequent, but none met the criteria of a classical form. The median time between the first clinical symptoms and the symptoms of heart failure was 6 days. The majority (29/35) were admitted directly to the intensive care unit (those admitted to general paediatrics deteriorated within the first 24 hours).

The LVEF was <30% in one third of the children; 80% required inotropic support and 28% were treated with ECMO. 22 (63%) had invasive mechanical ventilation. 6 patients with coronary dilation, no aneurysm. Inflammation markers suggested a cytokine storm (mean IL6: 135 pg/mL) and macrophage activation (mean: D-dimers 5284 ng/mL). Mean BNP was high (5743 pg/mL).

31 patients (89%) tested positive for SARS-CoV-2 infection by PCR (12 nasopharyngeal swabs, 2 fecal samples) or serology (30/35). However, 2 negative patients showed typical pulmonary imaging features. All patients received intravenous immunoglobulins and one-third of patients also received corticosteroid therapy. Left ventricular function was restored in 25/35 of the patients discharged from the intensive care unit.

No patients died and all patients treated with ECMO were successfully weaned.

Takeaways

Multisystemic inflammatory syndrome in children (MIS-C) is a new syndrome that is temporarily linked to previous exposure to SARS-CoV-2. Similarities with atypical Kawasaki disease, but the major clinical signs are different. Myocardial impairment with acute heart failure is probably due to myocardial sideration or edema rather than inflammatory lesions of myocardium.

While the initial presentation may be severe in some patients requiring mechanical circulatory and respiratory support, rapid recovery with the use of immunoglobulins and steroids has been observed.

Strength of evidence Weak

Case series, n=.35, multicenter in France and 1 centre in Switzerland
7 patients still hospitalized or with residual left ventricular dysfunction
Missing data due to lack of standardization of follow-up
Many errors on percentages and inconsistencies on the number of centers (14 / 12+1)

Objectives

Describe a complex new syndrome in febrile children admitted for acute heart failure, linked to previous exposure to SARS-CoV-2 (multisystemic inflammatory syndrome in children - MIS-C)

Method

Case series in France (12 centres) and Switzerland (1 centre), centres with intensive care units treating paediatric cardiogenic shocks. Patients admitted between March 22 and April 30.

Inclusion criteria: fever (>38.5°C) - cardiogenic shock or acute left ventricular dysfunction (LVEF <50%) + biological inflammatory syndrome (CRP> 100mg/ml)

Diagnosis COVID-19: all have been tested: nasopharyngeal and/or faecal and/or tracheal swab RT-PCR and/or serology (IgG IgA IgM). A patient was considered infected if one of those tests were positive.

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