Kawasaki-like multisystem inflammatory syndrome in children during the covid-19 pandemic in Paris, France: prospective observational study
Main result
Inclusion of 21 children and adolescents hospitalized with Kawasaki disease criteria. Their median age is 7.9 years (3 to 16 years), 12 (57%) are girls and 12 (57%) have at least one parent from sub-Saharan Africa or the Caribbean.
Temporal association with potential SARS-CoV-2 infection:
9/21 report a recent history of symptoms of viral infection and 10/21 report a recent history of contact with a symptomatic relative. The median time between these symptoms or contact and the first Kawasaki type symptoms is 45 days (18-79 days) and 36 days (18-45 days) respectively.
Tests :
19/21 patients (90%) have at least one positive test for SARS-CoV-2 (positive RT-PCR: 8/21, positive serology: 19/21).
Two patients are negative for both tests.
Other viral infections have been investigated: only one patient is positive for a recent EBV infection.
Clinical:
11/21 of the patients present arguments for a complete form of Kawasaki disease. The most frequent symptoms among the main criteria in favour are: polymorphic skin rashes (76%), damage to the lips and oral mucosa (76%) and bilateral conjunctivitis (81%). All patients had early onset gastrointestinal symptoms (abdominal pain, vomiting and diarrhea) with peritoneal effusion in 4 subjects, 2 of whom had acute surgical abdomen. Pericardial effusion was found in 10/21 patients, pleural effusion in 3/21, myocarditis in 16/21 (76%) with LVEF between 10% and 57%.
Imaging and biology :
18/21 had chest imaging (simple X-ray, CT scan) with signs suggestive of COVID-19 in 8 (44%) of them.
On echocardiography: coronary dilatations in 5/21 and "brilliant" and hyperechoic appearance in 3/21. Absence of aneurismal dilatation observed.
All patients present an elevation of biological inflammatory markers: hyperleukocytosis with PNN, elevation of CRP, PCT or IL-6. Lymphopenia was objectively diagnosed in 17/21 patients with frequent anemia. 95% (n=20) had hyponatremia/hypoalbuminemia and 52% (n=11) had transient renal failure. Abnormalities in liver function tests are also common, as are elevations in D-Dimer (95%), ultra-sensitive troponin (81%) and BNP (78%).
Treatment:
Routine treatment with at least 1 dose of IV immunoglobulin (2 doses in 5 resistant patients) and low-dose aspirin. 7 have received corticosteroids.
17/21 were admitted to the intensive care unit for hemodynamic instability and 12 developed Kawasaki shock syndrome. The median length of stay in the intensive care unit was 5 days (range 3-15 days).
At the end of follow-up, no deaths occurred and all patients returned home.
Takeaways
Furthermore, in this series of cases of Kawasaki syndrome, digestive symptoms are systematic, which is not usually the case. Similarly, hemodynamic instability and myocarditis are more prominent.
Finally, it should be noted that a large proportion of the children have a parent of African or Caribbean origin, which raises the question of the link with the susceptibility to contracting COVID-
Strength of evidence Weak
- small group
- Probable recall bias towards recent viral symptoms or contact with a symptomatic subject.
- follow-up too short to diagnose all the coronary complications that may appear at a distance
- selection bias: the Necker Hospital is a referral centre and concentrates cases
- no systematic SARS-CoV-2 testing of relatives
- risk of false positive serology due to cross-reactivity
Objectives
Method
Prospective monocentric cohort study for descriptive purposes.
Population :
- patients 18 years of age or younger
- hospitalised between 27/04/2020 and 11/05/2020 in a regional reference centre for emerging infectious diseases of children in France (Necker hospital in Paris)
- meeting the criteria for Kawasaki disease.
Follow-up carried out until 15/05/2020.
Diagnosis:
Kawasaki disease:
according to the American Heart Association criteria for the presence of complete or incomplete Kawasaki disease. criteria proposed by Kanegaye et al. for Kawasaki disease shock syndrome of SARS-CoV-2 infection:
- RT-PCR testing of at least 2 nasopharyngeal swabs collected within 3 days of admission to rule out nosocomial infection.
- serological test for anti-SARS-CoV-2 IgG
- coronary artery dilatation: coronary artery diameter Z dimension between 2.0 and 2.5
- coronary aneurysm: coronary artery diameter Z rating greater than or equal to 2.5
- resistance to IV immunoglobulin treatment: persistence or recrudescence of fever in the period between 36 hours and 7 days after the end of the first injection.
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