May 15, 2020

Abdominal visceral infarction in patients with COVID-19, and an outbreak of severe Kawasaki-like disease in Italy

By Denise Baez

NEW YORK -- May 15, 2020 -- In today’s DG Alert, we cover abdominal visceral infarction in patients with coronavirus disease 2019 (COVID-19), and an outbreak of severe Kawasaki-like disease in Italy.

A small case series published in Emerging Infectious Diseases describes 3 patients with COVID-19 who developed abdominal viscera infarction.

All 3 patients were male, aged older than 52 years, and presented to the emergency department with symptoms associated with COVID-19. All patients tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), were hospitalised, and subsequently developed left/right flank pain or severe abdominal pain (details of each case are described fully in the article).

In patient 1, CT scan demonstrated a large right kidney arterial infarction. He was treated with low molecular weight heparin (LMWH) and discharged after 4 days. In patient 2, CT scan demonstrated large infarcted areas involving the spleen and the left kidney. He was treated with LMWH and discharged home after 7 days. In patient 3, CT scan demonstrated small bowel ischemia associated with massive splenic infarction. He underwent resection of the ischaemic bowel loop and splenectomy, was treated with heparin in continuous infusion, and was discharged from the intensive care unit 2 days later. As of May 9, he was still hospitalised but his condition was improving.

“The possibility of abdominal visceral infarction during COVID-19 has major implications in clinical practice,” wrote Giulia Besutti, MD, Azienda Unità Sanitaria Locale di Reggio Emilia–Istituto di Ricovero e Cura a Carattere Scientifico di Reggio Emilia (AUSL–IRCCS), Reggio Emilia, Italy. “First, when patients with COVID-19 report severe abdominal pain, visceral infarction should be considered in differential diagnosis and taken into account in laboratory and imaging diagnostic workups. Second, this finding should further prompt the scientific community to stress the need to routinely use low-molecular-weight heparin (LMWH) in patients with COVID-19 and to open the debate on the appropriate dosage. Finally, the prothrombotic state in patients with COVID-19 may justify therapeutic rather than prophylactic LMWH.”

In another study, published in The Lancet, Lucio Verdoni, MD, Hospital Papa Giovanni XXIII, Bergamo, Italy, and colleagues found a 30-fold increased incidence of Kawasaki disease in children shortly after the spread of SARS-CoV-2 to the Bergamo region of Italy.

In a period spanning 5 years (January 1, 2015-February 17, 2020), there were 19 cases of Kawasaki-like disease at the Hospital Papa Giovanni XXIII. However, in a period spanning only 2 months (February 18, 2020-April 20, 2020) -- shortly after the spread of SARS-CoV-2 -- there were 10 cases of Kawasaki-like disease at the hospital.

Children diagnosed before the pandemic were younger (mean age, 3.0 vs 7.5 years), had less cardiac involvement (2 vs 6), did not have Kawasaki Disease Shock Syndrome (0 vs 5) or Macrophage Activation Syndrome (MAS; 0 vs 5), and had less need for adjunctive steroid treatment (3 vs 8; P < 0.01 for all).

Nasopharyngeal and oropharyngeal swab sampling for SARS-CoV-2, available from February 24, 2020, was positive in 2 (20%) of the 10 patients from group 2. All patients were tested at least twice. Serology for SARS-CoV-2 antibodies, available from April 13, 2020, was performed in all 10 patients, and 8 (80%) were IgG positive; 3 were also IgM positive.

Two patients from group 1 diagnosed before the start of the epidemic were contacted and tested for SARS-CoV-2 antibodies, and both were negative.

To date, all patients in group 2 have been discharged, treatment with aspirin at an antiplatelet dose is ongoing, and a follow-up echocardiogram is scheduled at 8 weeks.

“In the past month we found a 30-fold increased incidence of Kawasaki-like disease,” the authors wrote. “Children diagnosed after the SARS-CoV-2 epidemic began showed evidence of immune response to the virus, were older, had a higher rate of cardiac involvement, and features of MAS. Outbreaks of Kawasaki-like disease might occur in countries affected by the SARS-CoV-2 pandemic, and might present outside the classic Kawasaki disease phenotype. This condition might be serious and requires prompt and more aggressive management. Future research on the cause of Kawasaki disease and similar syndromes should focus on immune responses to viral triggers.”

SOURCE: Emerging Infectious Diseases and The Lancet