May 8, 2020

SARS-CoV-2 may manifest as hyperinflammatory shock in asymptomatic children

By Denise Baez

NEW YORK -- May 8, 2020 -- Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may manifest as a hyperinflammatory syndrome with multiorgan involvement similar to Kawasaki disease shock syndrome in asymptomatic children, according to a case series published in The Lancet.

Shelley Riphagen, MD, Evelina London Children's Hospital Paediatric Intensive Care Unit, London, United Kingdom, and colleagues reported that during a period of 10 days in mid-April, they treated 8 children aged 4 to 14 years (5 boys) with hyperinflammatory shock, showing features similar to atypical Kawasaki disease, Kawasaki disease shock syndrome, or toxic shock syndrome.

Children presented with fever, variable rash, conjunctivitis, peripheral oedema, and generalised extremity pain with significant gastrointestinal symptoms, including abdominal pain, diarrhoea, and vomiting. Laboratory tests showed elevated concentrations of C-reactive protein, procalcitonin, ferritin, triglycerides, and D-dimers. 

Patients were given intravenous immunoglobulin 2 g/kg in the first 24 hours and antibiotics; 6 children received aspirin.

All children progressed to warm, vasoplegic shock that was refractive to volume resuscitation, eventually requiring noradrenaline and milrinone for haemodynamic support. Most of the children had no significant respiratory involvement, although 7 of the children required mechanical ventilation for cardiovascular stabilisation.

Four children had known family exposure to coronavirus disease 2019 (COVID-19) and all tested negative for SARS-CoV-2 on broncho-alveolar lavage or nasopharyngeal aspirates. In 7 children, no pathological organism was identified; adenovirus and enterovirus were isolated in 1 child.

A common echocardiographic finding was echo-bright coronary vessels, which progressed to giant coronary aneurysm in 1 patient within a week of discharge from the paediatric intensive care unit (PICU). One child developed arrhythmia with refractory shock, requiring extracorporeal life support, and died from a large cerebrovascular infarct.

All of the children were discharged from the PICU 4 to 6 days after admission. After discharge, 2 of the children have tested positive for SARS-CoV-2 (including the child who died, in whom SARS-CoV-2 was detected post mortem). All children are receiving ongoing surveillance for coronary abnormalities.

“We suggest that this clinical picture represents a new phenomenon affecting previously asymptomatic children with SARS-CoV-2 infection manifesting as a hyperinflammatory syndrome with multiorgan involvement similar to Kawasaki disease shock syndrome. The multifaceted nature of the disease course underlines the need for multispecialty input (intensive care, cardiology, infectious diseases, immunology, and rheumatology),” the authors wrote. 

“As this correspondence goes to press, 1 week after the initial submission, the Evelina London Children’s Hospital paediatric intensive care unit has managed more than 20 children with similar clinical presentation -- the first 10 of whom tested positive for antibody (including the original 8 children in the cohort described above).”

SOURCE: The Lancet