May 21, 2020

Treatment with immune globulin, steroids gives positive outcomes in children with COVID-related multi-system inflammatory syndrome

Immune globulin therapy and steroids restored heart function in the majority of children with COVID-related multisystem inflammatory syndrome, according to a study published in Circulation.

Zahra Belhadjer, MD, Université de Paris, Paris, France, and colleagues retrospectively collected and analyzed clinical, biological, therapeutic and early outcome data for children admitted to pediatric intensive care units in France and Switzerland from March 22 to April 30, 2020, with fever (>38.5°C), cardiogenic shock or acute left ventricular dysfunction (left ventricular ejection fraction <50%) with inflammatory state (C-reactive protein > 100 mg/mL).

This analysis included 35 children (ages 2 to 16; median age of 10 years). Thirty-one (88.5%) children tested positive for SARS-CoV-2 infection, and none of the children had underlying cardiovascular disease. Co-morbidities were limited, and 17% of patients were overweight (n=6). All patients presented with fever and asthenia lasting approximately 2 days, and 83% of patients (n=29) presented with gastrointestinal symptoms.

Left ventricular systolic dysfunction was present in all patients in association with low systolic blood pressure. Left ventricular ejection fraction was <30% in one third of patients (n=10). Almost all patients required respiratory assistance (n= 33). Ten patients required mechanical circulatory assistance with veno-arterial extracorporeal membrane oxygenation (V-A ECMO).

The majority of the patients (n=28) received intravenous inotropic support. First line treatment was intravenous immune globulin in 25 patients. One patient was treated with repeated intravenous immune globulin due to persistent fever 48 hours after first infusion. Twelve patients received intravenous steroids having been considered high-risk patients with symptoms similar to an incomplete form of Kawasaki disease. Three children received treatment with an interleukin 1 receptor antagonist (anakinra) because of persistent severe inflammatory state. In addition, 23 patients were treated with therapeutic dose heparin. 

Clinical evolution has been favorable for 28 patients, with 7 patients who were either still in the hospital or with residual left ventricular dysfunction. Complete recovery of left ventricular function was observed in 25 (71%) patients at a median delay of 2 days after admission. Five patients had residual mild to moderate left ventricular systolic dysfunction with a left ventricular ejection fraction >45% at last follow-up (median 12 days). None had a thrombotic or embolic event. No deaths were reported and all patients treated with ECMO were successfully weaned.

The authors noted that the majority of patients recovered within a few days following intravenous immune globulin, with adjunctive steroid therapy used in one third. “Treatment with immune globulin appears to be associated with recovery of left ventricular systolic function,” they concluded.

SOURCE: Circulation