Multisystem inflammatory syndrome associated with SARS-CoV-2 infection in 45 children: a first report from Iran

Abstract During the coronavirus disease 2019 (COVID-19) pandemic, a new phenomenon manifesting as a multisystem inflammatory syndrome in children (MIS-C) which has a similar clinical presentation to Kawasaki disease, toxic shock syndrome and severe sepsis has emerged. Although the number of MIS-C reports is increasing, rare reports in Asia is still available. To our knowledge, this study is the largest series of published MIS-C cases in Iran. We performed a retrospective study of all patients with case definition for MIS-C admitted to the three paediatric hospitals in Iran. All of these hospitals are located within the most active COVID-19 pandemic areas (Tehran, Qom and Mazandaran) in Iran. Demographic characteristics, clinical data, laboratory findings, imaging and echocardiographic findings, treatment and outcomes were collected. Between 7 March and 23 June 2020, 45 children were included in the study. The median age of children was 7 years (range between 10 months and 17 years). Common presenting symptoms include fever (91%), abdominal pain (58%), nausea/vomiting (51%), mucocutaneous rash (53%), conjunctivitis (51%) and hands and feet oedema (40%) with median duration of symptoms prior to presentation of 5 (interquartile range (IQR) 3, 7) days. Fifty-three percent of children showed lymphopaenia. Overall, the majority of cases at admission had markedly elevated inflammatory markers erythrocyte sedimentation rate (ESR) (95.5%) and C-reactive protein (CRP) (97%). Ferritin was abnormal in 11 out of 14 tested patients (73%), and it was highly elevated (>500 ng/ml) in 47% of cases. Median fibrinogen level was 210 (IQR 165, 291) mg/dl, D-dimer was 3909 (IQR 848, 4528) ng/ml and troponin was 0.6 (IQR 0.1, 26) ng/ml, respectively. Twenty out of 31 patients (64.5%) had hypoalbuminaemia. In addition, hyponatraemia was found in 64% of cases. Twenty-five patients (56%) presented with cardiac involvement and acute renal failure was observed in 13 cases (29%). Pleural, ascitic, ileitis and pericardial effusions were found in 18%, 11%, 4% and 2% of cases, respectively. In conclusion, this is a first large case series of hospitalised children who met criteria for MIS-C in Iran. There was a wide spectrum of presenting signs and symptoms; evidence of inflammation with abnormal values of CRP, ESR, D-dimer, ferritin and albumin; and multi-organ involvement.

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COVID-19 related multisystem inflammatory syndrome in children (MIS-C): a case series from a tertiary care pediatric hospital in Qatar

10.21203/rs.3.rs-124953/v1 ◽

2021 ◽

Author(s):

Mohammad Hasan ◽

Khaled Al Zubaidi ◽

Karim Diab ◽

Yahia Hejazi ◽

Sharon Bout-Tabaku ◽

...

Keyword(s):

Clinical Features ◽

Early Recognition ◽

Tertiary Care ◽

Case Series ◽

Case Definition ◽

Cardiac Biomarkers ◽

Medical Attention ◽

Laboratory Findings ◽

First Case ◽

Inflammatory Syndrome

Abstract Background: Multisystem Inflammatory Syndrome in Children (MIS-C) is a severe complication of coronavirus disease 2019 (COVID-19) in children, which is increasingly being reported worldwide. Here we report the first case series of 7 children diagnosed with MIS-C in Qatar. Methods: Clinical features and outcomes of COVID-19 positive patients admitted to Sidra Medicine, Qatar from June to October 2020, who met the WHO case definition for MIS-C were reviewed.Results: The mean age in our case series was 5.6 years, of which 71.4% were males. All patients were previously healthy but had a history of COVID-19 infection. Fever, rash, vomiting and abdominal pain were the most common symptoms (70%-100%). The average hospitalization was 12.9 days with no case fatalities. Laboratory findings included lymphopenia and thrombocytopenia in most patients, as well as evidence of coagulopathy and elevated inflammatory markers such as C-reactive protein, ferritin and procalcitonin. Many patients (71.4%) required inotropic support in intensive care, while only one required respiratory support. Although all patients had elevated cardiac biomarkers, cardiovascular involvement was observed in 42.9% of patients with one patient developing a giant coronary aneurysm. All patients received intravenous immunoglobulin (IVIG) and 86% of patients received corticosteroids, with two patients requiring treatment with IL-1 inhibitors.Conclusions: Our report is one of the first reports on MIS-C from Asia. Although clinical features and outcomes are not significantly different from those reported elsewhere, lack of case fatalities in our cohort may indicate that early recognition and prompt medical attention is necessary for a favorable outcome in MIS-C.

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Rhinolithiasis: A Misleading Entity

Allergy & Rhinology ◽

10.1177/2152656718783596 ◽

2018 ◽

Vol 9 ◽

pp. 215265671878359 ◽

Cited By ~ 4

Author(s):

Hayat Adib ◽

Mohamad Ali El Natout ◽

Georges Zaytoun ◽

Usamah Al Hadi

Keyword(s):

Wide Spectrum ◽

Medical Center ◽

Treatment Options ◽

Case Series ◽

Signs And Symptoms ◽

American University ◽

American University Of Beirut ◽

Presenting Symptoms ◽

Diagnostic Modalities ◽

High Index Of Suspicion

Introduction Rhinolithiasis is a rare entity; it entails a stone located in the nasal cavity. The entity presents with different signs and symptoms that can be easily confused with other more common clinical entities such as chronic rhinosinusitis. However, it can also mimic sinonasal tumors, making its proper diagnosis crucial. Materials and Methods In this article, we present a case series of 15 patients over the past 13 years between 2002 and 2015 who were seen in the clinics at the American University of Beirut Medical Center. We will shed light on the common presenting symptoms, physical examination findings, proper diagnostic modalities, and treatment options. Our data will be compared to the literature. Conclusion Rhinolithiasis could present with a wide spectrum of signs and symptoms and could be overlooked or mistaken for other diagnosis such as sinusitis or malignancy. It could be differentiated from other entities by rigid nasal endoscopy and computed tomography scan. The diagnosis of rhinolithiasis requires a high index of suspicion.

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COVID-19 related multisystem inflammatory syndrome in children (MIS-C): a case series from a tertiary care pediatric hospital in Qatar

BMC Pediatrics ◽

10.1186/s12887-021-02743-8 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Mohammad Rubayet Hasan ◽

Khaled Al Zubaidi ◽

Karim Diab ◽

Yahia Hejazi ◽

Sharon Bout-Tabaku ◽

...

Keyword(s):

Clinical Features ◽

Early Recognition ◽

Tertiary Care ◽

Case Series ◽

Case Definition ◽

Cardiac Biomarkers ◽

Medical Attention ◽

Laboratory Findings ◽

First Case ◽

Inflammatory Syndrome

Abstract Background Multisystem Inflammatory Syndrome in Children (MIS-C) is a severe complication of coronavirus disease 2019 (COVID-19) in children, which is increasingly being reported worldwide. Here we report the first case series of 7 children diagnosed with MIS-C in Qatar. Methods Clinical features and outcomes of COVID-19 positive patients admitted to Sidra Medicine, Qatar from June to October 2020, who met the WHO case definition for MIS-C were reviewed. Results The mean age in our case series was 5.6 years, of which 71.4% were males. All patients were previously healthy but had a history of COVID-19 infection. Fever, rash, vomiting and abdominal pain were the most common symptoms (70–100%). The average hospitalization was 12.9 days with no case fatalities. Laboratory findings included lymphopenia and thrombocytopenia in most patients, as well as evidence of coagulopathy and elevated inflammatory markers such as C-reactive protein, ferritin and procalcitonin. Many patients (71.4%) required inotropic support in intensive care, while only one required respiratory support. Although all patients had elevated cardiac biomarkers, cardiovascular involvement was observed in 42.9% of patients with one patient developing a giant coronary aneurysm. All patients received intravenous immunoglobulin (IVIG) and 86% of patients received corticosteroids, with two patients requiring treatment with IL-1 inhibitors. Conclusions Our report is one of the first reports on MIS-C from Asia. Although clinical features and outcomes are not significantly different from those reported elsewhere, lack of case fatalities in our cohort may indicate that early recognition and prompt medical attention is necessary for a favorable outcome in MIS-C.

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Ocular and Systemic Manifestations in Paediatric Multisystem Inflammatory Syndrome Associated with COVID-19

Journal of Clinical Medicine ◽

10.3390/jcm10132953 ◽

2021 ◽

Vol 10 (13) ◽

pp. 2953

Author(s):

Tzu-Chen Lo ◽

Yu-Yen Chen

Keyword(s):

Serum Antibody ◽

Case Series ◽

Pooled Analysis ◽

Rt Pcr ◽

Laboratory Findings ◽

Systemic Manifestations ◽

Polymerase Chain ◽

Exposure History ◽

Systemic Symptoms ◽

Inflammatory Syndrome

This study aimed to achieve a better understanding of the epidemiological and clinical characteristics of multisystem inflammatory syndrome in children (MIS-C) following coronavirus disease 2019 (COVID-19). We searched PubMed and Embase between December 2019 and March 2021 and included only peer-reviewed clinical studies or case series. The proportions of patients who had conjunctivitis, systemic symptoms/signs (s/s), Kawasaki disease (KD), and exposure history to suspected/confirmed COVID-19 cases were obtained. Moreover, positive rates of the nasopharyngeal real-time reverse transcriptase polymerase chain reaction (RT-PCR) and serum antibody for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were recorded. Overall, 32 studies with 1458 patients were included in the pooled analysis. Around half of the patients had conjunctivitis. The five most common systemic manifestations were fever (96.4%), gastrointestinal s/s (76.7%), shock (61.5%), rash (57.1%), and neurological s/s (36.8%). Almost one-third presented complete KD and about half had exposure history to COVID-19 cases. The positivity of the serology (82.2%) was higher than that of the nasopharyngeal RT-PCR (37.0%). MIS-C associated with COVID-19 leads to several features similar to KD. Epidemiological and laboratory findings suggest that post-infective immune dysregulation may play a predominant role. Further studies are crucial to elucidate the underlying pathogenesis.

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Varied presentations of cutaneous vasculitis: a case series

International Journal of Research in Medical Sciences ◽

10.18203/2320-6012.ijrms20203465 ◽

2020 ◽

Vol 8 (8) ◽

pp. 3066

Author(s):

Pinky Gupta ◽

Shweta Ganorkar ◽

Surekha Bhalekar ◽

Rajiv Rao

Keyword(s):

Blood Vessels ◽

Histopathological Examination ◽

Wide Spectrum ◽

Systemic Disease ◽

Case Series ◽

Clinical Severity ◽

Cutaneous Vasculitis ◽

Venous Stasis ◽

Duration Of Symptoms ◽

Organ Systems

Vasculitis involves a wide spectrum of clinicopathological process with reactive damage to the involved blood vessels. There is loss of vessel integrity instigating haemorrhage & luminal compromise leading to ischemia and necrosis of the tissue supplied by the involved vessels. It may affect varied size and type of blood vessels at different locations. It may be primary or secondary to systemic disease. It may involve a single organ like skin or may involve different organ systems at the same time. This case series include six cases of cutaneous vasculitis affecting different organs with varied presentations. Skin biopsies of six patients with unusual presentations were studied. Their complete history, physical examinations, laboratory investigations including serology were analysed and correlated with histopathological findings. The patients presented with different duration of symptoms varying from as short as 15 days to 1 year. Skin lesions were present in all cases while cardiac manifestation was seen in one. Serology and autoimmune disease markers were negative in all cases except one. However, histopathological features were in concordance with the clinical diagnosis of vasculitis. They were further classified as vasculitis secondary to Churg Strauss syndrome, venous stasis, Henoch Schonlein purpura or leucocytoclastic vasculitis.Vasculitis though a rare disease may manifest as an acute or chronic condition. It needs timely diagnosis by histopathological examination to aid in further management. It is important to assess the clinical severity in primary and secondary vasculitis, as it determines morbidity and mortality.

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Intradural spinal arachnoid cyst resection: implications of duraplasty in a large case series

Journal of Neurosurgery Spine ◽

10.3171/2017.8.spine17605 ◽

2018 ◽

Vol 28 (5) ◽

pp. 548-554

Author(s):

Ziev B. Moses ◽

Gabriel N. Friedman ◽

David L. Penn ◽

Isaac H. Solomon ◽

John H. Chi

Keyword(s):

Case Series ◽

Signs And Symptoms ◽

Symptom Improvement ◽

Preoperative Pain ◽

Lumbosacral Region ◽

Duration Of Symptoms ◽

Large Patient ◽

Large Case Series ◽

Pain Symptoms ◽

Large Case

OBJECTIVEOptimal diagnosis and management strategies for intradural spinal arachnoid cysts (SACs) are still unresolved given the rare nature of this entity, with few large case series and virtually no statistical analyses of patient characteristics in the literature. Here, the authors studied a large patient cohort with these lesions to determine whether pre- or postoperative attributes could be used to aid in either diagnosis or prognosis.METHODSA chart review was completed at a single institution for the period from 2002 to 2016 to determine the preoperative characteristics and postoperative outcomes of 21 patients with exclusively intradural SACs. Patients were assessed for symptoms such as weakness, pain, sensory changes, bowel and/or bladder dysfunction, and gait changes. Postoperatively, patients were analyzed for symptom improvement, complication occurrence, and duration of follow-up.RESULTSApproximately two-thirds of the patients in this series had developed SACs idiopathically, and the mean duration of symptoms prior to diagnosis was 15 months among all patients. A slight majority (57%) underwent CT myelography in the course of diagnosis, and a quarter of the patients had a syrinx. There was a statistically significant association between location of the SAC and number of presenting signs and symptoms; that is, patients with cysts in the lumbosacral region had more symptoms than those with cysts at the cervical or thoracic levels (p = 0.031). Overall, outcomes were largely positive, with approximately 60%–70% of patients experiencing postoperative improvement in symptoms, with motor weakness showing the highest response rate (71%) and pain symptoms the least likely to subside (50%). In the cohort with preoperative pain, those who had undergone expansile duraplasty were significantly more likely to experience relief of their pain symptoms (p = 0.028), which may have been a result of the superior restoration of cerebrospinal fluid pathways allowing for more adequate reduction in compression.CONCLUSIONSIn this large case series on intradural SACs, new light has been shed on aspects of both pre- and postoperative care for patients with these rare lesions. Specifically, the authors revealed that lumbosacral intradural SACs may be associated with a higher disease burden and that patients who undergo expansile duraplasty may have an increased likelihood of experiencing postoperative pain relief.

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Acute onset hemoglobinemia and/or hemoglobinuria and sequelae following Rho(D) immune globulin intravenous administration in immune thrombocytopenic purpura patients

Blood ◽

10.1182/blood.v95.8.2523.008k13_2523_2529 ◽

2000 ◽

Vol 95 (8) ◽

pp. 2523-2529 ◽

Cited By ~ 1

Author(s):

Ann Reed Gaines

Keyword(s):

Immune Globulin ◽

Health Care Professionals ◽

Immune Thrombocytopenic Purpura ◽

Case Series ◽

The United States ◽

Reporting Rate ◽

Case Definition ◽

Laboratory Findings ◽

Thrombocytopenic Purpura ◽

First Case

Rho(D) immune globulin intravenous (anti-D IGIV) was licensed by the United States Food and Drug Administration (FDA) in March 1995 to treat patients with immune thrombocytopenic purpura (ITP). Anti-D IGIV induces extravascular hemolysis, an expected adverse reaction that is consistent with the presumed mechanism of action. Between licensure and April 1999, the FDA received 15 reports of hemoglobinemia and/or hemoglobinuria following anti-D IGIV administration that met the case definition for this review. The mechanism responsible for hemoglobinemia and/or hemoglobinuria is unexplained. Review of these reports was prompted by the seriousness and the unexpectedness of treatment-associated sequelae experienced by 11 patients. Of these patients, 7 developed sufficient onset or exacerbation of anemia that orders were written for packed red blood cell transfusions, although only 6 patients were transfused. Eight patients experienced the onset or exacerbation of renal insufficiency, and 2 patients underwent dialysis. One patient died due to complications of exacerbated anemia. Six patients experienced 2 to 3 sequelae. Absent validated incidence data, a 1.5% estimated incidence rate from published clinical trial data and a 0.1% estimated reporting rate from FDA and drug utilization data were calculated for reported cases of hemoglobinemia and/or hemoglobinuria. This review presents the first case series of anti-D-IGIV–associated hemoglobinemia and/or hemoglobinuria and provides pretreatment and posttreatment clinical and laboratory findings of the case series patients. The primary purpose of this review is to increase awareness of this potentially serious occurrence among physicians and health care professionals who manage ITP patients treated with anti-D IGIV, thereby enabling prompt recognition and treatment of sequelae.

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Signs and symptoms associated with synthetic cannabinoid toxicity: systematic review

Australasian Psychiatry ◽

10.1177/1039856216663733 ◽

2016 ◽

Vol 24 (6) ◽

pp. 598-601 ◽

Cited By ~ 21

Author(s):

Julie Courts ◽

Virginia Maskill ◽

Andrew Gray ◽

Paul Glue

Keyword(s):

Systematic Review ◽

Emergency Services ◽

Case Reports ◽

Synthetic Cannabinoids ◽

Case Series ◽

Signs And Symptoms ◽

Synthetic Cannabinoid ◽

Symptom Reporting ◽

Presenting Symptoms ◽

Study Population

Aims: Use of synthetic cannabinoids is associated with significant physical and psychological harms. This research quantified reported toxicities from published reports and assessed the influence of size of the reported study population on rates of symptom reporting. Methods: Systematic review of published case reports and case series of toxicity associated with use of synthetic cannabinoids. Results: Symptoms associated with synthetic cannabinoid toxicity were reported for 3695 individuals, predominantly young males. Symptoms included physiological (e.g. tachycardia, hypertension, nausea/vomiting), emotional (e.g. agitation, irritability, paranoia), behavioural (e.g. drowsiness, aggression) and perceptual (e.g. hallucinations) domains. Most common symptoms were tachycardia (30.2% of cases), agitation (13.5%), drowsiness (12.3%), nausea/vomiting (8.2%) and hallucinations (7.6%). Death or serious medical complications were uncommon (e.g. death 0.2%, stroke 0.1%, myocardial infarction 0.09%). Case reports/smaller case series ( n<10) reported statistically significantly higher rates for 29/34 symptoms than larger case series ( n≥10), which could represent selection bias. Conclusions: Symptoms of synthetic cannabinoid toxicity are variable and cover a number of physical and psychological domains. Symptom reporting varies by study population size. Due to the variable presenting symptoms of synthetic cannabinoid toxicity, clinicians in emergency services should consider synthetic cannabinoid toxicity when evaluating young adult male patients presenting with unexplained agitation or cardiovascular symptoms.

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Case Report: Case Series of Children With Multisystem Inflammatory Syndrome Following SARS-CoV-2 Infection in Switzerland

Frontiers in Pediatrics ◽

10.3389/fped.2020.594127 ◽

2021 ◽

Vol 8 ◽

Author(s):

Athina Fouriki ◽

Yves Fougère ◽

Caroline De Camaret ◽

Géraldine Blanchard Rohner ◽

Serge Grazioli ◽

...

Keyword(s):

Clinical Features ◽

Toxic Shock Syndrome ◽

Case Series ◽

Serum Levels ◽

Intravenous Immunoglobulins ◽

Toxic Shock ◽

Laboratory Findings ◽

First Line Therapy ◽

Ivig Resistance ◽

Inflammatory Syndrome

Since the beginning of the severe SARS-CoV-2 pandemic, an increasing number of countries reported cases of a systemic hyperinflammatory condition defined as multi-system inflammatory syndrome in children (MIS-C). The clinical features of MIS-C can be an overlap of Kawasaki Disease (KD), Toxic Shock Syndrome (TSS), Macrophage Activation Syndrome (MAS), or have often an acute abdominal presentation. Intravenous immunoglobulin (IVIG) is recommended as first line therapy in KD. Recent evidence suggests intravenous immunoglobulins (IVIG) resistance in some cases of SARS-CoV-2 related MIS-C, thereby questioning the benefit of immunomodulators such as IL-1 or IL-6 blocking agents. We report on a cohort of 6 Swiss children with SARS-CoV2 related MIS-C presenting with clinical features compatible with Incomplete KD and Toxic Shock Syndrome associated to a cytokine storm. Serum cytokine profile investigations showed increased IL1RA levels (8 to 22-fold) in 5 of the 6 patients (one patient had not been tested), whereas, IL-6 serum levels were increased only in the 3 patients of the 6 who were tested. With exception of one patient who had only benefited by Anakinra, all patients received at least one dose of IVIG. One patient has only received Anakinra with favorable evolution, and three patients had also a steroid treatment. In addition to all this anti-inflammatory medication two patients have also received one dose of anti-IL6. In conclusion, our case series reports on clinical and laboratory findings of most of Swiss cases with MIS-C and suggests the use of Anakinra as an alternative to steroids in these children, most of whom presented with high IL-1RA levels.

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Examining Multisystem Inflammatory Syndrome in Children (MIS-C) Amidst the SARS-CoV-2 Pandemic

Proceedings of IMPRS ◽

10.18060/24625 ◽

2020 ◽

Vol 3 ◽

Author(s):

Matthew Harris ◽

Dibyadyuti Datta ◽

Katrina Co ◽

Samina Bhumbra ◽

Chandy John

Keyword(s):

Gastrointestinal Symptoms ◽

Care Patient ◽

Common Finding ◽

Laboratory Findings ◽

Patient Reports ◽

Reactive Protein ◽

Presenting Symptoms ◽

Literature Searches ◽

Clinical Presentations ◽

Inflammatory Syndrome

Background/Objective: Multisystem Inflammatory Syndrome in Children (MIS-C) is a novel and rare pediatric post-infectious complication associated with SARS-CoV-2 infection. First described in April 2020, our scope of understanding is limited but rapidly growing. Our objective was to construct a literature repository containing MIS-C patient data from available publications to serve as a curated collection of literature on the topic. This collection facilitates direct comparison of data from various sources, allowing for informed discussions of MIS-C. Methods: A database search strategy was developed for locating primary literature on MIS-C available on PubMed, medRxiv, and bioRxiv databases. Literature searches were conducted from June 26, 2020 to July 10, 2020. Search results were tested against several criteria before inclusion in the repository. Intrinsic limitations for each publication were identified during quality review. Data from each source was organized in a standardized format for analysis. Results: 26 publications met inclusion criteria, 9 (35%) in pre-print status. 742 cases of probable or confirmed MIS-C were reported. Individuals ranged from 7 months to 20 years old and 58% were male. By SARS-CoV-2 PCR testing, 257/707 (36%) were positive while 485/597 (81%) were positive by SARS-CoV-2 serology testing. Common presenting symptoms included fever, one or more gastrointestinal symptoms, and rash. Laboratory testing varied, but elevated C-Reactive Protein was the most common finding (411/689, 60%), followed by elevated D-Dimer (214/470, 46%). Echocardiogram findings included coronary artery dilation in 38/414 (9%) and decreased ejection fraction in 177/330 (54%). Treatments offered included intravenous immunoglobulin (486/742, 65%), followed by steroids (376/742, 51%). 450/577 (78%) required ICU care. Patient outcomes were generally favorable, with 11 (1%) fatalities at the time of publication. Conclusion/Impact: Our repository of MIS-C literature compiled patient reports to identify common clinical presentations and laboratory findings. Future literature reviews are necessary to elucidate mechanisms associated with MIS-C and establish diagnostic criteria.

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