scholarly journals Sinus bradycardia as the initial manifestation of multisystem inflammatory syndrome in children

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
K Gonzalez ◽  
I Mendoza Britto ◽  
M Mateu ◽  
E Marcano ◽  
J De Izaguirre ◽  
...  
Keyword(s):  
Clinical Laboratory ◽  
Sinus Bradycardia ◽  
Case Series ◽  
Intravenous Immunoglobulins ◽  
Cardiovascular Complications ◽  
Laboratory Evaluation ◽  
Initial Manifestation ◽  
Funding Sources ◽  
Coronary Abnormalities ◽  
Inflammatory Syndrome

Abstract Background While cardiovascular complications, including arrhythmias are now a recognized manifestation of Multisystem inflammatory syndrome in children (MIS-C), there are no reports of primary bradycardia preceding the clinical presentation. We sought to describe a case series of sinus bradycardia as an initial manifestation of MIS-C. Methods We included a series of 10 consecutive patients with confirmed COVID-19 who met WHO and CDC criteria for MIS-C, who developed sinus bradycardia with a heart rate measured in the awake state that was below the normal range for age for children, as an initial manifestation of the disease, in a prospective observational multicenter study. Patients underwent clinical, laboratory evaluation, ECG, Holter, telemetry, echocardiogram, chest X Ray, and a chest CT scan. Results Of the 10 patients included, 6 were male, with a mean age of 6.52±5.35 years, range 4 months to 14 years. All cases were Hispanic. Bradycardia was transient and did not merit treatment. Coronary abnormalities were noted in 6 cases; 4 patients had mild coronary ectasia; 9 patients had pericardial effusion with no evidence of tamponade. All patients had a mild clinical course; none had shock, heart failure, the need for mechanical ventilation, or died. All blood markers (Troponin, BNP, Platelet count, C-reactive protein, D-dimer, Ferritin) returned to normal levels by discharge/follow-up with a favorable outcome including resolution of coronary dilatation in all but 2 in which aneurysm persisted. Treatment All patients received steroids and low-weight-molecular heparin 10 patients, 8 aspirin and 8 intravenous immunoglobulins. Conclusion Sinus bradycardia may be the initial manifestation of MIS-C, usually transient and mild. Physicians should be aware of this presentation. FUNDunding Acknowledgement Type of funding sources: None. Kid, MIS-C. Bradycardia/Atrial Rhythm

scholarly journals Multi-Inflammatory Syndrome in Children: A View into Immune Pathogenesis from a Laboratory Perspective

2021 ◽  
Author(s):  
Mary Kathryn Bohn ◽  
Peter Yousef ◽  
Shannon Steele ◽  
Lusia Sepiashvili ◽  
Khosrow Adeli
Keyword(s):  
Clinical Laboratory ◽  
Disease Onset ◽  
Cardiovascular Complications ◽  
School Age Children ◽  
Inflammatory Disorder ◽  
Brain Natriuretic Peptides ◽  
Circulating Autoantibodies ◽  
Long Term Impact ◽  
Inflammatory Syndrome

Abstract Background Multi-inflammatory syndrome in children (MIS-C) is a novel and rare inflammatory disorder associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in school-age children. Reports in the past year have suggested a multi-system pathophysiology characterized by hyperinflammation, gastrointestinal distress, and cardiovascular complications. Clinical laboratory investigations, including routine blood testing for inflammatory (e.g., CRP, ferritin) and cardiac (e.g., troponin, brain natriuretic peptides) markers have provided insight into potential drivers of disease pathogenesis, highlighting the role of the laboratory in the differential diagnosis of patients presenting with similar conditions (e.g., Kawasaki Disease, Macrophage Activating Syndrome). Content While few studies have applied high-dimensional immune profiling to further characterize underlying MIS-C pathophysiology, much remains unknown regarding predisposing risk factors, etiology, and long-term impact of disease onset. The extent of autoimmune involvement is also unclear. In the current review, we summarize and critically evaluate available literature on potential pathogenic mechanisms underlying MIS-C onset and discuss the current and anticipated value of various laboratory testing paradigms in MIS-C diagnosis and monitoring. Summary From initial reports, it is clear that MIS-C has unique inflammatory signatures involving both adaptive and innate systems. Certain cytokines, inflammatory markers, and cardiac markers assist in the differentiation of MIS-C from other hyperinflammatory conditions. However, there are still major gaps in our understanding of MIS-C pathogenesis, including T cell, B cell, and innate response. It is essential that researchers not only continue to decipher initial pathogenesis but also monitor long-term health outcomes, particularly given observed presence of circulating autoantibodies with unknown impact.

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

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.

scholarly journals 305. Cholecystitis as a Possible Immunologic Consequence of COVID-19; Case Series from a Large Healthcare System

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S258-S259
Author(s):  
Anna Jacobs ◽  
Christopher Polk ◽  
Mindy Sampson ◽  
Banks Kooken ◽  
Thomas Ludden ◽  
...  
Keyword(s):  
Immune Activation ◽  
Chart Review ◽  
Clinical Laboratory ◽  
Case Series ◽  
Panel Member ◽  
Retrospective Chart Review ◽  
Patient Characteristics ◽  
Biliary Disease ◽  
Inflammatory Syndrome ◽  
Research Grant

Abstract Background Gastrointestinal manifestations are commonly seen in COVID-19 disease with up to 50% of patients reporting nausea or diarrhea. Cholecystitis has been described in rare cases related to COVID-19, possibly in consequence of immune activation, but biliary disease from SARS-CoV-2 infection is not well described. We examined a case series of patients with both COVID-19 and cholecystitis at our institution. Methods We performed a retrospective chart review of all patients with a diagnosis of cholecystitis within 3 months of SARS-CoV-2 infection; looking at clinical, laboratory, and radiographic characteristics of this population. Results 30 individuals were identified with a diagnosis of cholecystitis within 3 months of diagnosis of SARS-CoV-2 infection. Most patients presenting with cholecystitis were female and obese (see Table 1). 14 individuals were diagnosed with SARS-CoV-2 infection during the same presentation as their cholecystitis diagnosis, usually as part of pre-operative screening. Of 16 individuals diagnosed with SARS-CoV-2 prior to their cholecystitis presentation, a mean of 24 and 17 days elapsed between SARS-CoV-2 infection and cholecystitis symptom onset and radiographic diagnosis, respectively (see Figure 1). Most of these patients had mild respiratory disease, with only 9 developing an oxygen requirement, and only 3 requiring mechanical ventilation. While 17 patients were treated surgically for their cholecystitis, this did not appear to impact symptom resolution. Table 1. Patient Characteristics Figure 1. Time between COVID-19 and Cholecystitis Conclusion Cholecystitis may be an uncommon complication of COVID-19 disease. Cholecystitis may manifest most often 2-4 weeks following SARS-CoV-2 infection. This timing is similar to that in Multisystem Inflammatory Syndrome following SARS-CoV-2 infection and given similarities in timing to we hypothesize that cholecystitis in our patients could be driven by immune activation. Disclosures Christopher Polk, MD, Atea (Research Grant or Support)Gilead (Advisor or Review Panel member, Research Grant or Support)Humanigen (Research Grant or Support)Regeneron (Research Grant or Support) Mindy Sampson, MD, Regeneron (Grant/Research Support) Catherine Passaretti, MD, Nothing to disclose

scholarly journals Bradycardia associated with Multisystem Inflammatory Syndrome in Children with COVID-19: a case series

2021 ◽  
Author(s):  
Gian Paolo Ciccarelli ◽  
Eugenia Bruzzese ◽  
Gaetano Asile ◽  
Edoardo Vassallo ◽  
Luca Pierri ◽  
...  
Keyword(s):  
Left Ventricular Dysfunction ◽  
Ventricular Dysfunction ◽  
Myocardial Dysfunction ◽  
Sinus Bradycardia ◽  
Gastrointestinal Symptoms ◽  
Case Series ◽  
Left Ventricular ◽  
Cardiac Monitoring ◽  
History Of ◽  
Inflammatory Syndrome

Abstract Background Multisystem Inflammatory Syndrome in Children (MIS-C) is a rare life-threatening clinical condition that can develop in patients younger than 21 years of age with a history of infection/exposure to Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The cardiovascular system is a main target of the inflammatory process that frequently causes myocardial dysfunction, myopericarditis, coronary artery dilation, hypotension, and shock. MIS-C-associated myocarditis is usually characterized by fever, tachycardia, nonspecific ECG abnormalities and left ventricular dysfunction, but serious tachyarrhythmias may also occur. We report 2 cases of patients with MIS-C-associated myocarditis who developed severe bradycardia. Case summary Two female adolescents with recent history of COVID-19 were initially hospitalized for long-lasting high-grade fever and severe gastrointestinal symptoms. Both patients were diagnosed with MIS-C-associated myocarditis for elevation of markers of myocardial injury (mean highly-sensitive cardiac Troponin 2663 pg/ml, mean NT-pro-BNP 5097 pg/ml) and left ventricular dysfunction, which was subsequently confirmed by cardiac magnetic resonance. Both patients developed a severe sinus bradycardia (lowest HR 36 and 42, respectively), that appeared refractory to the treatment with intravenous Methylprednisolone and Immunoglobulins, despite a clinical and biochemical improvement. The use of Anakinra (a recombinant IL-1 receptor antagonist), was associated with a rapid improvement of cardiac rhythm and excellent clinical outcome at 6 months follow-up. Discussion In patients with MIS-C-associated myocarditis, a continuous cardiac monitoring is mandatory to promptly identify potential conduction abnormalities. Adolescents may present bradycardia as a rhythm complication. We experienced a rapid recovery after treatment with Anakinra, to be considered as add-on therapy in cases refractory to standard anti-inflammatory treatment.

scholarly journals Mortality and Clinical Characteristics of Multisystem Inflammatory Syndrome in Children (MIS-C) associated with COVID-19 in critically ill patients: an observational multicenter study (MISCO STUDY)

2021 ◽  
Author(s):  
Lorena Acevedo ◽  
Byron Enrique Piñeres-Olave ◽  
Laura Fernanda Niño-Serna ◽  
Liliana Mazillo-Vega ◽  
Ivan Jose Ardila Gómez ◽  
...  
Keyword(s):  
Critically Ill ◽  
Clinical Characteristics ◽  
Clinical Laboratory ◽  
Myocardial Dysfunction ◽  
Cardiovascular Complications ◽  
High Income ◽  
Critically Ill Children ◽  
Middle Income ◽  
One Year ◽  
Inflammatory Syndrome

Abstract Background The clinical presentation and severity of Multisystem Inflammatory Syndrome in Children associated with COVID-19 is widespread and presents a very low mortality rate in highincome countries. This research describes the clinical characteristics of MIS-C in critically ill children in middle-income countries compared to described series in high-income countries along with the factors associated with mortality and worse outcomes. Methods An observational cohort study was conducted in 14 PICUs in Colombia between April 01, 2020 and January 31, 2021. Patient´s age ranged between one month and 18 years and they met the requirements set forth by WHO for MIS-C. Results There were seventy-eight children in this study. The median age was seven years (IQR 1- 11), 18% (14/78) were under one year old, and 56% were male. Thirty-five percent (29/78) were obese or overweight. The PICU stay was six days (IQR 4-7), and 100% had a fever on admission lasting five days (IQR 3.7-6). Seventy percent (55/78) had diarrhea, and 87% (68/78) had shock or myocardial dysfunction (78%). Compared to the United Kingdom (UK) study, there were more children under the age of five (37% vs. 10%; p=0.004), and there was a higher frequency of obesity (29.5% vs. 10%; p=0.008). With regard to the US study, there was more lymphadenopathy (23% vs. 13%; p=0.02), diarrhea (70.5% vs. 53%; p=0.001), lymphopenia (64% vs. 35%; p=0.001), shock (87% vs. 35%; p=0.001), elevated troponin (51% vs. 31%; p=0.006) and elevated proBNP (82% vs 43%; p=0.001), as well as greater mortality (9% vs 1.8%; p=0.001). The group that did not survive had a longer duration of the disease until admission to the PICU (6 days vs. 5 days; p = 0.003), more frequency of ferritin above 500 ngr/mL (100% vs. 45%; p = 0.012) and more cardiovascular complications (100% vs. 54%; p = 0.019) compared to the group that survived. Conclusions Multisystem Inflammatory Syndrome in Children due to SARS-CoV-2 in critically ill children living in a middle-income country has some clinical, laboratory, and echocardiographic characteristics similar to those described in high-income countries. It was observed inflammatory response, and cardiovascular involvement were conditions that, added to the difficulties in accessing healthcare systems in countries with limited resources, may explain the higher mortality seen in these children.

scholarly journals Multisystem inflammatory syndrome (MIS-C) in Pakistani children: A description of the phenotypes and comparison with historical cohorts of children with Kawasaki disease and myocarditis

PLoS ONE ◽  
2021 ◽  
Vol 16 (6) ◽  
pp. e0253625
Author(s):  
Shazia S. Mohsin ◽  
Qalab Abbas ◽  
Devyani Chowdhary ◽  
Farah Khalid ◽  
Abdul Sattar Sheikh ◽  
...  
Keyword(s):  
Kawasaki Disease ◽  
Clinical Laboratory ◽  
Tertiary Care ◽  
Viral Myocarditis ◽  
Intravenous Immunoglobulins ◽  
Left Ventricular ◽  
World Health ◽  
Fulminant Myocarditis ◽  
Severe Left Ventricular Dysfunction ◽  
Inflammatory Syndrome

Objectives To determine clinical, laboratory features and outcomes of Multisystem Inflammatory Syndrome in children (MIS-C) and its comparison with historic Kawasaki Disease (KD) and Viral Myocarditis (VM) cohorts. Methods All children (1 month– 18 years) who fulfilled the World Health Organization criteria of MIS-C presenting to two tertiary care centers in Karachi from May 2020 till August 31st were included. KD and VM admitted to one of the study centers in the last five years prior to this pandemic, was compared to MIS-C. Results Thirty children with median age of 24 (interquartile range (IQR)1–192) months met the criteria for MIS-C. Three phenotypes were identified, 12 patients (40%) with KD, ten (33%) VM and eight (26%) had features of TSS. Echocardiography showed coronary involvement in 10 (33%), and moderate to severe Left Ventricular dysfunction in 10 (33%) patients. Steroids and intravenous immunoglobulins (IVIG) were administered to 24 (80%) and 12 (41%) patients respectively while 7 (23%) received both. Overall, 20% children expired. During the last five years, 30 and 47 children were diagnosed with KD and VM, respectively. Their comparison with MIS-C group showed lymphopenia, thrombocytosis, and higher CRP as well as more frequent atypical presentation in MIS-C KD group with less coronary involvement. The MIS-C VM was more likely to present with fulminant myocarditis. Conclusions Our MIS-C cohort is younger with higher mortality compared to previous reports. MIS-C is distinct from historic cohorts of KD and VM in both in clinical features and outcomes.

scholarly journals Theophylline in Treatment of COVID-19 Induced Sinus Bradycardia

2021 ◽  
Vol 11 (2) ◽  
pp. 332-336
Author(s):  
Khalid Sawalha ◽  
Fuad J. Habash ◽  
Srikanth Vallurupalli ◽  
Hakan Paydak
Keyword(s):  
Medical History ◽  
Clinical Laboratory ◽  
Sinus Bradycardia ◽  
Case Series ◽  
Past Medical History ◽  
Significant Past Medical History ◽  
Retrospective Case ◽  
Record System ◽  
Treatment Data ◽  
History Of

This is a retrospective case series of two patients with laboratory-confirmed coronavirus 2 (SARS-CoV-2) infection, presented to the University of Arkansas for Medical Sciences in January 2021. Medical records of these patients were reviewed using the EPIC electronic health record system. Clinical, laboratory, and treatment data were reviewed against periods of bradycardia in each patient. Both of the patients presented with dizziness and presyncope related to sinus bradycardia in which they received treatment with 1 mg of IV atropine and theophylline 200 mg orally. We share these two cases of theophylline treatment in COVID-19 induced sinus bradycardia. The first patient was a 39-year-old female, with a past medical history of polycystic ovarian syndrome, who presented to the emergency department with lightheadedness and dizziness. Two weeks prior to her presentation, she was tested positive for COVID-19 infection that was treated with azithromycin, dexamethasone and aspirin. Upon presentation, her ECG showed sinus bradycardia at a rate of 48 bpm. The second patient, a 21-year-old female with no significant past medical history, presented with presyncope. Three weeks prior to her presentation, she tested positive for COVID-19 infection that was treated symptomatically at her home. Upon presentation, her ECG showed junctional rhythm at a heart rate of 51 bpm.

Study of Toll-like Receptor 3 Gene Polymorphism as a Novel Risk Factor for HCV-related Hepatocellular Carcinoma in Egypt

2020 ◽  
Vol 20 (5) ◽  
pp. 382-389 ◽  
Author(s):  
Shimaa EL-Sharawy ◽  
Osama El- Sayed Negm ◽  
Sherief Abd-Elsalam ◽  
Hesham Ahmed EL-Sorogy ◽  
Mona Ahmed Helmy Shehata
Keyword(s):  
Hepatocellular Carcinoma ◽  
Risk Factor ◽  
Gene Polymorphism ◽  
Clinical Laboratory ◽  
Treatment Options ◽  
Laboratory Evaluation ◽  
Toll Like Receptor ◽  
Focal Lesions ◽  
Tlr3 Gene ◽  
Cirrhotic Patients

Background & Aims: Hepatocellular carcinoma (HCC) is a highly aggressive cancer with few treatment options. Toll-like receptor 3 (TLR3) plays a key role in innate immunity and may affect the development of cancers. This study aimed to investigate the association between TLR3 gene polymorphism and HCV-related hepatocellular carcinoma in Egypt. Methods: This work was conducted on 70 individuals; fifty HCV cirrhotic patients were included in two groups; with HCC (30 patients) and without HCC (20 patients) compared with a group of 20 apparently healthy controls. All of the studied individuals underwent clinical-laboratory evaluation. TLR3 gene single-nucleotide polymorphism (SNP) (+1234C/T) was tested by polymerase chain reaction- restriction fragment length polymorphism. Results: This study reported that the prevalence of TLR3 +1234TT genotype was significantly increased in cirrhotic patients with HCC than without HCC, while it was not detected at all among the controls. When analyzing the TLR3 SNP +1234C/T with different clinical parameters in HCC patients, there was a significant association between+1234C/T SNP; namely TT genotype and each of the hepatic focal lesions᾽ number, size and the patients᾽ higher Okuda and BCLC stages. No association could be detected between TLR3 SNP and the age, sex, Child-Pugh grades, MELD score or AFP of the studied HCC cases. Conclusion: TLR3 gene SN P +1234C/T could be a novel risk factor for the HCV-related HCC among the Egyptian population.

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