Hyperinflammatory Shock Seen in Some Children With Current, Past COVID-19

Pharmacists should be aware of the symptoms of a new COVID-19-related condition being seen in children. Children with fevers not responding to medication, variable rash, conjunctivitis, peripheral edema, and generalized extremity pain with significant gastrointestinal symptoms should be referred for immediate evaluation/treatment and novel coronavirus testing, according to public health officials. Here are more details.

LONDON – Until now, it had been assumed that children would be a demographic groups largely escaping the dangerous health effects of COVID-19.

A very small percentage of pediatric cases were reported as serious, and, in China, where the novel coronavirus outbreak began, only two deaths of children had been reported as of a May 1 report in The Lancet Respiratory Medicine. (The U.S. National Center for Health Statistics reports 10 deaths for patients under the age of 14 as of May 2.)

https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30152-1/fulltext

As with many issues involving the novel coronavirus, the situation might be changing quickly. In the UK, the South Thames Retrieval Service in London, which provides pediatric intensive care support and retrieval to two million children in South East England, has reported “an unprecedented cluster” of eight children with hyperinflammatory shock. The patients presented with features similar to atypical Kawasaki disease, Kawasaki disease shock syndrome, in mid-April, and one child died.

A report in The Lancet says the center usually sees one or two children per week. In this case, all of the children were previously in good health. The article points out that six of the children were of Afro-Caribbean descent, and five of the children were boys. Four children had known family exposure to COVID-19.

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(20)31094-1.pdf

Meanwhile, the New York State Department of Health sent out an alert stating that 64 cases of a similar condition had been report statewide. Cases also had been found in Louisiana, Mississippi and California, where a six-month old presented with the illness.

http://dmna.ny.gov/covid19/docs/all/DOH_COVID19_PediatricInflammatorySyndrome_050620.pdf

https://hosppeds.aappublications.org/content/hosppeds/early/2020/04/06/hpeds.2020-0123.full.pdf

In addition, 50 cases were reported in European countries, including the British cases.

Pharmacists should be aware of the clinical presentations for the illness: unrelenting fever (38–40°C), variable rash, conjunctivitis, peripheral edema, and generalized extremity pain with significant gastrointestinal symptoms. All progressed to warm, vasoplegic shock, refractory to volume resuscitation and eventually requiring noradrenaline and milrinone for hemodynamic support.

The report from the UK advises that none of the children had no significant respiratory involvement, although seven of the children required mechanical ventilation for cardiovascular stabilization. It notes that other notable features included development of small pleural, pericardial, and ascitic effusions, suggestive of a diffuse inflammatory process.

In the UK report, all children tested negative for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), but the authors write, “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).”

New York health officials report, on the other hand, that many of the children who have become sick with the syndrome there fell into one of two categories: they had a positive test for COVID-19 at the time their symptoms presented or they testing positive on antibody tests, raising the question of whether the response was a post-infection condition.