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Hyperinflammatory shock in children during COVID-19 pandemic

Our take —

This small case series from the UK identified an unusual cluster of cases of acute inflammatory shock, resembling atypical Kawasaki disease, in children, most of whom were of Afro-Caribbean descent. Many of these children had exposure to known cases of COVID-19, though only 2/8 tested positive with PCR, and antibody testing was not performed. This study helps call attention to a severe and poorly understood, though uncommon, pediatric manifestation of SARS-CoV-2 infection.

Study design

Case Series

Study population and setting

This study included 8 children with hyperinflammatory shock (5 of 8 male, median age 8 years, age range 4-14 years, 6 of 8 of Afro-Caribbean descent) from a pediatric network in South East England, UK, identified over a ten-day span in April, 2020.

Summary of Main Findings

All children had previously been in good health. All patients presented with fever, rash, conjunctivitis, peripheral edema, gastrointestinal symptoms, and extremity pain; most had no significant respiratory symptoms. Pleural, pericardial, and ascitic effusions were common. Patients exhibited high concentrations of inflammatory biomarkers and cardiac enzymes. All patients subsequently progressed to warm shock, and were treated with noradrenaline, milrinone, and IV immunoglobulin. 7/8 required mechanical ventilation for cardiovascular stabilization. One child died from a cerebral infarction after requiring life support, and the other 7 were discharged alive from the PICU after 4-7 days. All children tested negative for SARS-CoV-2 at admission; 4/8 had likely exposures from close family members. Two children subsequently tested positive, including one post-mortem.

Study Strengths

Cases were well-characterized.

Limitations

This initial report describes a very small cluster of cases. Although SARS-CoV-2 infection is a suspected cause of the syndrome, there were only 2 confirmed cases among the 8 children. Antibody testing was not performed; of note, in a similar case series (Verdoni et al.), 2/10 children tested positive for SARS-CoV-2 infection via PCR, but 8/10 were antibody-positive.

Value added

This was one of the very first reports of a multi-system inflammatory syndrome affecting children that appears to be related to SARS-CoV-2 infection.