COVID-19 and mysterious disease in children

In recent days, the media are reporting a “mysterious disease” in children and its connection to COVID-19 infection. Cases with symptoms resembling Kawasaki disease are reported. Reports come from Italy, Great Britain, France, Spain, and the United States.

What is Kawasaki disease?

Kawasaki disease is an acute inflammation of small and medium vessels, with an increased risk of coronary artery involvement. Although the disease was first described in 1967, it is still unknown what causes it. The disease occurs seasonally, more often in spring and autumn, mostly in healthy children under 5 years old. It is recognized that Kawasaki disease may be an abnormal immune response following a previous respiratory infection or other causative agents, but the studies conducted so far have not been conclusive.

What are the symptoms?

Symptoms of Kawasaki disease are primarily:
– persistent high fever lasting at least 5 days,
– bilateral, nonpurulent conjunctivitis,
– changes on the mucous membranes of the upper respiratory tract, including red throat, red, dry and cracked lips, and so-called “strawberry tongue”,
– enlarged cervical lymph nodes, not related to bacterial infection of the upper respiratory tract,
– polymorphic rash with erythema on the hands and feet and characteristic skin peeling around the nails.

What worries most about Kawasaki disease?

The most disturbing symptom is coronary artery involvement, which can lead to coronary artery aneurysms and lasting consequences on cardiac function. Prompt initiation of correct treatment for Kawasaki disease significantly reduces the risk of complications, including the risk of coronary artery aneurysms.

What is the treatment?

The treatment aims to suppress the abnormal inflammatory response of the immune system and antiplatelet therapy. It consists of intravenous administration of immunoglobulins and oral administration of acetylsalicylic acid (i.e. aspirin). Intravenous steroids are also given in severe cases.

What is the connection between Kawasaki disease and COVID-19?

In a work published on May 13, 2020, in Lancet, Italian doctors from the Bergamo Hospital describe the sudden onset of a large number of children reporting to the hospital with symptoms resembling Kawasaki disease. Reports indicate that for 5 years (from January 2015 to February 2020) 19 patients with Kawasaki disease were treated in hospital, while currently 10 patients with symptoms of the disease were treated during the prevailing pandemic (from February 18 to April 20, 2020).
Researchers indicate that shortly after the coronavirus outbreak in the Bergamo region of Italy, there was a 30-fold increase in the incidence of Kawasaki-like disease. All children described since February had a proven immune response to SARS-CoV-2 (positive antibodies).

Why are we talking about a Kawasaki-like disease, not directly about Kawasaki disease?

In the “Rapid Risk Assessment” published by the European Center for Disease Prevention and Control (ECDC) published on May 15, we read about Pediatric Multisystemic Inflammatory Disease about a possible association with SARS-Cov2 (pediatric multisystem inflammatory syndrome – PMIS-TS).
This publication describes 230 cases reported in Europe similar to Kawasaki’s disease, including only 2 deaths. In this group of patients, children are older than described so far with the classic Kawasaki disease. Currently, more severe cases requiring intensive treatment are observed. A link between the occurrence of the pediatric inflammatory multisystem syndrome and COVID-19 is very likely but requires further investigation.

Positive thoughts at the end

Of all confirmed COVID-19 cases in Europe, only 2.1% were children under 14 years of age. COVID-19 infection in children is usually mild and asymptomatic. The reported incidents of PMIS-TS are individual cases. They draw attention to the fact that in the general population there are people with a predisposition to a different course of illness. We still do not know why some children will develop Kawasaki disease or multi-system inflammatory disease. Unable to predict which children are predisposed, fast and correct treatment is the best course of action. It is important to have good contact between the parents of the sick child and doctors so that there is no delay in diagnosis and undertaking appropriate treatment, which significantly reduces the risk of complications.

Bibliography:

1. https://tvn24.pl/swiat/koronawirus-w-usa-coraz-wiecej-przypadkow-tajemniczej-choroby-u-dzieci-4583479

2. https://fakty.interia.pl/raporty/raport-koronawirus-chiny/aktualnosci/news-who-bada-zwiazek-koronawirusa-z-tajemniczym-syndromem-u-dzie,nId,4497751

3. Nowa wieloukładowa choroba zapalna u dzieci o możliwym związku z zakażeniem SARS-CoV-2, dr n. med. Magdalena Okarska-Napierała, dr hab. n. med. Ernest Kuchar, Medycyna Praktyczna

4. Shekerdemian LS, Mahmood NR, Wolfe KK, et al. Characteristics and Outcomes of Children With Coronavirus Disease 2019 (COVID-19) Infection Admitted to US and Canadian Pediatric Intensive Care Units. JAMA Pediatr. Published online May 11, 2020. doi:10.1001/jamapediatrics.2020.1948

5. An outbreak of severe Kawasaki-like disease at the Italian epicentre of the SARS-CoV-2 epidemic: an observational cohort study. Lucio Verdoni, Angelo Mazza, Annalisa Gervasoni, Laura Martelli, Maurizio Ruggeri, Matteo Ciuffreda, Ezio Bonanomi, Lorenzo D’Antiga, The Lancet Published online May 13, 2020

6. Kawasaki-like disease: emerging complication during theCOVID-19 pandemic, *Russell M Viner, Elizabeth Whittaker, The Lancet Published online May 13, 2020

7. Shekerdemian LS, Mahmood NR, Wolfe KK, et al. Characteristics and Outcomes of Children With Coronavirus Disease 2019 (COVID-19) Infection Admitted to US and Canadian Pediatric Intensive Care Units. JAMA Pediatr. Published online May 11, 2020. doi:10.1001/jamapediatrics.2020.1948

8. European Centre for Disease Prevention and Control. Paediatric inflammatory multisystem syndrome and SARS-CoV-2 infection in children – 15 May 2020. ECDC: Stockholm; 2020.