Acute myocarditis and multisystem inflammatory emerging disease following SARS-CoV-2 infection in critically ill children
Acute myocarditis and multisystem inflammatory emerging disease following SARS-CoV-2 infection in critically ill children
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DOI：
10.1186/s13613-020-00690-8
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发表时间：
2020-06-01
影响因子：
8.1
通讯作者：
Oualha, Mehdi
中科院分区：
文献类型：
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作者：
Grimaud, Marion;Starck, Julie;Oualha, Mehdi
背景：在COVID-19暴发的背景下，近期入院的低血压休克和发热儿童有所增加，迫切需要对SARS-CoV-2感染的参与进行表征和评估。这是对2020年4月15日至4月27日期间因休克、发烧和疑似SARS-CoV-2感染而入住儿科重症监护病房（PICU）的所有儿童在巴黎4个学术三级医疗中心进行的病例系列研究。结果20例因休克入院的危重症患儿合并急性心肌炎(左室射血分数35% (25 ~ 55)；肌钙蛋白，269 ng/mL(31-4607))，动脉低血压，临床表现以血管截瘫为主。入PICU前的首发症状为剧烈腹痛和发热6天（1-10）。所有儿童的c反应蛋白（> 94 mg/L）和降钙素原（> 1.6 ng/mL）均升高，无微生物原因。所有患儿均至少有一种川崎病的特征（发热20例，皮疹10例，结膜炎6例，口唇炎5例，腺炎2例），但均无典型表现。SARS-CoV-2 PCR阳性10例，血清学阳性15例。一名儿童的SARS-CoV-2 PCR和血清学均为阴性，但进行了典型的SARS-CoV-2胸部断层扫描。除1例患儿外，其余患儿均需插管使用肌力/血管活性药物支持（肾上腺素，n = 12；米力酮，n = 10；多巴酚丁胺，n = 6；去甲肾上腺素，n = 4）， 8例患儿插管。所有儿童均接受静脉注射免疫球蛋白（2 g / kg）和辅助皮质类固醇（n = 2）、IL- 1受体拮抗剂（n = 1）或针对IL-6受体的单克隆抗体（n = 1）。所有患儿均存活，出院时无发热，左心室功能完全恢复。结论急性心肌炎合并全身剧烈炎症和不典型川崎病是SARS-CoV-2感染后新出现的儿科重症疾病。早期认识到这种疾病是必要的，建议转诊到专家中心。怀疑是延迟和不适当的宿主免疫反应。虽然潜在的机制尚不清楚，但需要进一步的研究来确定最佳的治疗方法。
Background A recent increase in children admitted with hypotensive shock and fever in the context of the COVID-19 outbreak requires an urgent characterization and assessment of the involvement of SARS-CoV-2 infection. This is a case series performed at 4 academic tertiary care centers in Paris of all the children admitted to the pediatric intensive care unit (PICU) with shock, fever and suspected SARS-CoV-2 infection between April 15th and April 27th, 2020. Results 20 critically ill children admitted for shock had an acute myocarditis (left ventricular ejection fraction, 35% (25-55); troponin, 269 ng/mL (31-4607)), and arterial hypotension with mainly vasoplegic clinical presentation. The first symptoms before PICU admission were intense abdominal pain and fever for 6 days (1-10). All children had highly elevated C-reactive protein (> 94 mg/L) and procalcitonin (> 1.6 ng/mL) without microbial cause. At least one feature of Kawasaki disease was found in all children (fever, n = 20, skin rash, n = 10; conjunctivitis, n = 6; cheilitis, n = 5; adenitis, n = 2), but none had the typical form. SARS-CoV-2 PCR and serology were positive for 10 and 15 children, respectively. One child had both negative SARS-CoV-2 PCR and serology, but had a typical SARS-CoV-2 chest tomography scan. All children but one needed an inotropic/vasoactive drug support (epinephrine, n = 12; milrinone, n = 10; dobutamine, n = 6, norepinephrine, n = 4) and 8 were intubated. All children received intravenous immunoglobulin (2 g per kilogram) with adjuvant corticosteroids (n = 2), IL 1 receptor antagonist (n = 1) or a monoclonal antibody against IL-6 receptor (n = 1). All children survived and were afebrile with a full left ventricular function recovery at PICU discharge. Conclusions Acute myocarditis with intense systemic inflammation and atypical Kawasaki disease is an emerging severe pediatric disease following SARS-CoV-2 infection. Early recognition of this disease is needed and referral to an expert center is recommended. A delayed and inappropriate host immunological response is suspected. While underlying mechanisms remain unclear, further investigations are required to target an optimal treatment.