MIS-Covid case series by Dr.ashish goti pediatrician

Misc disease of covid in children

1. Case Series SPACT DATE: 31/07/2020 Dr Ashish Goti

2. Case 1 10 yr Male Absolutely alright before 6 days c/o Fever x 5 days Cough x 2days Vomiting x 2 days Conjunctival injection x 2 days Weakness x 2 days No any covid 19 contact

3. Examination GC stable Red lips Red eye Throat congestion Mild edema

4. Vitals HR: 136 / min Rr 24 /min Fever 102.3 f Sop2 98 % room air S/E RS : CTAB CVS : Tachycardia , BP 100/60 mmhg P/A : soft, no hsm

5. Investigation on 14/07/2020 ( day 5 of fever ) HB: 11.5 TLC: 9800 (N 81, L 10, E 4, M 4, B 1) PLT: 1.66 Lac Xray Chest: NL

6. D/D VIRAL INFECTION OTHER THEN COVID Multiple system involved Normal blood count Borderline platelet COVID 19 Pandemic time High fever Weakness STEPTOCOCCAL INFECTION Throat congestion

7. Treatment Ivf Antibiotic – Augmentin Iv Vitamin c Zink Vitamin D Sos Paracetamol

8. Progress Continue high grade fever spike ( every 4 – 6 hourly) Continue tachycardia Sleeping HR : 126 (no fever) Started loose motion and abdominal pain So repeat investigation after 48 hour of progressive illness

9. On 16/07/2020, Day 7 of fever HB: 10.5 TLC: 11300 ( N 80, L 11, E4, M4, B 1) PLT: 1.42 Lac MP: - Ve CRP : 106.80 mg/dl ( Normal Range 0-6 ) D-dimer : 1.2 mg/dl ( Normal < 0.5 ) Ferritine : 284.82 ng/dl ( Normal Range 21-274)

10. Further test Rapid Antigen test : Negative RT PCR : Negative

11. Progress Now HR 146/min BP: 76/50 mmhg So 2D echo done : Poor Myocardial Function (EF 30%) So started Dobutamine infusion

12. Suspecting MIS C As Hypotension and decrease cardiac function without respiratory element So Sent Covid Igg Started IVIg (2gm/kg) , Steroid (30mg/kg/day) , Aspirine ( 6mg/kg/day) , Pantoprazole ( 40 mg / day) , Ceftriaxone

13. After 1 st dose of methylprednisolone no fever Gradually congestion reduce EF improved 45 % after 72 hour completion of methylprednisolone ( 3 day pulse therapy)

14. Follow up Shifted to oral prednisolone Discharged on day 7 Vitals on discharge Hr 78/min Bp 106/ 70 mm hg Echo Good function ( no coronary involved ) Adv Follow up echo after 1 month

15. CASE 2 6 month Female c/o Diarrhea x 5 days Fever x 5 days Was admitted for 5 days and took DOR on 08/06/2020 child was sick and not playful as per talk with pediatrician

16. INVESTIGATION Date 04/06/20 06/06/20 08/06/2020 HB 9.3 9.1 8.7 TLC 10000 11800 7600 N/L/E/M/B 51/42/02/05/00 58/31/03/08/00 55/36/02/07/00 PLT 3.76 3.62 3.59 CRP 59.85 64.59 32.14 Na 146 K 3.7

17. 24/06/2020 After 12 days afebrile Again started multiple episode vomiting and diarrhea ??Seizure episode at home so, Consulted senior pediatrician Dia : AGE with Some Dehydration with Some stary look Referred to Tertiary care hospital

18. 24/06/2020 Hr : 159/min RR : 40 / min Sign of Dehydration ++ And Seizure query ?? In PICU ( D/D acute encephalitis or meningitis (viral)) Started fluid resuscitation And sent investigation

19. 25/06/2020 SGPT : 12.6 CSF TC : 05 POLY : 05% LYMP: 95% RBCS : 10-12 / Hfc MRI : BESSI (benign enlargement of the subarachnoid spaces of infancy

20. Progress Supportive treatment started Also given low dose Dexa Afebrile for 3 days again fever started Blood culture grown pseudomonas

21. 26/06/2020 Date 26/06/2020 HB 7.0 TLC 29100 N/L/E/M/B 87/07/01/05/00 PLT 1.57 CRP 222.93 ALBUMIN 2.10 gm/dl

22. Progress So antibiotic changed to Meropenem No seizure But irritability persistent Edema and Ascites Tachycardia persistent

23. 29/06/2020 Date 29/06/2020 26/06/2020 HB 7.5 7.0 TLC 10800 29100 N/L/E/M/B 20/70/02/08/00 87/07/01/05/00 PLT 1.57 CRP 52.46 222.93 ALBUMIN 2.10 gm/dl

24. Still fever continue and edema increase Again had 3-4 episode of convulsion and cyanosis. Shifted to PICU Loaded with AED ( Gardinal , Levera , Eptoine ) Autonomic disturbance as well ( tachycardia ) Taken opinion of senior consultant (?IEM/Immune encephalitis)

25. 03/07/2020 Date 03/07/2020 HB 8.8 TLC 11300 N/L/E/M/B 20/78/01/01/00 PLT 3.76 I.CA++/MG+ 0.8/ 1.5 ALBUMIN 2.10 gm/dl INR 1.2 FERRITINE 250 AMMONIA 47

26. Albumin, BT, Calcium given Child improved but spikiong fever every 12 hourly And persistent irritability Taking feeding now Repeat investigation

27. 07/07/2020 Date 26/06/2020 HB 6.5 TLC 9900 N/L/E/M/B 08/80/01/11/00 PLT 2.94 CRP 36.26 ESR 75

28. DOR Discharge given as per request Follow up after 2 days Fever continue , Persistent irritability So adv. ECHO Echo: Pericardial Effusion Suspecting vasculitis and low Hb ref to hematologist Adv w/f Biotin deficiency, Immune deficiency Give supplement iron, fa, sos BONE marrow

29. As per pathophysiology Irritability Low hb Fever No definitive localization of bacterial infection So started oral steroid ( brahmastra ) after sending covid IgG Follow up after 3 days no fever Irritability only while handling Continue steroid for 1 week more Child absolutely normal

30. Case 3 Cur.Dr Nehal (Sola Ahmedabad)

31. History A 14 year old male child presented with complaints of : - Pain in abdomen for 10-12 days, periumbilical region - Fever for 10-12 days, high grade - Bloody diarrhoea for 10 days - Redness of eyes for 8-10 days - Cough, dry nature on and off - Neck swelling

32. There was no significant event on the day of admission except fever. All routine investigations were sent. Due to prolonged fever, extra investigations were drawn like serum Widal , HIV, HbsAg , stool and urine routine and culture. A covid-19 RT-PCR swab was also sent along with ferritin, d-Dimer. Workup of tuberculosis was done. An electrocardiogram was done which was normal. Ophthalmology reference was done concluded subconjunctival congestive and subconjunctival haemorrhages with normal vision. His routine investigations were normal. Tb workup normal. Sonography of abdomen was normal, sonography of neck suggested enlarged lymph nodes bilaterally of inflammatory origin. Covid-19 RT-PCR was negative but d-Dimer and ferritin were high . On day 2 of admission (24/7/20), he was provisionally diagnosed with covid-19 linked syndrome - PIMS ( Pediatric Inflammatory Multisystem Syndrome) and intravenous immunoglobulin (IVIG) was started. To confirm the diagnosis a covid-19 antibody test was done which was positive . So methylprednisolone was also started. 2D echo of heart was done which suggested mild dilatation of coronary arteries ., thus aspirin was also started in the patient . apTT was slightly prolonged so fresh frozen plasma (FFP) was also given.

33. Next day, 3rd day of admission (25/7/20), he had mild distress. Chest X-ray was done which was normal. A HRCT chest was planned which suggested - patchy areas of consolidation in postero -basal segment of bilateral lower lobes along with bilateral mild pleural effusion . Next day was uneventful. Vitals were stable. There was no respiratory distress, no fever for last 36 hours, decrease in conjunctival congestion, no diarrhoea or dysentry and appetite had improved. On 5th day of admission his blood investigations were repeated to see for improvement in parameters.

34. Investigations 20/7 21/7 22/7 23/7 24/7 25/7 27/7 Hb 15.5 15.0 12.6 10.8 10.6 12.8 TC 9650 10860 11570 13900 4900 17000 DC 87/07 78/12 80/10 88/08 73/23 65/20 Plt 1.30 1.20 1.64 1.77 2.01 4.31 ESR 56 40 CRP 34.3 +ve 1.2 +ve 1.2 +ve Creat 1.3 0.8 0.8 Na 130 137 136 K 3.5 3.6 4.7 S. Bili 1.1 0.4 SGPT 24 28 D-dimer 1590 2053 1945 1846 1296 Ferritin 953.1 615.3 759 PT/INR/aPTT 14.8/1.07/57.4 17.24/ 1.24/25.59 S. Widal - Negative Urine routine - normal Urine culture - ?candida Stool routine - normal Stool culture - normal Covid-19 RT-PCR swab - Negative Covid-19 Antibidy test - POSITIVE IL-6 - 3.62 (<7.0) Dengue NS1 - Negative Dengue IgM - Negative

35. Case 4

36. Case 5 3yr male Fever x 2 days Rhinorrhea x 2 days No focus opd based symptomatic rx given Came on day 5 of fever Toxic look Rash

37. Admitted Fever 6 hourly Eye Congestion Tachycardia ( 152 basal , with fever 172), BP : 90/60 mmhg Cbc : Normal CRP : 25 LDH: 311 D Dimer: 6.4 Pro BNP : 541 ECHO : Nl function

38. Today 31/07/2020

39. Spectrum Case 1 (Dermatological + Cardiac + GI) Mod to severe Case 2 ( GI + CNS + Cardiac + Hemat ) Severe Case 3 ( GI + Dermat + Respiratory + RE + Cardiac + Hemat ) Severe Case 4 ( Dermat + Respiratory + Cardiac + Hemat ) Severe Case 5( Dermat + cardiac + hemat ) mild Aim NO over diagnosis No under diagnosis

40. Learning Is a life long process MIS –C By Dr Ashish Goti Nice Children Hospitals

41. Case Definition for MIS-C Age < 20 yr with Fever >  3days

42. + Lab Markers of Inflammation( ANY 3) CRP ESR Fibrinogen Procalcitonin D-Dimer Ferritin LDH IL 6 Low albumin Dec Lymphocytes In Neutrophils

43. + Multisystem ≥ 2 Organ Involvement 1) Cardiac 2) Renal 3) Respiratory 4) Hematology 5) Gastrointestinal 6) Dermatology 7) Neurological

44. Low blood pressure Tachycardia 1. Cardiac Elevated troponin /NT Pro-BNP Pericarditis, Valvulitis, Decrease function This Photo by Unknown Author is licensed under CC BY Coronary dilatation

45. 2. Renal Acute Kidney Injury Renal Failure

46. 3. Respiratory This Photo by Unknown Author is licensed under CC BY-SA-NC This Photo by Unknown Author is licensed under CC BY-NC Pneumonia ARDS Pulmonary Embolism

47. 4. Hematology High or Low D-Dimer High

48. 5. Gastrointestinal Vomiting / Diarrhoea High Bilirubin, Enzyme

49. 6. Dermatological Rash Mucocutaneous Lesion BL Non purulent Conjunctivitis

50. 7. Neurological Encephalopathy Meningitis

51. + No alternative Diagnosis

52. + Covid-2 Positive tests( any one) Serology ( IgG, IgM, IgA) Rapid antigen Test RT PCR

53. + Covid 19 Exposure Within 4 weeks

54. Symptoms Fever ( as per definition all case 100 %) 97% Tachycardia 80% Gastrointestinal symptoms 60% Rash 56% Conjunctival injection 27% Mucosal changes. 53% Evidence of myocarditis 80% were admitted to an intensive care unit

55. Elevated levels of C-reactive protein in 100% Elevated levels of d-dimer in 91% Elevated levels of troponin in 71% 62% received vasopressor support

56. TESTS Testing aimed at identifying laboratory evidence of inflammation as listed in the Case Definition SARS-CoV-2 (Any of 3 Described)

57. Treatment No definitive evidence till date according to WHO and CDC Ivig + Steroid in severe dysfunction Ivig or Steroid in moderate dysfunction Oral steroid in mild dysfunction + organ support + Aspirin + Broad spectrum antibiotic + PPI

58. DON’T KNOW Antibody titer and severity of disease Inflammatory marker and severity of disease ( some what ) Vaccine can cause MIS C?? Vaccine may contraindicated below age 20 ? Age related system involvement?

59. Thanking You