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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 19  |  Issue : 1  |  Page : 90-92

Post-COVID-19 infection; paediatric multisystemic inflammatory syndrome in an 8-month-old infant


1 Department of Paediatrics, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Paediatrics, Abubakar Tafawa Balewa University Teaching Hospital, Bauchi, Nigeria
3 Department of Paediatrics, Bayero University, Kano, Nigeria

Date of Submission06-Apr-2021
Date of Decision15-Mar-2022
Date of Acceptance11-Apr-2022
Date of Web Publication12-Jul-2022

Correspondence Address:
Dr. Umar Isa Umar
Department of Paediatrics, Bayero University, Kano, P.M.B, 3011 Kano
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0331-8540.350719

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  Abstract 

The coronavirus disease 2019 (COVID-19) associated with multisystem inflammatory syndrome in children and adolescents is an emerging challenge and has been described as a new dangerous childhood disease that is temporally associated with COVID-19. An 8-month-old infant presented with unrelenting fever of 2 weeks, associated non-purulent conjunctivitis, redness of the lips and tongue, as well as tenderness, swelling and desquamation of the palms and digits and diarrhoea. She also had associated irritability, refusal to feed and poor sleep. She had positive polymerase chain reaction (PCR) COVID-19 test 3 months earlier. However, a repeat PCR test was negative at presentation. She had raised erythrocyte sedimentation rate of 85 mn/h, good systolic function on echocardiogram with normal rhythm electrocardiogram. She was diagnosed with post-COVID-19 paediatric multisystemic inflammatory syndrome and treated with intravenous immunoglobulin, oral prednisolone and aspirin. Patient symptoms improved significantly after 72 h of treatment. Therefore, a high index of suspicion is required in all children presenting with unexplained fever.

Keywords: Children, coronavirus disease 2019, Kawasaki disease-like illness, Nigeria, paediatric multisystem inflammatory syndrome


How to cite this article:
Adamu H, Zaidu AM, Sabo UA, Bashir L, Umar UI. Post-COVID-19 infection; paediatric multisystemic inflammatory syndrome in an 8-month-old infant. Niger J Basic Clin Sci 2022;19:90-2

How to cite this URL:
Adamu H, Zaidu AM, Sabo UA, Bashir L, Umar UI. Post-COVID-19 infection; paediatric multisystemic inflammatory syndrome in an 8-month-old infant. Niger J Basic Clin Sci [serial online] 2022 [cited 2022 Nov 29];19:90-2. Available from: https://www.njbcs.net/text.asp?2022/19/1/90/350719


  Introduction Top


The paediatric multisystem inflammatory syndrome (PMIS) associated with coronavirus disease 2019 (COVID-19) infection in children and adolescents is an emerging challenge and has been described as a new dangerous childhood disease that is temporally associated with COVID-19.[1] There are increasing reports describing children and adolescents with COVID-19-associated PMIS which was previously called Kawasaki disease (KD)-like illness.[2] The condition may coexist with acute COVID-19 infection in some cases[3] but in the majority of cases, it develops after the infection has resolved.[2] Although the condition was initially described as KD-like illness because of certain similar clinical features with the KD, it is distinct from KD and other well-described inflammatory syndromes in children such as KD shock syndrome and toxic shock syndrome.[4],[5]

It is believed to be triggered by immunological response to the virus affecting multiorgan systems of the body, especially/particularly the medium and large vessels.[5] Clinical presentation begins, in some cases, from 3 weeks to 3 months post-COVID infection and manifests with persistent fever, non-purulent conjunctivitis, adenitis, mucosal inflammation and erythema and gastrointestinal symptoms as early features.[2] Tender and swollen extremities with desquamation of the skin of the palms and soles may also be seen.[2] Coronary artery aneurysm, left ventricular dysfunction and pericardial effusion are cardiac manifestations.[6] So far, there are no widely accepted guidelines on the management of this condition, but many organisations have published their own guidelines based on specific symptoms, previous treatment of similar conditions such as KD, or COVID-19 treatment guidelines for adult patients. But generally, supportive care is important, particularly attention to vital signs, hydration, electrolytes balance and metabolic status. Other supportive care common to all guidelines is the use of antiviral therapy (if polymerase chain reaction [PCR] positive for SARS-COV-2), aspirin, prednisolone and immunotherapy.[2] We report an 8-month-old female infant who was diagnosed with COVID-19 infection in May 2020 and has remained asymptomatic until August 2020, when she presented with typical features of PMIS. This case report is to raise awareness among health personnel, especially those frontliners in the management of COVID-19-infected patients.


  Case Report Top


An 8-month-old infant presented to us with unrelenting fever of 2 weeks, associated non-purulent redness of the eyes, lips and tongue. By day seven of fever onset, the child developed tenderness, swelling and desquamation of the palms and soles, diarrhoea, associated irritability, refusal to feed and poor sleep. There was a history of mild running nose but no cough or difficulty with breathing. The child tested positive for COVID-19 3 months before presentations when her father had COVID-19 disease. She remained asymptomatic until the onset of current symptoms. Other family members living with the child were COVID-19-negative. She had received empirical treatment for malaria and sepsis with adequate doses of antimalaria (3 doses in 24 h of intravenous artesunate followed with oral coartem for 3 days), amoxicillin and ceftriaxone, in the outpatient department without change in her clinical condition.

On examination, she was febrile with temperature of 38.9°C, irritable, erythematic conjunctiva, hyperaemic buccal mucosa including the tongue and pharynx, nasal discharge, tender and minimally swollen palms and digits [Figure 1], with desquamation of the skin of the left thumb. She had only tender submandibular lymph node enlargement. She weighed 7.5 kg, normal for her age. Peripheral pulses were regular at rate of 110/min, her blood pressure was 96/56 mmHg. The apex beat was at the 4th left intercostal space midclavicular line, with normal 1st and 2nd heart sounds. Respiratory rate was 36/min and chest was clinically clear. Saturation was 97% in room air and warm extremities. Other systems were essentially normal.
Figure 1: Swollen palm and digits

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Complete blood count within normal range and blood culture yielded no growth. Normal coagulation profile, liver and renal functions. A diagnosis of probable post-COVID-19 infection PMIS was made. Further evaluation revealed raised erythrocyte sedimentation rate (ESR) of 85 mn/h, normal systolic function and coronary vessels on echocardiogram [Figure 2] and [Figure 3] with normal rhythm electrocardiogram.
Figure 2: Image of Echocardiography showing normal systolic function

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Figure 3: Image of Echocardiography showing normal myocardial and coronary vessels

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She received oral prednisolone at 3 mg/kg per day in three divided doses, oral acetylsalicylate at 1 mg/kg daily and intravenous human immunoglobulin at 1 g/kg/d as an infusion for 48 h. She had remarkable improvement evidence by crushing of the fever within 72 h, reduction in swelling and tenderness of the hands, improved appetite and socialisation. Serial ESR monitoring at 3-day interval showed a progressive decline (73 mm/h, 65 mm/h and 55 mm/h). Repeat ESR 2 weeks later was 15 mm/h and the child was symptoms free.


  Discussion Top


The diagnosis of COVID-19-associated PMIS (KD-like illness) was based on the WHO preliminary case definition of multisystem inflammatory disorder of children and adolescents 0–19 years of age. The presence of fever of ≥3 days and two of the following: (1) rash or bilateral non-purulent conjunctivitis or mucocutaneous inflammation signs (oral, hands or feet); (2) hypotension or shock; (3) features of myocardial dysfunction, pericarditis, valvulitis or coronary abnormalities (including ECHO findings or elevated Troponin/NT-proBNP); (4) evidence of coagulopathy (by prothrombin time, partial thromboplastin time, elevated D-dimers); (5) acute gastrointestinal problems (diarrhoea, vomiting or abdominal pain); and elevated markers of inflammation such as ESR, C-reactive protein or procalcitonin; and no other obvious microbial cause of inflammation, including bacterial sepsis, staphylococcal or streptococcal shock syndromes; and evidence of COVID-19 (reverse transcription–PCR, antigen test or serology positive), or likely contact with patients with COVID-19.[7]

Our patient presented with persistent fever which is seen in all reported cases.[4],[8] Associated clinical features and failure to respond to initial treatment with antimalarial drugs and antibiotics, coupled with raised ESR and history of asymptomatic confirmed positive COVID-19 test raised our suspicion to PMIS (KD-like illness). Furthermore, the resolution of symptoms following immunosuppressive therapy supports the diagnosis of PMIS. According to our clinical and ECHO cardiogram findings, our patient did not have any of the cardiac manifestations. Although not seen in all reported cases, but it is a common finding as reported by Sumantra et al.[3] in his case report of a 5-month-old infant with incomplete KD and concomitant COVID-19 infection and Riphagen et al.[5] who report a series of eight patients with hyperinflammatory shock syndrome in children during the COVID-19 pandemic. This may be due to our early intervention at the 2nd week of illness probably preventing the cardiac affectation that is typically seen from the 3rd week of illness.[6] The PMIS (KD-like illness) may coexist with acute COVID-19 infection in some cases,[3] but in our case, as seen in the majority of cases, it seems to develop after the acute stage of the infection.[2]


  Conclusion Top


Paediatric patients are vulnerable to COVID-19 infection irrespective of ethnicity or geographical region with distinct manifestations and outcomes. Therefore, a high index of suspicion is required in all children presenting with unexplained fever.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ahmed M, Advani S, Moreira A, Zoretic S, Martinez J, Chorath K, et al. Multisystem Inflammatory Syndrome in Children: A Systematic Review. Eclinicalmedicine 2020;26:100527.  Back to cited text no. 1
    
2.
Jiang L, Tang K, Levin M, Irfan O, Morris Sk, Wilson K, et al. Covid-19 and Multisystem Inflammatory Syndrome in Children and Adolescents. Lancet Infect Dis 2020;20:E276-88.  Back to cited text no. 2
    
3.
Sumantra R, Satyabrata R, Subhajit B, Mihir S, Mousumi N. Incomplete Kawasaki Disease as Presentation of Covid 19 Infection in an Infant: A Case Report. J Trop Pediatr 2020;67:1-4.  Back to cited text no. 3
    
4.
Jones Vg, Mills M, Suarez D, Hogan Ca, Yeh D, Segal Jb, et al. Covid-19 and Kawasaki Disease: Novel Virus and Novel Case. Hosp Pediatr 2020;10:537-40.  Back to cited text no. 4
    
5.
Riphagen S, Gomez X, Gonzalez-Martinez C, Wilkinson N, Theocharis P. Hyperinflammatory Shock In Children During Covid-19 Pandemic. Lancet 2020;395:1607-8.  Back to cited text no. 5
    
6.
Sperotto F, Friedman Kg, Son Mb, Vanderpluym Cj, Newburger Jw, Dionne A. Cardiac Manifestations in Sars-Cov-2-Associated Multisystem Inflammatory Syndrome in Children: A Comprehensive Review and Proposed Clinical Approach. Eur J Pediatr 2021;180:307-22.  Back to cited text no. 6
    
7.
World Health Organization. Multisystem Inflammatory Disorder in Children And Adolescents. 15 May, 2020 Statement. Geneva: World Health Organization; 2020. Available From: http://www.who/2019-ncov/sci_brief/multisystem_syndrome_children/2020.1. [Last accessed on 2020 Oct 15].  Back to cited text no. 7
    
8.
Verdoni L, Mazza A, Gervasoni A, Martelli L, Ruggeri M, Ciuffreda M, et al. An Outbreak of Severe Kawasaki-Like Disease at the Italian Epicentre of the Sars-Cov-2 Epidemic: An Observational Cohort Study. Lancet 2020;395:1771-8.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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