Cardiac manifestations, treatment characteristics, and outcomes of paediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus-2: A systematic review

Abstract

Objective To investigate cardiac manifestations, treatment characteristics, and outcomes of paediatric inflammatory multisystem syndrome (PIMS) temporally associated with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) (PIMS-TS) Method We performed a comprehensive literature search of several databases and qualitatively synthesized findings from studies. Results Twenty-six studies were included with 1228 pooled subjects, with a mean age of 8.6 years, which were dominated by male gender (53%), and African ethnicity (31%). 732 (38%) patients were reactive on a serological test, and 457 patients (45%) were positive on SARS-CoV-2 RT-PCR. ST-segment abnormalities were the most common ECG findings (16%, n/N: 34/212). Various markers of troponin and the pooled mean of BNP and NT-pro-BNP levels were elevated. Cardiomegaly and pericardial effusion (21.8%, n/N: 164/751) was the most common chest X-ray findings. In echocardiography, the majority of patients’ left ventricular ejection fraction was reduced (59.0%, n/N: 180/305), with pericardial effusion/ pericarditis seen the most (17.44%, n/N: 221/1267), and Z score ≥ 2 in 28% (n/N: 42/139). Cardiac MRI findings were consistent with acute myocarditis. Intravenous immunoglobulin, corticosteroids, and vasoactive drugs were frequently utilized. The mean length of stay was 6 days, with most patients (71%, n/N: 834/1163) were admitted to the ICU. However, the overall prognosis was favourable, with 98% alive (n/N: 1235/1260), and more than 50% of patients experienced recovery of left ventricular systolic functions at discharge (116 out of 206 patients). Conclusion PIMS-TS is a rare clinical syndrome associated with a multiorgan system dysfunction, especially acute cardiac injury, and mandates a higher level of care. Nevertheless, when appropriate treatments are available, the cardiac function rapidly reverted to normal in most cases, and it was associated with a favourable outcome in general. Of concern, medium and long-term prognosis remains to be elucidated.

Role of Endomyocardial Biopsy in Diagnostics of Myocarditis

“…Pediatric reviews showed a high incidence of clinically suspected myocarditis in children presenting with multisystem inflammatory syndrome [ 70 , 71 , 72 , 73 ]. There were only a few reported pediatric cases supported by CMR findings or confirmation by biopsy or autopsy [ 50 , 74 , 75 ]. The COVID-19 pandemic has also highlighted the need for EMB and autopsy sample collection to determine the correct underlying process and possible treatment directions, when facing novel pathogens [ 76 , 77 ].…”

Cardiac manifestations and diagnostic imaging in pediatric inflammatory multisystem syndrome temporally associated with COVID-19: a systematic review

“…The most common echocardiography abnormalities were reduced left ventricular (LV) function, pericardial effusion with pericarditis, myocarditis, and valvular abnormalities, which are similar to other systematic reviews. 36,38,39 Patients with impaired left ventricle function, specifically impaired LV global longitudinal strain and LV apical four-chamber peak longitudinal strain at clinical presentation, are at higher risk for developing adverse acute clinical course. Subclinical left myocardial dysfunction may persist for weeks after recovery in these patients.…”

“…This cardiac involvement may become a long-term health issue, as shown in a previous study that only 28.3% of patients had improved LVEF after hospital discharge. 39 Reduced LVEF may manifest as left-sided heart failure, which may cause fatigue, edema, and fluid retention, leading to a significant impairment on quality of life. 41 Treatments should aim to minimize the long-term impact of PIMS-TS.…”

Pediatric Inflammatory Multisystem Syndrome or Multisystem Inflammatory Syndrome in Children: A New Thread in Pandemic Era

“…PMIS, in the other hand, affects predominantly previously healthy children, 12 although some presented comorbidities such as obesity or overweight, chronic lung disease such as asthma. 20 …”

“…Majority of PMIS cases are admitted to the ICU and stayed hospitalized for a median length of 4 to 12 days; fortunately, most are discharged alive until the inflammatory markers return to normal, when they are afebrile for at least 24 hours, normotensive, well hydrated, and do not require supplementary oxygen or inotropic help to keep cardiac function. 3 , 12 , 20 , 30 , 34 The mortality rate of PMIS is low, only 2% of the infected patients died from PMIS; in the US, there have been only 36 deaths from PMIS. 23 , 26 The recommended follow-up for recovering PMIS is every 1 to 2 weeks and echocardiograms 4 to 6 weeks after discharge.…”