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 Table of Contents  
LETTER TO THE EDITOR
Year : 2020  |  Volume : 7  |  Issue : 6  |  Page : 364-365

Pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus 2 infection: Getting ready for the onslaught


Department of Pediatrics, Division of Pediatric Critical Care, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission24-Sep-2020
Date of Acceptance03-Oct-2020
Date of Web Publication11-Nov-2020

Correspondence Address:
Dr. Suresh Kumar Angurana
Department of Pediatrics, Division of Pediatric Critical Care, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JPCC.JPCC_151_20

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How to cite this article:
Angurana SK. Pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus 2 infection: Getting ready for the onslaught. J Pediatr Crit Care 2020;7:364-5

How to cite this URL:
Angurana SK. Pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus 2 infection: Getting ready for the onslaught. J Pediatr Crit Care [serial online] 2020 [cited 2020 Nov 30];7:364-5. Available from: http://www.jpcc.org.in/text.asp?2020/7/6/364/300583



Sir,

We read with interest the recently published article “Pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus 2 - An emerging problem of PICU: A case series” by Mukund et al.[1] The authors reported three children (6.5, 7, and 12 years) with febrile illness with multisystem and hyperinflammation who had evidence of recent or current infection or exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The management included supportive care, intravenous immunoglobulin (IVIG), and/or methylprednisolone, which lead to clinical recovery.

As highlighted by authors,[1] children with pediatric inflammatory, multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus 2 (PIMS-TS) share some of the clinical and laboratory features with Kawasaki disease (KD). However, PIMS-TS usually involves children older than 5 years and adolescents; associated with marked elevation of inflammatory markers, leukopenia/lymphopenia, and thrombocytopenia; more frequent cardiovascular complications (shock, myocarditis, left ventricular dysfunction, coronary artery abnormalities, pericardial effusion); predominantly interleukin (IL)-6 and IL-8 driven inflammatory process; and often unresponsive to IVIG. Furthermore, until recently, MIS-C has not been reported form Asian countries where KD is otherwise common.

PIMS-TS is commonly reported from countries like the USA, UK, France, Italy[2],[3] but not from other countries like India (until recently), China, Russia, South American, and African countries where the burden of COVID-19 is also high. Also, this condition is more common in minority ethnic population. The possible reasons for these findings could be the change in the virus over time leading to change in pathogenicity; genomic diversity of the virus in different geographical regions causing different manifestations; protective effect of Bacillus Calmette–Guérin vaccine in some countries; host genetic factors; different immunological response to virus; and under-recognition, and under-reporting.

Recently, PIMS-TS has been reported from India[4],[5] and we also started encountering children with PIMS-TS in pediatric emergency and pediatric intensive care units (PICU). As the peak of MIS-C occurs 2–4 weeks after the peak of COVID-19,[2],[3] the countries currently progressing toward the peak of COVID-19 should upscale the healthcare facilities to face the peak of PIMS-TS. There is a need to sensitize the clinicians, pediatricians, and intensivists to diagnose this condition early in any child who presents with acute febrile illness with gastrointestinal, mucocutaneous, cardiovascular manifestations, and laboratory evidence of hyperinflammation. As most of children with PIMS-TS had positive SARS-CoV-2 antibody test, these tests should be easily available, affordable, standardized, and should have a short turn-around time. Majority of children with PIMS-TS need PICU admission, invasive mechanical ventilation, vasoactive drugs, and immunomodulators (IVIG, steroids, and biologicals). Therefore, efforts should be made to arrange an adequate number of trained intensivists, intensive care beds, and mechanical ventilators; adequate supply of steroids, IVIG, biologicals, and other supportive care equipment. The multidisciplinary teams consisting of intensivists, infectious disease specialists, cardiologists, hematologists, rheumatologists, and pharmacologists should be ready.

Since PIMS-TS is a new condition and we are still learning about it, there is an urgent need to understand its pathophysiology, clinical course, treatment modalities, outcome, and long-term prognosis (especially among those having cardiac involvement). The multicentric studies should be planned to have answer to some of these questions in near future and to formulate treatment guidelines. So that children with PIMS-TS can be managed appropriately for a good clinical outcome.



 
  References Top

1.
Mukund B, Sharma M, Mehta A, Kumar A, Bhat V. Pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus 2 – An emerging problem of PICU: A case series. J Pediatr Crit Care 2020;7:271-5.  Back to cited text no. 1
  [Full text]  
2.
Kaushik A, Gupta S, Sood M, Sharma S, Verma S. A systematic review of multisystem inflammatory syndrome in children associated with SARS-CoV-2 infection. Pediatr Infect Dis J 2020;39:e340-6.  Back to cited text no. 2
    
3.
Davies P, Evans C, Kanthimathinathan HK, Lillie J, Brierley J, Waters G, et al. Intensive care admissions of children with paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) in the UK: A multicentre observational study. Lancet Child Adolesc Health 2020;4:669-77.  Back to cited text no. 3
    
4.
Dhanalakshmi K, Venkataraman A, Balasubramanian S, Madhusudan M, Amperayani S, Putilibai S, et al. Epidemiological and clinical profile of pediatric inflammatory multisystem syndrome-Temporally associated with SARS-CoV-2 (PIMS-TS) in Indian children. Indian Pediatr 2020:S097475591600220. Epub ahead of print. PMID: 32769230.  Back to cited text no. 4
    
5.
Jain S, Sen S, Lakshmivenkateshiah S, Bobhate P, Venkatesh S, Udani S, et al. Multisystem inflammatory syndrome in children with COVID-19 in Mumbai, India. Indian Pediatr 2020:S097475591600230. Epub ahead of print. PMID: 32788432.  Back to cited text no. 5
    




 

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