by Pierre Tissières and Jean-Louis Teboul
Recent paediatric cases of acute myocarditis following a
SARS-CoV-2 infection have raised the possibility of post-infective
complications of COVID-19. This short editorial is reviewing current
understanding of this new complication, its pathophysiology, diagnosis and
therapeutic strategy.
COVID-19 post-infective acute myocarditis, an unrecognized
complication?
Recent descriptions of a short outbreak of acute myocarditis
in otherwise healthy children raise the hypothesis of additional critical
complications of SARS-CoV-2 infection [1,2,3,4,5,6]. Grimaud et al. just reported in Annals
of Intensive Care, a series of 20 critically ill children with shock admitted,
during a 12-day period, in four pediatric intensive care units in the Paris
urban area [1]. This outbreak occurred after
4–6 weeks of strict lockdown. All children had acute myocardial
dysfunction requiring cardiovascular support. This study confirmed similar
observations from United Kingdom, France and Switzerland [2,3,4,5,6]. In the Grimaud et al. study, 19 out of
20 children had either positive SARS-CoV-2 detection by quantitative PCR or
positive serology. The remaining child had a typical SARS-CoV-2 chest
tomography scan. Note that all children had abdominal symptoms [1].
Acute heart failure is clearly a dissonant clinical feature
of COVID-19 infection in children that is known to be less frequent and less
severe than in adults and with very low mortality [7, 8]. Besides its unusual nature, the main
characteristic of COVID-19 acute myocarditis is its association with major
multisystem inflammatory syndrome, mimicking a well-known pediatric entity, the
Kawasaki disease. Currently three case definitions issued from the World Health
Organization, the Centers for Disease Control and Prevention and the Royal
College of Paediatrics and Child Health related to this emerging inflammatory
condition during COVID-19 pandemic exist. Those definitions identify the
multisystem inflammatory syndrome in children (MIS-C) or the Pediatric
Inflammatory Multisystem Syndrome (PIMS) [4]. All three case definitions include
either partial or full criteria for Kawasaki disease and evidence of COVID-19
diagnosis (clinical and/or biological—serology/PCR). Kawasaki disease’s, which
affect mostly young children of less than 5 years of age, has typical
clinical features including: (1) prolonged fever, (2) conjunctivitis, (3) dry
cracked lips, ((4) cervical adenopathy (5) diffuse skin rash involving the
trunk and extremities, subsequent desquamation of the tips of the toes and
fingers, and 6) edema. In addition to classical manifestations of Kawasaki
disease, MIS-C patients, who are much older, display digestive symptoms, shock
and myocardial involvement more frequently [9]. Kawasaki disease pathophysiology refers
to a systemic arteritis with the most severe complication being coronary
aneurysm. Kawasaki disease can follow by a few days or weeks a wide range of
infection involving numerous viruses such as EBV, MERS- and SARS-CoV-1, H1N1
influenza and other respiratory illnesses [10]… cont
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