Dozens of children in the United States and around the world are battling a mysterious illness that is possibly linked to the novel coronavirus COVID-19 (SARS-CoV-2). The coronavirus impact on children has previously been thought to be minor. This illness challenges those assumptions. The illness is referred to as Pediatric Inflammatory Multisystem Syndrome (PIMS). Recently, the Centers for Disease Control and Prevention (CDC) termed the illness Multisystem Inflammatory Syndrome in Children Associated with COVID-19 (MIS-C).
Since many primary sources continue to refer to the illness as PIMS, we will do so in this article. Please note, however, that PIMS and MIS-C are the same illness.
In April 2020, medical officials in Britain, Spain and Italy warned doctors around the world to be on the lookout for a “mysterious illness” affecting infants and children. Many of these illnesses are attributed to Kawasaki disease, and others are attributed to TSS. While the link between the illness and coronavirus is still under investigation, experts are urging doctors in the U.S. to be vigilant. Coronavirus risk to infants and children may be much more serious than anyone knows.
Infectious disease specialist Dr. Larry Kociolek says,
“It raises our antenna a bit and tells us we need to be vigilant about unusual and more severe complications of COVID-19” in children.
Coronavirus Impact on Children More Significant Than Previously Thought
Researchers do not know for sure how PIMS may be linked to COVID-19. There are no reported cases of PIMS in Asia, so doctors in the U.S. are focusing on what they know about the cases here. It appears that PIMS develops in children who have had COVID-19. Researchers believe that PIMS is the result of an infant or child’s immune system responding in “overdrive” to a coronavirus infection.
Chief of pediatric and critical care medicine at Cohen’s Children Medical Center, Dr. James Schneider, says,
“That overactive immune system leads to this whole systemic inflammation that leads to the cardiovascular system being compromised.”
Parents may not know that their child had COVID-19 because most children exhibit few or no symptoms. Therefore, a diagnosis of PIMS may be the first diagnosis for COVID-19 as well. Furthermore, PIMS may develop up to six weeks after a COVID-19 infection.
Currently, this suspected coronavirus impact on children has affected around 85 children across the U.S. It has been identified in hospitals in:
- District of Columbia
- New York
There are other suspected cases in hospitals across the U.S., and experts warn doctors and hospitals to be aware of the symptoms and take action promptly. Experts also warn that there are increasing reports of COVID-19 leaving patients with heart damage, including children. This is further raising questions about possible complications of COVID-19. Dr. Barry Trachtenberg from Houston Methodist Heart Failure and Transplantation Cardiology says,
“There’s a whole range of cardiac symptoms that can occur due to COVID and we are just beginning to understand this.”
PIMS and Coronavirus Impact on Children and Infants
PIMS is a rare inflammatory illness that primarily affects the heart. The illness presents symptoms that are similar to Kawasaki disease or toxic shock syndrome (TSS), but it is a distinct illness. Doctors warn parents to be on the lookout for symptoms including:
- High fever that does not respond to Motrin or Tylenol
- Difficulty breathing
- Redness around the eyes
- Severe abdominal pain
Timely diagnosis and treatment of PIMS is crucial. PIMS can cause serious health conditions including diarrhea, kidney injury and cardiac dysfunction.
Diagnosing and Treating PIMS
Doctors diagnose PIMS using a combination of tests. This may include:
- Blood tests to look for inflammatory markers
- Tests to see if the child’s blood is clotting too quickly
- Echocardiogram with detailed assessment of arteries
- Kidney function tests
- Gut health tests
- SARS-CoV-2 antibody tests
- At least two organ systems involved (cardiac, gastrointestinal, dermatologic, hematologic, neurologic, renal or respiratory)
Doctors are generally treating PIMS using the standard treatment used for Kawasaki disease. The goal of treatment is to reduce inflammation and prevent long term damage to the arteries and heart. The course of treatment will depend on the severity of the illness and the symptoms presented.
Treatment options include:
- Anticoagulation medication (Coumadin, heparin, Xarelto, Eliquis)
- IV immunoglobulin (plasma transfusion)
- IL-1 or IL-6 blockade (antibody treatment that helps the body fight autoimmune and inflammatory diseases)
- Corticosteroids (Decadron, Mometasone, Cotolone)
- Vasopressors (milrinone and noradrenaline are needed for hemodynamic shock since it does not respond to fluid support)
These treatments are considered highly effective, and most children recover without complications.
What is Kawasaki Disease?
Kawasaki disease (KD), also called Kawasaki syndrome, is an acute febrile illness that most often affects children under five years old. It is named Kawasaki disease because it was first described in 1967 by Tomisaku Kawasaki. The first reported cases of KD outside of Japan occurred in 1976. Since then, it has been reported in countries around the world, though it is still most prevalent in Japan.
In the United States, KD is considered a “leading cause of acquired heart disease.” It primarily affects children five years old and younger, though children 18 and under can develop the disease. KD is more common in males than females. The etiology of the disease is currently unknown.
The Kawasaki Disease Foundation estimates that, in the U.S.:
- 5,447 infants and children are diagnosed with KD each year.
- Around 19 per 100,000 children will develop KD.
- Among annual cases, 25 cases are at risk for coronary aneurysms.
- Among annual cases, 74 cases are among children under the age of five.
- In 2000, 77 percent of patients with KD were under five years old.
Symptoms of Kawasaki Disease
The most common symptoms of KD include:
- Rash on the trunk or torso
- Redness and swelling of feet and hands
- Irritation and redness in the eyes
- Swollen lymph glands in the neck
- Irritation and/or inflammation of the lips, mouth and throat
Treating Kawasaki Disease
Standard treatment for KD includes aspirin and intravenous immunoglobulin aimed at reducing inflammation. These treatments also decrease the likelihood of the patient developing coronary artery abnormalities. Treating KD requires hospitalization. Experts say that treatment should be done by specialists at hospitals that are equipped with intensive care units. Some children who have KD develop more serious illness or complications more quickly than others.
KD is a serious medical condition and there are a variety of possible complications. These include aneurysm and coronary artery dilation.
Is Kawasaki Disease Related to COVID-19?
In countries where KD is more prevalent, the number of cases has risen during the coronavirus outbreak. However, that does not necessarily mean that all of these mysterious illnesses are, in fact, KD. Researchers are still investigating a possible link between the two.
What is Toxic Shock Syndrome?
Many doctors and researchers also note that PIMS symptoms resemble some symptoms of toxic shock syndrome (TSS). TSS is a medical condition caused by exposure to bacteria. Most commonly, TSS develops as a result of Staphylococcus aureus or Streptococcus pyogenes. Bacteria like these often live naturally on or inside the human body. Generally, people develop antibodies to fight off possible infection caused by toxins in the bacteria.
People who do not have antibodies are at risk of developing TSS if the bacteria penetrates into the bloodstream. There are a variety of infections that can lead to TSS. You should be mindful of the risk of TSS if you have recently experienced:
- Bacterial cellulitis
- Osteomyelitis (bone infection)
- Skin wounds (burns, cuts, surgical site)
People with certain chronic medical conditions are the most at-risk for TSS. This includes people with:
- Chronic lung disease
- Heart disease
While certain people may be more at risk for developing TSS, it is a condition that can affect people of all ages and with a variety of causes or underlying conditions.
Symptoms of Toxic Shock Syndrome
Many people who develop TSS report variations in their symptoms. This may be because of the underlying cause of the infection, or the type of TSS they have – Staphylococcus aureus or Streptococcus pyogenes. Generally, the symptoms are broken down as the following:
- Fever over 102° F
- Red, flat rash
- Shedding of the skin (primarily palms and soles of feet)
- Muscle pain
- Low blood pressure
- Decreased liver function
- Decreased urine output
- Disorientation or confusion
- Malaise (despair or uneasiness)
- Decreased kidney function
- Bruising (low platelet count)
- Red, flat rash
- Shedding of the skin
- Difficulty breathing
- Low blood pressure
Diagnosing and Treating Toxic Shock Syndrome
Diagnosing TSS can be a complicated process. First, doctors must eliminate the possibility of other conditions. Next, doctors use diagnostic studies to determine if the patient has TSS. These studies include:
- Blood cultures to find and identify microorganisms.
- Blood tests to measure bleeding time, clotting, electrolytes, liver function and cell counts.
- Urine tests
- Lumbar puncture to check for bacteria in spinal fluid.
If the diagnosis is TSS, doctors must work quickly to assess the patient and initiate treatment. Treatment options for TSS may vary depending on the type of bacteria and the severity of the illness. Treatment methods include:
- IV antibiotics
- Intravenous fluids
- Blood pressure medication
- Blood transfusion
- Supplemental oxygen or ventilator support
- Deep surgical cleaning if an infected wound is present
Treatment of TSS aims to preserve important organs and bodily functions. Unfortunately, TSS is a very severe illness. Estimates suggest that the mortality rate among patients with TSS is around six percent. In children, the mortality rate is between three and five percent. Those who do survive are at risk for complications like liver, kidney or heart failure.
Key Takeaways for Parents on Coronavirus Impact on Children
Researchers are not sure where the link is between coronavirus and Pediatric Inflammatory Multisystem Syndrome (PIMS). Therefore, parents should err on the side of caution. If your child develops any symptoms of PIMS, KD or TSS, contact your healthcare provider right away. This new suspected coronavirus impact on children does not have to change your families lives.
Remember, your child does not have to have a COVID-19 diagnosis in order for her or him to have the illness and be at risk.