Author

Dr. Anand P Rao

Browsing

An eight year old was brought to the emergency room of a hospital in a stage of shock. She had a short duration illness with fever, skin rash, red eyes with vomiting and diarrhea. The child was given intravenous fluids and oxygen and rushed to the pediatric intensive care unit. She was started on antibiotics and supportive treatment. When the history was reviewed, it was noted that she had come in contact with a relative with COVID-19 infection three to four weeks before. She was diagnosed to have Pediatric inflammatory multisystem syndrome (PIMS) – temporally related to COVID-19 (PIMS-TS) or Multisystem inflammatory syndrome in children (MIS-C) – temporally related to COVID-19.

Pediatric inflammatory multisystem syndrome– temporally related to COVID-19 (PIMS-TS) is a newly described condition with the first reports in the journals about a few months ago.

Year 2020 has had this dubious distinction of being a year of turmoil. The COVID-19 pandemic has been an event which happens once in a century. Last such event which affected the world as we know it, was way back in 1918 when the Spanish flu wreaked havoc across the whole world.  Children have been reported to be affected very mildly as compared to adults and elderly. 

Initial Reports

In the month of April 2020, there started emanating reports in medical literature of children who were previously well presenting with illness, fever, red eyes and swelling of glands in the neck. This description resembled a condition known as Kawasaki disease. But what made it worse was that these children presented with hypotension (low blood pressure). 60-100% of children had features of vomiting, abdominal pain, and diarrhea. About 60% of children had features of brain fever.  They were managed in the emergency room because the blood pressure had fallen significantly. Some of these children also had decreased heart function and swelling of coronary arteries which supply the muscles of the heart with oxygen rich blood which could have led to a circulatory shock. These reports from the United Kingdom were followed by reports from Italy, USA and recently from India too. 

The unique phenomenon which was noticed by epidemiologists was that the areas from which these patients were being reported were from those geographic areas which had witnessed a surge of COVID-19 infections three to four weeks prior. This has led to some experts suggesting a temporal association of COVID-19 infection with this multisystem inflammatory syndrome.

Symptoms & Treatment

The usual age of children being affected by this condition is about 8 to 10 years. These children present with fever for 3 to 4 days associated with redness of eyes, mouth and lips with skin rashes and presence of tender nodes in the neck. They have a sudden deterioration in the form of low blood pressure, cold clammy extremities and feeling faint with decreased urine output. These children need admission to the intensive care unit most of the times. The children need to be resuscitated with fluids and drugs to improve their blood pressure. Supportive treatment is very important. Drugs like intravenous immunoglobulin and steroids can be used to control the inflammation in the various organs of their body.

High fever in children, in contact with Covid-19 patients, could be due to PIMS-TS
High fever in children, in contact with Covid-19 patients, could be due to PIMS-TS

Many of these children according to the literature when evaluated for COVID-19 antibodies were found to be positive. This would substantiate the claims of temporal association of this condition with COVID-19 infection. The knowledge about this condition is still in a stage of evolution as more and more cases across the globe are being reported. There have already been reports of this condition from the cities hit by the COVID-19 infection like Delhi, Mumbai, Chennai and Pune. This condition has been reported in those geographic areas which have had a surge of COVID-19 cases about 4 to 6 weeks prior. The most important aspect is recognition of this condition early and early initiation of treatment. However the condition thankfully is associated with low mortality.  

Summary Pediatric Inflammatory Multisystem Syndrome – temporally related to COVID-19:

  • Predominantly seen in older children rather than infants or toddlers.
  • Suspect if child is febrile with skin rashes, red eyes and gland swelling in the neck.
  • Loose stools, vomiting and abdominal pain can be the presenting symptoms.
  • If the child is acutely ill with disorientation and cold hands and feet, he needs to be seen by a health care provider as soon as possible.
  • Treatment is available and mortality is very low when treated adequately on time.

Rohan, a six-year-old boy was brought by his distraught parents for leg pains which used to be worse at nights. This story has been going on for the past 6 months or so. It was distressing to the family to have the child wake up night after night complaining of pains. He was taken to his pediatrician for a check-up. He was evaluated by his pediatrician and was diagnosed to have ‘Growing pains’.

Growing pains in children typically seen between 2 to 12 years of age. It might be the reason why it has been labeled or mislabelled as growing pains. Firstly, it has nothing to do with the growth of the child. The usual story is that of a physically active child who either complains of lower limb pain typically in calves, shin, or behind the knees, typically just before going to bed or wakes up at night due to pains. The pains tend to be seen in both lower limbs in 80-90% of the patients. There might be periods of time when the pain seems to disappear completely for a few days or weeks. The pain typically gets better with some massage or paracetamol use.  There are multiple theories of why growing pains in children happens. It is thought to be related to happen due to muscle/bone fatigue due to lower limb overuse. This might be supported by the fact that the pain tends to be worse on days of increased physical activity.

It might also be related to psychological stressors like marital discord at home, stressors at school, or bullying at school. Some of these children might have a lower pain threshold which would mean that they experience pain even with minimal painful stimulus.  

The condition tends to resolve in most of the children in the teenage years. It is estimated the pain is experienced anywhere between 10% to 20% of children. The treatment is usually symptomatic with massage and hot fomentation like the immersion of the lower limbs in a bucket of warm water. Medications like paracetamol can be useful in a few patients.