key: cord-0801449-185sobau
authors: Fabi, Marianna; Filice, Emanuele; Andreozzi, Laura; Conti, Francesca; Gabrielli, Liliana; Balducci, Anna; Vergine, Gianluca; Cicero, MD, Cristina; Iughetti, Lorenzo; Guerzoni, Maria Elena; Corinaldesi, Elena; Lazzarotto, Tiziana; Pession, Andrea; Lanari, Marcello
title: Spectrum of cardiovascular diseases in children during high peak COVID-19 period infection in Northern Italy: is there a link?
date: 2020-12-06
journal: J Pediatric Infect Dis Soc
DOI: 10.1093/jpids/piaa162
sha: ec7fc2e3e352d96660e7d4954234c94f7825cf51
doc_id: 801449
cord_uid: 185sobau

BACKGROUND: Children with COVID-19 have a milder clinical course than adults. We describe the spectrum of cardiovascular manifestations during a COVID-19 outbreak in Emilia-Romagna, Italy. METHODS: Cross-sectional multicenter study including all diagnosis of KD, myocarditis and multisystem inflammatory syndrome in children (MIS-C) from February to April,2020. KD patients were compared to those diagnosed before the epidemic. RESULTS: KD: 8 patients (6/8 boys, all negative for SARS-CoV-2); complete presentation in 5/8; 7/8 IVIG-responders; 3/8 showed transient coronary lesions (CALs). MYOCARDITIS: one 5-year-old girl negative for SARS-CoV-2, positive for Parvovirus B19. She responded to IVIG. MIS-C: 4 SARS-CoV-2 positive boys (3 patients with positive swab and serology, 1 patient with negative swab and positive serology). Three presented myocardial dysfunction and pericardial effusion, one developed multicoronary aneurysms and hyperinflammation; all responded to treatment. The fourth boy had mitral and aortic regurgitation that rapidly regressed after steroids. CONCLUSIONS: KD, myocarditis and MIS-C were distinguishable cardiovascular manifestations. KD did not show a more aggressive form compared to previous years: coronary involvement was frequent, but always transient. MIS-C and myocarditis rapidly responded to treatment without cardiac sequelae despite high markers of myocardial injury at onset suggesting a myocardial depression due to systemic inflammation rather than focal necrosis. Evidence of actual or previous SARS-CoV-2 infection was documented only in patients with MIS-C.

Coronavirus disease is a new disease due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It has rapidly become a major global health issue due to the current pandemic outbreak this year. Italy is among the most severely affected countries. Data from the Italian National Health Institute (Istituto Superiore di Sanità), updated on May 7, indicate that Emilia-Romagna is the third most affected Italian region with a cumulative incidence of 591.53 per 100,000 people 1 , a total of 26,379 recorded cases accounting for a 12.3% of total Italian cases, 632 (2.4%) younger than 20 years of age.

Clinical manifestations of COVID-19 in adult patients include primarily respiratory symptoms and signs ranging from dry cough to severe acute respiratory syndrome, that can lead to severe complications and death 2 . On the contrary, children diagnosed with COVID-19 disease seem to have a milder clinical course, with a benign respiratory involvement, rare complications and favorable outcomes 3, 4 .

Even though the symptoms affecting the respiratory system are the most noticeable, SARS-CoV-2 is responsible for a systemic inflammation with cytokine release that can result in multiorgan dysfunction.

SARS-CoV-2 enters the cells through the Angiotensin-converting enzyme 2 (ACE2) receptor. ACE2 receptor is widely distributed over organs, accounting for the systemic nature of the disease 5, 6 . A wide range of cardiovascular manifestations has been described, including myocardial infarction, myocardial injury, myocarditis, arrhythmias and venous thromboembolism, usually associated with pulmonary lesions 7 . A c c e p t e d M a n u s c r i p t

We performed a cross-sectional multicenter study including patients aged from 0 to 17 years diagnosed with KD, myocarditis and MIS-C from February 2020 to April 2020. KD was diagnosed in 4 pediatric departments located in Emilia-Romagna (Bologna, Rimini, Modena, Piacenza); myocarditis and MIS-C were diagnosed in Bologna Hospital, a tertiary referral Hospital.

KD diagnoses were made according to 2017 American Heart Association (AHA) Guidelines 1 , distinguishing between complete and incomplete/atypical forms of clinical presentation. The onset of illness was defined as the first day of fever.

All patients were given the standard treatment (immunoglobulins [IVIG] at 2 g/Kg in a single infusion within the tenth day with aspirin at 30-50 mg/Kg/day, subsequently switched to 3-5 mg/Kg/day once the patient became afebrile for at least 48 hours).

IVIG-resistance was defined as persistent/recrudescent fever for at least 36 hours, but not longer than 7 days after the completion of the first IVIG infusion. In case of IVIG-unresponsiveness, a second dose of IVIG was administered, as recommended 12 . Intravenous 2 mg/Kg/die methylprednisolone was administered in children with persistent fever at least 36 hours after the completion of the second IVIG dose, according to RAISE study 13 .

Myocarditis was diagnosed according to the ESC criteria 15 , if more than one clinical and more than one diagnostic criteria were met. Clinical findings included: acute chest pain; new-onset or worsening of dyspnea and/or fatigue; palpitation, unexplained arrhythmia symptoms, syncope, aborted sudden cardiac death; unexplained cardiogenic shock. Diagnostic criteria included laboratory and instrumental non-invasive investigations (myocardiocytolysis markers, ECG/Holter/stress tests, echocardiogram, coronary angiography and magnetic resonance imaging [MRI] ). Children diagnosed with myocarditis were given 2g/kg IVIG and vasoactive agents, when necessary. Since then, a real-time PCR assay are performed on nasopharyngeal samples, to detect SARS-CoV-2 nucleic acid.

Ten patients were tested with serological assays for SARS-CoV-2. Commercially available chemiluminescent-immunoassays for the detection of SARS-CoV-2 specific IgG and IgM antibodies (iFlash-SARS-CoV-2 IgG and IgM, Yhlo Biotech, Shenzhen, China) were performed on a fully automated iFlash Immunoassay Analyzer (Yhlo Biotech, Shenzhen, China). The assays were performed according to the manufacturer's protocols. The IgG and IgM titer were automatically calculated as arbitrary units (AU/ml) and the cut-off value for a positive test was 10 AU/ml. All patients received a transthoracic echocardiogram (TTE) to evaluate systolic function measured by ejection fraction (EF), mitral and aortic valve function, presence of pericardial effusion.

The diameters of coronary arteries were measured and indexed to Body Surface Area (BSA) and subsequently recorded as z-score. We classified coronary involvement according to 2017 AHA criteria 12 : z-score<2, normal; z-score between 2 and 2.5, dilation; small aneurysm when ≥2.5 and <5, medium aneurysm when ≥5 and <10, and absolute dimension <8 mm, large/giant aneurysm when ≥10 or absolute dimension ≥8 mm.

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Continuous data are presented as mean ± standard deviation (SD).

We tested the normality for each variable through the Kolmogorov-Smirnov.

For categorical variables, the percentage of patients in each category was calculated and compared with Chi-square or Fisher's exact test, when appropriate.

The two groups were compared running a two-tailed Independent-Samples T-Test. Levene's test was used to assess the equality of variances for the considered variables. P<0.05 was considered statistically significant. The study analysis was performed using SPSS V26 for Macintosh.

There was no funding source. The study was approved by the local Ethics Committee (approval 

Demographic, clinical, laboratory and imaging, echocardiographic data and therapy of all patients are presented in Table 1 . All patients were previously healthy. Eight patients were diagnosed with KD (Group 1), 1 with myocarditis (Group 2) and 4 with MIS-C (Group 3).

Eight patients (Patients 1 to 8 in Table 1 ) were diagnosed with KD: 5/8 (62.5%) children showed complete presentation. Exanthema and erythema of oral mucosa and lips were the most common clinical manifestations in incomplete forms (3/4 patients, 75%).

All children were given standard treatment. One patient (Pt3) was IVIG non-responder (1/8, 12.5%).

In the Cohort CRP, ESR, ferritin and fibrinogen values were high (mean+SD respectively: 17.16+11.95, normal < 0.5 mg/dL; 66+31.94, normal <11mm/h; 142+72, normal 24-336 ng/mL; 574.57+159.49 normal 150-400 mg/dL). IL-6 was elevated when tested (Pt 1, 2, 3, 4; 193.9+206 pg/ml, normal < 5.9 pg/mL).

All children tested for SARS-CoV-2 and resulted negative.

Two patients performed chest imaging: Pt 3 showed findings consistent with pneumonia, Pt 5 with bronchitis.

A c c e p t e d M a n u s c r i p t Coronary aneurysms were detected in 3/8 patients (Pt 1, 3, 4; 37.5%). All coronary lesions (CALs) regressed by the third week after onset. These data were confirmed at 6-weeks follow-up echocardiography. ECG showed no abnormalities in 8/8 (100%).

Compared to our historic regional cohort of KD, age (48.08+34.28 vs 32.8+27.3 months, p>0.05), the percentages of IVIG-responders and CALs were not significantly different (respectively, 87.5% vs 72.9%, and 37.5% vs 22.57%, p >0.05). Comparing laboratory, cytokines and immunological features of the KD patients diagnosed in Bologna in 2020 with those diagnosed in Bologna from 2016 to 2019 (Table 2) , significantly lower ESR and higher CD3+CD8+ percentage in KD group diagnosed in 2020 were observed, while cytokines were comparable.

Myocarditis was diagnosed in a 5 years-old girl (Pt9), admitted for repeated syncope and abdominal pain, presenting with mild arterial hypotension. She required inotropic support.

BNP and cTnI were elevated. Echocardiography findings are shown in Table 1 . Comparison of lymphocyte immunophenotyping of MIS-C patients with KD patients showed no significant difference ( Table 3) .

At the 4 months cardiological follow-up all patients showed normal EF, valve function and coronary arteries.

In the current COVID-19 scenario, a wide variability of manifestations has been reported, probably due to the systemic nature of SARS-CoV-2 infection and its physiopathological mechanisms.

We report a spectrum of cardiovascular manifestations in children during the high peak period of the outbreak of the COVID-19 from February 1 st to April 30 th in the Italian region of Emilia-Romagna, which has been deeply affected by SARS-CoV-2.

In our experience, KD and MIS-C, despite presenting overlapping features and manifestations, were distinguishable.

In adults, cardiovascular manifestations increase COVID-19 mortality when associated with pneumonia 17 . Despite the fact that children and adolescents seem to be less affected by A c c e p t e d M a n u s c r i p t usually with milder disease severity compared to adults, either in China and in USA 18 , a recent new alert has risen concerning an outbreak of severe Kawasaki-like disease 9 , hyperinflammatory shock syndrome 11 and KD 4,10 , describing clusters of children and adolescents presenting with fever and clinical manifestations KD-like and shock, requiring intensive care support 19 . However, despite an increase of reported cases diagnosed as KD, it is likely that many of them might be MIS-C given the outbreak of COVID-19 ongoing at the time.

The wide spectrum of COVID-19 manifestations can be explained by the distribution of SARS-CoV-2 site of entry, ACE2 6 . ACE2 is highly expressed in type-2 lung alveolar cells 20 but also in the intestinal epithelium, kidneys, skin, immune organs 6 . The myocardial damage may be secondary to two mechanisms: direct cardiotoxicity since ACE2 is present in more than 7.5% of myocardiocytes 21 and indirect injury through a cytokine storm and the subsequent release of proinflammatory cytokines 22 that depress myocardial function. ACE2 is also expressed on vascular endothelium of veins and arteries such as coronary arteries 6 explaining vasoplegia and coronary involvement.

Since February, 1 st 2020,8 cases of KD in a 3-month period were reported in the Italian region of Emilia-Romagna, while previously, about 14-15 new cases of KD per year were reported. Although the method of collecting data is retrospective, thus data may be missing, it seems that during the first months of the current year more diagnosis have been made compared to last years during the same time period. However, the "temporal clusters" and seasonality of KD make it difficult to compare the incidence of KD in the COVID-19 period with previous years. In our experience, the disease did not present a peculiar and more aggressive form: at onset classical features of KD with complete presentation were present in more than half of children.

Compared to our historic cohort 5 24 , KD patients were older but not statistically significant, and similarly, they presented a male prevalence (2:1 vs 1.4:1) and were mostly IVIG-responders (8/9, 88.9% vs 214/257, 83.3%, p>0.05). Although coronary abnormalities were frequent (4/9, 44.4%), they were not severe (3 mild aneurysms and 1 dilation) and all regressed 3 weeks from onset. In addition, the incidence was not different compared to previous years (p>0.05).

Comparing children diagnosed with KD in Bologna in 2020 to those diagnosed in 2016-2019 (Table   2) In addition, oligoclonal IgA B-lymphocytes were identified driving the hypothesis that the immune system activation could be triggered by an intracellular respiratory pathogen. Furthermore, a higher proportion of CD8+ T-cells activation correlates with a worse response to IVIG treatment 25 Conflictual data are reported about coinfections in COVID-19 children: Chinese researchers report coinfections with common respiratory agents in 46% of screened SARS-CoV-2 children 30 , UK researchers isolated Adenovirus and Enterovirus in 1/8 children 8 , and none had coinfections when tested in the French study 10 . All considering, we support the need for SARS-CoV-2 screening during the peak season for respiratory infections.

To date, there is not a standard treatment for MIS-C and conflictual data are reported for myocarditis.

IVIG has an anti-inflammatory effect through different ways acting on macrophages and adhesion molecules to vascular endothelium, containing antibodies neutralizing cytokines and activated complement proteins, and influencing T-regulatory cells 31 . They represent the standard treatment in KD, while current evidence still does not support their routine use in myocarditis 15 , despite a recent meta-analysis suggested a superiority of IVIG therapy to conventional treatment in reducing inhospital mortality 32 . Regarding MIS-C, reported cases of children and adolescent treated with IVIG have shown positive outcome. Although in our cohort IVIG was administered to all but one patient, a proper diagnosis should be done to help clinicians to choose the optimal therapeutic regimen (beyond IVIG) and proper timing, to handle the potential complications of the disease and to assess the prognosis of the patient.

All children should have a cardiological follow-up since little is known about the cardio-vascular midand long-term complications of COVID-19.

In Emilia-Romagna, one of the most affected area by SARS-CoV-2 in Italy, KD, myocarditis and MIS-C were cardiovascular manifestations in the COVID-scenario. In our experience, KD presented classical manifestations, either complete and incomplete. Despite an outbreak of KD, our patients had negative SARS-CoV-2 serology. KD patients did not show a more aggressive form of the disease compared to KD diagnosed before the pandemic: coronary involvement was frequent, but always transient. MIS-C and myocarditis, as well, responded rapidly to treatment despite critical clinical onset, cardiac involvement and high markers of myocardial injury. The myocardial injury could be related to systemic inflammation rather than direct cardiotoxicity since cardiac sequelae were not detected on the short-term echocardiogram and MRI. In our experience, KD and MIS-C were 

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The authors declare that there is no conflict of interest regarding the publication of this article. The authors received no specific funding for this work. The current information has not been presented in any meeting. 

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