Dr. Kara Fitzgerald receives the Rosalind Franklin Society Special Award in Science
Many of you have reached out over the past few days with questions about recent reports in the press about a “mysterious” inflammatory condition associated with COVID-19 among children. Indeed, there is an apparent uptick in the incidence of what is now being called “pediatric multisystem inflammatory syndrome potentially associated with COVID-19” (PIMS). Though dubbed by the press as mysterious, it is an illness that shares features with several well-known pediatric inflammatory syndromes (most notably Kawasaki Disease and Toxic Shock) and there is widespread consensus in the pediatric community as to what early identification and treatment should look like.
First, I will just stop to tell you that the incidence of serious illness in children with COVID-19 is very rare; PIMS is rarer still and bad outcomes from PIMS are even rarer. Also know that empowered, knowledgeable parents help enable early detection, which in turn allows for early treatment and good outcomes.
Children with this syndrome may have some or all features of Kawasaki disease (KD), a rare childhood condition characterized by widespread inflammation of blood vessels (vasculitis) throughout the body. KD has been associated with a number of viral illnesses and is perhaps the most common vasculitis in childhood. Pre-COVID-19, the incidence of KD in the US per CDC estimates was between 9-19 per 100,000 children under the age of 5 per year. That is 0.02 percent of children per year. The exact cause of KD is unknown, but is thought to result from an immunologic response to a variety of environmental triggers, based on individual genetics. If you think of COVID-19 as primarily a disease affecting the endothelium (the lining of various organs and cavities in the body, including blood vessels), as reported in The Lancet journal in April, it is not entirely surprising that we are seeing something like KD associated with COVID-19.
Kawasaki disease is characterized by:
- high fevers
- bloodshot eyes
- cracked red lips and very red tongue
- swelling of the hands and feet
- rash
- swelling of the lymph nodes in the neck
- abdominal pain
These symptoms are not always present at the same time and do not present in any particular order, nor are they all necessary to diagnose KD— to diagnose it, you meet a certain threshold of these symptoms and lab findings. Pre COVID-19, about 7% of kids with KD develop Kawasaki Disease Shock Syndrome, requiring blood pressure support. PIMS seems to feature shock syndrome more prominently than typical KD and also appears to be affecting older children, including teenagers. Most PIMS patients seem to present with high fever, abdominal pain and rash. Kids with PIMS are eventually testing positive for COVID antibodies, but often negative for the PCR test, suggesting that they were infected with COVID-19 at some point before they developed PIMS symptoms, but are not concurrently infected with COVID-19.
Historically, for most patients (about 75%), KD appears to resolve on its own within 12-14 days. The reason it captures pediatricians’ attention and the imagination of the press, is that complications from KD can be serious, such as aneurysm of the blood vessels around the heart, inflammation within the heart and around the lining of the heart. So even though KD is rare and the complications from it are even more rare, it is a condition that we want to catch early and treat with the help of pediatric cardiologists, infectious disease specialists, rheumatologists and intensive care specialists. For pediatricians in specialist care settings, these constellations of symptoms are not at all mysterious or baffling, and overall, children are responding quite well to conventional treatment. Treatment generally includes intravenous immunoglobulin and any other supportive measures, such as blood pressure or respiratory support, as needed.
Scary though this sounds, the incidence of PIMS is still very small. At the time of this writing, following an international conference on the topic, there only appear to be approximately 50 in Europe and 15 in NYC. All indications are that the numbers will remain small, although we will most likely see an increase in reports as more folks convalesce from COVID-19 and we see more coordinated data-gathering.
As you navigate all the social, financial and medical uncertainties brought forth by COVID-19, don’t let PIMS feel like yet another big and scary unknown. It is not nearly as mysterious as it sounds. It is exceedingly rare and we have well-established ways to both identify and treat it successfully.
In the interest of focusing on the things that you can control, do what you can to optimize your family’s diet, mitigate stress and remain vigilant about your child’s symptoms should they get sick. There are things we don’t know about PIMS or COVID-19, but we do know that they wreak their havoc through inflammatory pathways. Do your best to establish a low-inflammation baseline by minding your family’s diet and stress. I talk about some ways to do this in my earlier blog about COVID-19 and the team at Sandy Hook Clinic has written about this extensively, from a variety of interdisciplinary perspectives.
Know that most kids with COVID-19 have very mild illnesses. Know that even with PIMS, kids appear to be generally doing very well with treatment. Also know that help is around the corner. Should your child have persistently high fevers, rash or abdominal pain, reach out to your pediatrician. Should you remain worried, ask for a second opinion and have a plan for follow up. There is also a small but growing army of integrative and functional pediatricians to both optimize your child’s wellbeing and help restore their good health should they become ill.
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