A recent case series illustrated that following novel coronavirus infection, acute myocarditis with severe multisystemic inflammation and atypical Kawasaki disease is a rising severe pediatric disorder. It emphasizes the variability and the large spectrum in the host response to this virus. It may be one of the upcoming clinical post-infective complications of coronavirus infection.

This retrospective, observational analysis was conducted to describe the characteristics, time course, and management of 20 critically ill children admitted to PICU (pediatric intensive care unit) with cardiogenic shock secondary to acute myocarditis and intense systemic inflammation after coronavirus infection.

In Paris, a case series was conducted at four academic tertiary care centers. Between 15 April 2020 and 27 April 2020, all the children with shock, fever, and suspected coronavirus infection were admitted to PICU.

The study results indicated that about 20 critically ill children admitted for shock had acute myocarditis, and arterial hypotension with mainly vasoplegic clinical presentation. Before PICU admission, the first symptoms were intense abdominal pain and fever for 6 days. All children had highly elevated CRP (C-reactive protein) and procalcitonin without microbial cause as depicted in Table 1:

In all the children, at least one feature of Kawasaki disease was found (as depicted in Table 2, but none had the typical form.

SARS-CoV-2 PCR (polymerase chain reaction) and serology were positive for 10 and 15 children, respectively. A negative SARS-CoV-2 PCR and serology, and a typical SARS-CoV-2 chest tomography scan was witnessed in one child. All participants but one required an inotropic/vasoactive drug support (as shown in Table 3, and 8 children were intubated.

All children received intravenous immunoglobulin (2 g per kilogram) with adjuvant corticosteroids (n=2), a monoclonal antibody against IL-6 receptor (n=1), or IL 1 receptor antagonist (n=1). All the participants were found to survive. They were discharged from the PICU with full recovery of ventricular systolic function and a substantial decline of inflammatory biomarkers. 

Thus, early recognition of this disease and referral to an expert center is warranted. While underlying mechanisms remain uncertain, further investigations should focus on targeting optimal treatment.