Case 1
A 12 year-old boy with history of chronic renal failure and recurrent hemodialysis, admitted with fever and chills from 7 days ago, rash from 3 days ago which disappeared before admission, diarrhea, weakness, and fatigue without respiratory complaints. He was toxic at admission time and vital signs were unstable: Temperature: 39.5 oc, blood pressure: 70/50 mmHg, heart rate: 120/min and SPO2: 92% in the ambient room. He didn’t have tachypnea or abnormal lung sounds. Hours later, he developed respiratory distress. Vasoactive drugs, oseltamivir, meropenem, vancomycin, hydroxychloroquine, and Kaletra were prescribed. In the chest computed tomography (CT) scan, patchy ground-glass opacity and interlobar septal thickening were found compatible with COVID-19. In the complete blood count (CBC), lymphopenia, anemia, and thrombocytopenia were seen. Raised blood urea and creatinine, increased liver transaminases, proteinuria, hematuria, and marked acidosis in the arterial blood gas (ABG) were also noted, but creatine phosphokinase (CPK), lactate dehydrogenase (LDH), and electrolytes were in normal values. The patient’s general condition got worse and he underwent tracheal intubation. Echocardiography showed mild mitral and tricuspid regurgitation, mild diastolic dysfunction, decreased left ventricular ejection fraction on the first day which deteriorated on the second day (Table 1). Packed red blood cell (packed cell), intravenous immunoglobulin (IVIG), and hydrocortisone prescribed. Before completion of the IVIG infusion, the patient’s condition got worse and he died on the third day after hospitalization. Result of COVID-19 RT-PCR was positive for him.
Table 1
Clinical, para clinical and therapeutic data in 10 patients with Pediatric Inflammatory Multisystem Syndrome (PIMS) Associated with SARS -CoV-2
Number of case, age, sex, date of admission | COVID-19 test | First presentation symptoms and signs | Ongoing presentation | Abdomino pelvic Ultrasonography | Chest imaging | Echocardiography | Laboratory data at admission | Ongoing laboratory data | treatments | Total admission days, PICU stay, Out come | First impression |
Case 1: 12 years old boy, 28 march | Covid-19 RT- PCR: positive | fever and chills, rash, diarrhea, fatigue, toxic appearance | Second day: respiratory distress, heart and respiratory failure | | Chest CT-scan: patchy ground glass opacity and interlobar septal thickening | First day: mild MR, Mild TR, mild diastolic dysfunction, LVEF 50%, Second day: moderate MR and TR, moderate diastolic dysfunction LVEF 30% | CBC: WBC: 8.7, N: 90, L: 10, Hb: 9.5, Plt: 75, CRP: 1+, ESR: 32, urea: 75, Cr: 2.5, AST: 62, ALT: 30, UA: Pro: 1+, WBC: many, RBC: 10–12 ABG: PH: 7.2, Hco3: 11.8, Pco2: 30, Po2: 32 | Cr: 3.2, urea: 126, D. dimer: 6888, CRP: 50 | Vasoactives, Oseltamivir, meropenem, vancomycin, hydroxychloroquine, Kaletra, IVIG 1 g/kg, hydrocortisone 2 mg/kg/dose, packed cell | Total: 3 days ICU: 3 days Died | COVID-19 infection |
Case 2: 5 years old girl, 8 April | COVID-19 RT-PCR positive | Fever, vomiting, diarrhea and skin rash, cough and otalgia, conjunctivitis, Loss of appetite | 3 to 5 days after admission: Tachypnea, drowsiness, generalized edema, headache, myalgia, pharyngeal congestion, purulent conjunctivitis, Abdominal pain | mild to moderate free fluid in abdomen and bilateral mild to moderate plural effusion | Normal CT-scan at admission. But on day 5, bilateral plural effusion and patchy infiltration, ground glass apearance | mild TR, trivial MR, normal coronary arteries on 2 occasion | CBC: WBC: 8.1, N: 60, Hb: 10, , Plt: 150, ESR: 71, CRP:28, Alb: 2.6 | CBC: WBC: 6.6, N: 74, L: 20, Hb: 7.4, Plt: 86, ESR: 28, CRP: 23, Alb: 2.2, total protein: 4 Vitamin D: 15 | Hydroxychloroquine, Azithromycin, Ceftriaxone, changed to meropenem,, IVIG 1gr/kg, Albumin, Red Packed cell | Total: 13 PICU: 5 Alive, without sequel | Sepsis |
Case 3: 13 months old boy, 13 April | COVID-19 RT-PCR positive | Fever, generalized erythematous patches, papule and some target shape lesion on edematous base | 3 days after admission, Respiratory distress, decrease spo2: 84% in ambient room and generalized edema | mild intra-abdominal fluid | at admission: Normal chest CT-scan. At day 3: Chest CT-scan: bilateral plural effusion, basilar patchy infiltration and reverse halo sign | Mild TR, mild MR and normal coronary arties on 2 occasion | CBC: WBC: 8.2, N: 65, Hb: 10.8, PLT: 189, Alb: 3.4 ESR: 54, CRP: 96 | day 3: CBC, WBC: 14.5, N: 58, L: 29, Hb: 7.5, Plt: 141 ESR: 60, CRP: 26, Alb: 2.2, | hydroxychloroquine, Ceftriaxone, changed to meropenem, Vancomycin, IVIG 1gr/kg, Albumin, Red Packed cell | Total: 8 PICU: 2 days, Alive, complete improvement without sequel | Acute hemorrhagic edema of infancy |
Case 4: 10 years old girl, 27 April | COVID-19 IgG: positive | Fever, itching skin rash, maculopapular and target shape rashes with more accumulation around neck and trunk and axilla cough, abdominal pain, oliguria, bilateral non purulent conjunctivitis, hypotension and toxic appearance | Generalized edema, right leg edema and sever pain, mild plural effusion | Urinary system ultrasonography was normal, color Doppler ultrasonography of lower limbs veins were normal | CXR and Chest CT-scan before admission: NL Chest CT-scan at day 4: COVID-19 compatible changes and mild bilateral plural effusion | mild MR, mild TR, Mild PI, EF: 60–64% in 3 occasion | CBC: WBC: 9, N: 69, L: 10, Hb: 7.5, Band: 12, Plt: 130, ESR: 30, CRP: 36, Urea: 78, cr: 2.3,, D Dimer: 6556 Alb: 2 | Third day: CBC: WBC: 13.9, N: 87 L: 6 Hb: 9.6 Plt: 211 | meropenem, clindamicine, vancomicine, vasoactives, IVIG 1 g/kg, red packed cell, albumin, enoxaparine, Vitamin D, zinc | Total: 11 PICU: 8 Alive, complete improvement without sequel | Toxic shock syndrome |
Case 5: 14 months old boy, 3 May | COVID-19 RT-PCR negative, IgM: positive | fever, irritability, macoulopapolar erythematous rashes, edema of hands and feet, Cracked and erythematous lips, erythematous tongue and bilateral non purulent conjunctivitis | Irritability, abdominal distension, giant coronary aneurysm | Liver span: 117 mm, spleen: 98 mm, greater than normal, mild intra-abdominal fluid, mild bilateral plural effusion | First day: CXR normal, Chest CT-scan showed non-significant changes Day 4: chest CT-scan: non-significant changes | First day: normal coronary arteries, minimal right Pleural effusion (5 mm), minimal MR, good EF | CBC: WBC: 22, N: 83, L: 5, 6, Band: 5, Hb: 10.6, plt: 197, ESR: 65, CRP: 38, Na: 129, AST: 200, ALT: 197, Alb: 2.3, PTT: 50, PT: 18, INR: 2 | Day 4: WBC 21.8, N: 79, L: 15, Hb: 8.7, Plt: 224, Alb: 3.2, AST: 57, ALT: 55, PT: 14.8, PTT: 42, INR: 1.3, Day 14: CBC: WBC: 25.7 N: 38, L: 44, Mono: 17, Hb: 11.6, Plt: 1168 CRP: 10.9, ESR: 25 | IVIG 2 g/kg/day × 2, Aspirin, hydroxychloroquine, zinc, Vitamin D, Cefotaxim, changeed to meropenem and vancomicine. Albumin, red packed cell, methyl prednisolone 2 mg/kg/day, vasoactives, heparin, warfarin, infliximab | Total: 24 PICU: 20 Alive, Giant coronary arteries aneurysm | Kawasaki disease |
Case 6: 6.5 years old boy, 4 May | COVID-19 RT-PCR negative, COVID-19 IgG positive | fever, anorexia abdominal pain, vomiting, loose defecation, erythematous rash around feet, hands, trunk and perioral, periorbital edema, erythema of oropharynx, right TM erythema | At day 2: dyspnea, repertory distress, spo2 87%, mild abdominal distension, irritability, anasarca edema | spleen: 117 mm, more than normal with normal parenchymal echo, free interloop fluid, sub hepatic and sub splenic, several reactive lymph nodes 15*7 mm in para aorta and peripancreatic | At admission: Chest CT, non-significant changes for COVID-19 At day 4: Chest CT-scan bilateral opacities compatible with COVID-19 | Day 2: minimal TR Day 4: mild TR, trivial MR | CBC: WBC: 4.7 N: 77, L: 14, band: 3, Hb: 10, Plt: 121, ESR: 48, CRP: 45, UA: blood: trace, WBC: 8–10, | CBC: WBC: 6.93 Hb: 7.8 Plt: 73 L: 14 N: 80 Alb: 2.3 CRP: 39 ESR: 58 | Ceftriaxone, Vancomycin, Meropenem, hydroxychloroquine, packed cell, Albumin | Total: 11 PICU: 7 Alive, without sequel | Urosepsis |
Case 7: 7.5 year old girl 4 May | COVID-19 RT-PCR negative | fever, irritability, abdominal pain, myalgia, vomiting, diarrhea and generalized erythematous maculopapular and patches | Facial edema, tachypnea and tachycardia developed and the patient got toxic with gallop in heart auscultation | Normal | Admission Chest CT: NL CXR: at day 3: bilateral mild Ground Glass opacity | Day 3: Mod MR, TR, low EF 50%, Dilated RV, LV: myocarditis Day 7: moderate MR, mild Pleural effusion, low LVEF, lack of tapering, brightness in RCA and LAD compatible with KD and Myocarditis | CBC: WBC: 9.8, N: 89, L: 10, Vitamin D: 4 ng/ml AST:93 ALT: 69 | CBC: WBC: 13.3 Hb: 7.5, Plt: 213 N: 85 L: 10 Alb: 1.9, ESR: 73, CRP: 35 Urea: 72 Cr: 1.1 | Ceftriaxone, changed to Vancomycin, Meropenem, hydroxychloroquine, Zinc, Vitamin D, magnesium sulfate, packed cell, Albumin, IVIg: 2 g/kg | Total: 12 PICU: 8 Alive, without sequel | myocarditis |
case 8: 20 months old boy, 9 may | COVID-19 RT-PCR negative, COVID-19 IgG, IgM negative | Fever, coryza, vomiting diarrhea, abdominal pain, irritability during urination and loss of appetite, erythematous papule in 2 centimeter diameter in the forehead, erythema of oropharynx | tachypnea with unilateral tongue swelling and drooling, with discrete ulcers under the tongue | Normal | Chest CT: bilateral ground opacity compatible with COVID-19 | lack of tapering in RCA and LAD, Mild dilatation of LA, LMCA: 3.7 mm, RCA: 2.2, LAD: 2.2, perivascular brightness around LAD, moderate MR, diastolic dysfunction | WBC: 52.5, N: 80, L: 10, band: 4, Hb: 9.5, Plt: 932, ESR: 100, CRP: 1+ SE: WBC: 4–5, RBC: 2–3 | ABG: PH: 7.33, Pco2: 37, HCO3: 19.9, PO2: 71, Alb: 2.5 | Ceftriaxone changed to clindamycin and Meropenem, hydroxychloroquine, Zinc, Vitamin D, IVIG 2 g/ kg, aspirin 80 mg/kg/day | Total: 11 PICU: 9 Alive, without sequel | KD |
Case 9: 7 years old boy, 23 may | COVID-19 IgM and IgG and RT.PCR negative | Fever with epigastric pain which shift to Right Lower Quadrant, nausea, vomiting | ill, abdominal distension and recurrent vomiting | Reactive lymph node, max diameter 6 mm, fat stranding in Right Lower Quadrant and free inter loop fluid | Chest CT: sub plural atelectasis, mild bilateral pleural effusion, some nodular like lesions in both inferior lobes of lungs compatible with COVID-19 | NL | CBC: WBC: 24000, L: 6%, N: 90%, band: 4%, Hb: 11, Plt: 356, ESR: 72, CRP: 2+ | Day 2: CBC: WBC: 13.5, N: 77, L: 10, Mono: 11, Hb: 10.3, Plt: 347, ESR: 90, CRP: 25 Alb: 3.2 | Meronidazole, Ceftriaxine changed to meropenem, hydroxychloroquine, Vitamin D, Zinc | Total: 6 | Appendicitis |
Case 10: 18 months old girl 13 June | RT- PCR COVID-19 positive | Fever and status epilepticus | Second day: ill and lethargic, maculopapolar blench able rash, tachypnea | | CXR: nl Chest CT in 2 occasion: bilateral nonspecific opacity in inferior lobes | Normal | CBC: WBC: 8.5, N: 80%, L: 14%, Hb: 11.8, PLT: 160 ESR: 15, CRP: 16 Alb: 2.3 | WBC: 1.88, N: 34, L: 59, M: 5, Hb: 10.2, plt: 103 CRP: 3 Alb: 2.5 | Meropenem, clindamycine, phenobarbital, hydroxychloroquine, Vitamin D Albumin, IVIG, 1 g/kg, Zinc | Total: 12 PICU: 9 | Prolonged febrile seizure |
ABG: Arterial blood gas |
Alb: Albumin, grams per deciliter |
Alt: Alanine aminotransferase, units per liter |
AST: Aspartate aminotransferase, units per liter |
CBC: Complete blood count |
Chest CT-scan: Chest computed tomography scan |
COVID-19: Coronavirus disease 2019 |
Cr: Creatinine, milligrams per deciliter |
CRP: C reactive protein, milligram per liter |
CXR: Chest roentgenogram |
D-dimer: ng/mL, increased level > 500, |
ESR: Erythrocyte sedimentation rate, millimeters per hour |
Hb: Hemoglobin, grams per deciliter |
IgM: Immunoglobulin M |
IgG: Immunoglobulin G |
INR: International normalized ration |
IVIG: Intravenous immunoglobulin |
KD: Kawasaki disease |
L: Lymphocyte, % |
LAD: Left anterior descending artery |
LMCA: Left main coronary artery |
LVEF: Left ventricular ejection fraction |
Mono: Monocyte, % |
MR: Mitral regurgitation |
NA: Not assessed, |
N: Neutrophil% |
Na: Sodium, mill equivalents per liter |
NL: Normal |
Plt: Platelet, × 109/Liter |
PICU: Pediatric intensive care unit |
Pro: Protein |
PT: Prothrombin time, seconds |
PTT: Partial thromboplastin time, seconds |
RCA: Right coronary artery |
RT-PCR: Reverse transcription polymerase chain reaction |
SARS-CoV-2: Acute respiratory syndrome coronavirus 2 |
TR: Tricuspid regurgitation |
Total protein: Grams per deciliter |
Urea: Milligrams per deciliter |
Vitamin D, ng/mL |
WBC: White blood cell, × 109/Liter |
Table 2
Wrap up data of hospitalized patients with Pediatric Inflammatory Multisystem Syndrome (PIMS) Associated with SARS -CoV-2, N: 10
Demographic Data | Laboratory abnormalities | COVID-19 Diagnostic measures |
Gender: girl/boy | 4/6 | lymphocyte > 1000/µL | 8 | COVID-19 RT-PCR | 3 |
Age | 5.37 ± 3.9 (13 months to 12 years old) | Hb < 10 g/dl | 8 | COVID antibodies | 3 |
Clinical Data | Plt < 100000/µL | 3 | Just chest CT-scan | 4 |
Duration of fever | 9.4 ± 1.77 (6–12) days | ESR > 30 mm/hour | 9 | Treatments |
Skin rash (Total) Maculopapular Target shape | 8 8 2 | CRP > 10 mg/L | 10 | Antibiotics | 10 |
Albumin < 3 g/dL | 8 | Hydroxychoroquine | 9 |
AST or ALT > 50 U/L | 2 | Packed cell | 7 |
Conjunctivitis(Total) Purulent Non-purulent | 3 2 1 | Blood group/RH A+ B+ O+ NA | 1 2 4 3 | Albumin | 7 |
Respiratory symptom (Total) At admission During admission | 8 3 8 | IVIG 1 g/kg | 6 |
IVIG 2 g/kg | 3 |
steroid | 2 |
Vasoactive drugs | 4 |
Imaging Data | Infliximab | 1 |
Ear drum erythema | 3 | Plural effusion | 4 | Hospital stay |
Oral mucosal change | 4 | Intra-abdominal fluid | 5 | PICU stay (9) | 7.8 ± 5.2 days (2–20 days) |
Gastrointestinal involvement (Total) Vomiting Diarrhea Abdominal pain | 9 5 6 7 | Abnormal coronary arteries* | 3 | Total hospital stay | 11 ± 5.5 (3–24) days |
Edema | 6 | Low cardiac ejection fraction* | 3 | First impression |
Chest CT-scan** Normal at admission time COVID-19 Compatible at the admission time Became COVID-19 compatible in the days after | 8 2 5 | Acute hemorrhagic edema of infancy | 1 |
Appendicitis | 1 |
COVID-19 | 1 |
Seizure | 1 | Kawasaki disease | 2 |
Myocarditis | 1 |
Prolonged febrile seizure | 1 |
Sepsis | 1 |
Lymphadenopathy | 0 | | | Toxic shock syndrome | 1 |
Acute Renal failure | 2 | | | Urosepsis | 1 |
Shock | 2 | | | | |
*: Echo cardiography performed for all of ten. ** Chest CT-scan performed for all the cases |
ALT: Alanine aminotransferase, AST: Aspartate aminotransferase, |
Chest CT-scan: Chest computed tomography scan |
COVID-19: Coronavirus disease 2019 |
CRP: C reactive protein |
ESR: erythrocyte sedimentation rate |
Hb: hemoglobin, |
IVIG: Intravenous immunoglobulin |
NA: not assessed, PICU: pediatric intensive care unit, |
PICU: Pediatric intensive care unit |
Plt: platelet |
SARS -CoV-2: acute respiratory syndrome coronavirus 2 |
Case 2
A 5 year-old girl presented with a history of 3 days high-grade fever (39–40 oc), vomiting and one episode of skin rash during fever, loss of appetite, intermittent cough, otalgia, and diarrhea. On admission, she was ill and irritable without respiratory distress and SPO2 was 99% in room air. She had bilateral otitis and bilateral non-purulent conjunctivitis. Her parents had a suspicious history of COVID infection, so the chest CT-scan was performed and was normal. Treatment with ceftriaxone and zinc gluconate started. Gradually, picture of the disease changed and preorbital edema (day 3), headache, limb pain, pharyngeal congestion with punctuated exudate and purulent conjunctivitis occurred. Due to abdominal pain and tenderness, abdomino-pelvic ultrasonography was performed which was normal, just mild to moderate free fluid was seen and also, mild to moderate bilateral pleural effusion was detected. Liver transaminases, serum amylase and lipase were in normal range. Because of a family history of COVID-19 infection and new changes in the second chest CT-scan compatible with COVID-19 infection, hydroxychloroquine and azithromycin started at the 3rd day and the patient was isolated. At day 5, COVID-19 RT-PCR result was positive, she was still febrile and her condition has deteriorated. She became drowsy, tachypneic (respiratory rate: 38 /min) without retraction and dry cough and generalized edema developed. She had SPO2 = 88% on room air. So, she was transferred to the pediatric intensive care unit (PICU). On CBC, severe anemia and thrombocytopenia in addition to hypoalbuminemia were noted (Table 1). So, packed red blood cells (packed cell), 1 g/kg IVIG and albumin were transfused and antibiotics changed to meropenem. Blood urea, Cr, LDH, peripheral blood smear, prothrombin time (PT), partial thromboplastin time (PTT), bilirubin, triglyceride, and fibrinogen level were in the normal range and urine analysis was normal. Blood and urine cultures were negative for any organism. Echocardiography showed mild tricuspid regurgitation, trivial mitral regurgitation with normal coronary arteries. During the first 8 days, fever subsided, but the patient was still tachypneic. Finally, the patient discharged after 13 days with a good general condition.
Case 3
He was a 13 month-old boy presented with a 4-day history of fever and 3 days of rash. Skin rash started from palms of the hands and the soles of the feet and then, erythematous patches, papule, and some target shape lesions on edematous base on the trunk, limbs and face developed without itching sensation. He also defecated loose stool 2 to 3 times and had loss of appetite and irritability without any respiratory complaints except left tympanic membrane erythema. His parents worked in a COVID-19 referral ward. On admission day, chest CT-scan was normal and he was treated with hydroxychloroquine and ceftriaxone. On day 3, the patient’s condition deteriorated, generalized edema, purulent conjunctivitis, respiratory distress with tachypnea, intercostal and subcostal retraction occurred. While SPO2 was 84% in the ambient room, the second chest CT-scan changed to typical COVID-19 findings (bilateral pleural effusion, basilar patchy infiltration, and reverse halo sign). Anemia and hypoalbuminemia occurred while both were in the normal range at the admission day (Table 1). So, the patient transferred to the PICU, and oxygen was administered with a hood and packed cell, albumin and IVIG (1 gr/kg) transfused. Antibiotic was changed to meropenem and vancomycin. Abdominopelvic ultrasonography was normal, just mild fluid in sub-hepatic, peri-splenic, and interloop space were seen. Echocardiography showed mild tricuspid and mitral regurgitation and normal coronary arteries on two occasions. The patient gradually improved, skin rashes got better, he became afebrile and without any distress. He discharged after 8 days and COVID-19 RT-PCR result was positive for him.
Case 4
A 10 year-old girl presented with fever and itching skin rash from 5 days ago referred. One day before admission, her general condition worsened; she got toxic and cough, abdominal pain, and generalized edema and oliguria developed. The skin rashes were maculopapular and target shape rashes with more accumulation around neck, trunk, and axilla. Mucous membranes were intact except for bilateral conjunctivitis and cracked lips. SPO2 was 90% in room air, blood pressure: 66/44 mmHg, pulse rate: 120 /min and respiratory rate: 36 /min. In the laboratory evaluations, anemia, hypoalbuminemia, and impaired renal function tests were noted (Table 1). According to hypotension and shock state, vasoactive drugs started in addition to meropenem, clindamycin, vancomycin, IVIG, packed cell, and albumin (Table 1). The hemodynamic status of the patient got stable after 3 days. Liver transaminases, PT, PTT, CPK, troponin, LDH, fibrin degradation products (FDP), C3, C4, and CH50 were in normal range. Antistreptolysin O, antiphospholipid antibody, and antinuclear antibody (ANA) were negative too. Blood and urine culture were also negative. Chest CT-scan before admission and chest roentgenogram (CXR) at admission day were normal. COVID-19 RT-PCR result was negative but COVID-19 immunoglobulin G (IgG) was positive, which was measured a week later. On day 3, the patient complicated with edema, severe pain of right lower extremity, and venous stasis due to placement of central vein catheter of right femoral vein. Color doppler ultrasonography of lower limb veins was normal. Enoxaparin was started as prophylaxis of deep vein thrombosis (DVT). Chest CT-scan at day 4 showed COVID-19 compatible changes with mild bilateral pleural effusion. The urinary system ultrasonography was normal. Echocardiography reported mild tricuspid regurgitation, mild mitral regurgitation, mild pulmonary insufficiency, and normal ejection fraction on 3 occasions. Fever subsided 4 days after admission, vitamin D, and zinc gluconate were added to the patient’s drugs. The general condition improved and inotrope drugs discontinued gradually. After 11 days, the patient discharged with complete improvement.
Case 5
He was a 14 month-old boy, presented with fever and irritability from 5 days and skin rash from 3 days ago. Maculopapular erythematous rashes first presented from the trunk and upper limb and then generalized and edema of hands and feet developed. Cracked and erythematous lips, erythematous tongue, and bilateral non-purulent conjunctivitis also happened. During the first admission day, the patient became toxic and transferred to the PICU. The CBC showed leukocytosis with significant neutrophil count. Elevated ESR, CRP, and liver transaminases and hypoalbuminemia were found. Urine analysis was normal. COVID-19 RT-PCR was negative, CXR was normal and Chest CT-scan showed non-significant changes. So, cefotaxime, hydroxychloroquine, 2 gr/kg IVIG and 60 mg/kg aspirin, zinc, vitamin D, and albumin started. Echocardiography in the first day showed normal coronary arteries, minimal right pleural effusion (5 mm), minimal mitral regurgitation without coronary artery abnormality. Because of prolonged PT and PTT, fresh frozen plasma (FFP), and vitamin K prescribed. Fever continued 2 days after IVIG infusion, and he was still toxic. So, the second dose of IVIG was infused in the fourth day of admission. Echocardiography in that time showed diastolic dysfunction, mild right and left coronary artery dilatation in left anterior descending artery (LAD) and left circumflex artery without aneurysm. Liver transaminases, PT and PTT decreased to the normal level but leukocytosis continued and packed cell transfused for severe anemia, and ceftriaxone changed to vancomycin and meropenem. The second chest CT-scan showed non-significant changes. While fever subsided at day 7, hydroxychloroquine discontinued, but echocardiography showed progression in coronary arteries dilatation, moderate mitral and tricuspid regurgitation, decreased ejection fraction, and mild diastolic dysfunction, so 2 mg/kg/day prednisolone, vasoactive drugs and furosemide started. On day 10, the patient got hemodynamically stable, so vasoactive drugs tapered but abdominal distension occurred with non-significant findings in the examination. Ultrasonography showed mild hepatosplenomegaly, mild intra-abdominal fluid, and mild bilateral pleural effusion. The CBC showed leukocytosis and initiation of thrombocytosis (platelet count: 420.000/µL). Echocardiography showed progressive coronary artery aneurysm and beading and clopidogrel started. Abdominal distension improved during the last 5 days, and the skin rash disappeared with pilling on day 14. Still afebrile, he was toxic. COVID-19 RT-PCR result was negative but COVID-19 IgM was positive. After that, marked thrombocytosis appeared in the CBC (platelet count: 1.168.000/µL), ESR and CRP normalized but coronary artery dilatation progressed to a giant aneurysm in day 17 as follows: right coronary artery (RCA): 8.3 mm, left main coronary artery (LMCA) and LAD: 6.7–7.2 mm with good left ventricular ejection fraction. So, warfarin and infliximab prescribed. The patient discharged from the hospital with aspirin and warfarin. Results of other evaluations during admission like serum vitamin D, LDH, CPK, and antiphospholipid antibodies were unremarkable. Two weeks later, the coronary diameters decreased to 6 mm in RCA and near to 5 mm in LMCA and LAD in follow-up echocardiography.
Case 6
A 6.5 year-old boy, presented with a history of 3 days fever, anorexia, and abdominal pain in periumbilical and hypogastric area with occasional vomiting (3 times), one loose defecation, and skin erythematous rash around ankles which spread to the trunk. He had no respiratory complaints and received a suppository of diclofenac and acetaminophen for pain and fever relief. He had a history of repaired duodenal atresia at birth. On physical exam, the patient was ill and febrile, had macular erythematous rashes around feet, hands, trunk and perioral, periorbital edema, erythema of oropharynx, right eardrum erythema and hypogastric tenderness. He had elevated ESR and CRP in addition to abnormal urine sediment. Ceftriaxone started and chest CT-scan performed with non-significant changes for COVID-19. Urine culture of the first day was negative. On the second day of admission, the patient got toxic and irritable with respiratory distress, low SPO2: 87%, mild abdominal distension, and anasarca edema. The patient transferred to the PICU. Serum albumin was 2.6 g/dL, while other indexes like amylase and lipase were in normal values. So, albumin started. During the last 2 days, general condition of the patient got worst, he became anemic and more toxic, so albumin, 1 gr/kg IVIG, packed cell, hydroxychloroquine, and vitamin D were administered and ceftriaxone changed to vancomycin and meropenem. A second chest CT-scan showed bilateral opacity compatible with COVID-19. COVID-19 RT-PCR was negative but COVID-19 IgG was positive which was measured a week later. Abdominal ultrasonography showed mild splenomegaly, free interloop fluid, and several reactive lymph nodes. Echocardiography at 2 occasions reported normal coronary arteries. Other investigations like Wright, Widal, blood, urine, and stool culture were negative. Transaminases, PT, PTT, LDH, FDP, and D-dimer were in normal values. The patient’s abdominal pain improved at day 6, and he discharged after 11 days.
Case 7
A 7.5 year-old girl presented with a history of fever, irritability, myalgia, vomiting, diarrhea, abdominal pain, generalized erythematous maculopapular and patches from 4 days ago without respiratory complaints. Her parents were infected with COVID-19 nearly 2 weeks ago. She received diclofenac and azithromycin before admission. On physical exam, she was ill with no distress. Erythema of the throat and generalized erythematous maculopapular and patches were observed. At the admission day, lymphopenia and vitamin D deficiency were noted (Table 1). Chest CT-scan, abdominal ultrasonography and stool exam were normal and cultures of the urine, blood, and stool were negative. So, ceftriaxone, hydroxychloroquine, zinc, and vitamin D prescribed. Evaluation for infection with COVID-19 with RT-PCR COVID-19 were negative. At the third admission day, facial edema, tachypnea and tachycardia developed and the patient got toxic with a gallop in heart auscultation. Due to marked hypoalbuminemia and anemia, packed cell and albumin were transfused. Blood urea and Cr raised, with normal values for serum electrolytes, PT, PTT, CPK, LDH, troponin, and liver transaminases. Anti-phospholipid antibodies were negative. Echocardiography showed low ejection fraction with dilated right and left ventricle, so, the diagnosis of myocarditis was raised; vasoactive drugs and 1 g/kg IVIG started and ceftriaxone changed to meropenem and vancomycin with magnesium sulphate for hypomagnesemia. CXR showed bilateral mild ground-glass opacity. Gradually, during last days, facial edema improved a little, but tachycardia and tachypnea was persistent at the 5th day. The second echocardiography report included mild pleural effusion, valve insufficiency, low ejection fraction, lack of tapering and brightness in RCA and LAD. So, another dose of IVIG (1 g/kg) with 60 mg/kg/day aspirin prescribed. With the improvement in the hemodynamic status, vasoactive drugs gradually tapered. On the 7th day, the patient became afebrile and discharged after 12 days with normal echocardiography and laboratory tests.
Case 8
A 20 month-old boy presented with intermittent fever from last week. Gradually, coryza, vomiting, and severe diarrhea, abdominal pain, irritability during urination, and loss of appetite appeared. Before admission, he received metronidazole, cefixime, nalidixic acid, diclofenac, and acetaminophen without improvement. He also had an erythematous papule with 2 centimeter diameter in the forehead and erythema of oropharynx. CBC at admission showed marked leukocytosis, thrombocytosis, anemia, and increased levels of ESR and CRP (Table 1). The stool exam had 4–5 white blood cells and 2–3 red blood cells. PT, PTT were normal and blood levels of creatinine, urea, LDH, and CPK were in normal values. Urine analysis was unremarkable and cultures of blood, urine, and stool were negative. Abdominal ultrasonography was normal but Chest CT-scan showed bilateral ground-glass opacity compatible with COVID-19. So, the patient isolated and ceftriaxone, hydroxychloroquine, vitamin D, and zinc gluconate started. Hours after admission, he got tachypnea and SPO2 was 90% without supplementary oxygen. Unilateral tongue swelling and drooling with discrete ulcers under the tongue were seen. So, he transferred to the PICU and ceftriaxone changed to clindamycin and meropenem. Echocardiography found a lack of tapering in RCA and LAD, mild dilatation of left atrium, and diastolic dysfunction. Before starting 2 g/kg IVIG and 80 mg/kg/day aspirin, fever subsided but he was still toxic. Seven days after admission, the patient’s condition improved and the second echocardiography after one week was normal. Results of COVID-19 RT-PCR, IgM, and IgG in the first week of admission were negative.
Case 9
He was a 7 year-old boy with fever from 3 days ago. He also suffered from epigastric pain which was shifted to the right lower quadrant (RLQ) after 2 days and was not associated with eating. He had nausea, vomiting, and normal defecation pattern. He was admitted 10 days ago for acute intravascular hemolysis due to glucose 6 phosphate dehydrogenase deficiency (G6PDd) and fava bean exposure and was treated with packed cell and hydration. In the recent admission, he was ill and febrile without respiratory symptoms. On physical examination, tenderness in RLQ and rebound tenderness were noted. Ultrasonography showed reactive lymph nodes, and free interloop fluid. In the CBC, leukocytosis with a shift to left was found. ESR and CRP were markedly elevated, urine and stool were unremarkable. So, the patient received ceftriaxone plus metronidazole and underwent appendectomy, but normal appendix with some exudative secretion in the peritoneal cavity was seen during the operation. After surgery, the patient's condition got worse and became toxic, developed abdominal distension and recurrent vomiting. Abdominal X-ray was normal and repeated ultrasonography reported mild interloop fluid only. A chest CT-scan showed findings compatible with COVID-19 infection. Ceftriaxone changed to meropenem and vitamin D, hydroxychloroquine, and zinc gluconate started. Three 3 days following admission, his fever subsided and abdominal complaints got better. Other investigations like liver transaminases, serum LDH and echocardiography were normal. After 4 days, the patient discharged. COVID-19 IgM and IgG and RT-PCR during admission were negative.
Case 10
An 18 month-old girl referred for a prolonged febrile seizure. The fever started from 4 days ago and seizure was generalized tonic colonic accompanied with loss of consciousness, upward gaze, and foaming, which lasted for 40 minutes, controlled with diazepam and phenobarbital in another hospital. The family was passenger from another province of Iran. She had an epileptic sister. In physical exam, she was lethargic and febrile without abnormal findings. In the CBC, there was lymphopenia. Cerebrospinal fluid (CSF) analysis and electrolytes were normal and CSF, blood, and urine culture were negative. Serum albumin level was decreased. Meropenem, clindamycin, phenobarbital, hydroxychloroquine, and vitamin D were prescribed. Brain CT-scan and CXR had no pathologic finding and chest CT-scan showed bilateral nonspecific opacity in inferior lobes. She was ill and lethargic during the first two days, so albumin, 1 g/kg/day IVIG, and zinc gluconate prescribed. On the third admission day, fever continued and maculopapular rashes appeared in the trunk. So, phenobarbital discontinued and echocardiography was done which was normal. On this day, the patient got tachypnea, ABG was normal and second chest CT-scan in the 4th day had the same features of the first. COVID-19 RT-PCR result was positive. On the 5th admission day, fever subsided and tachypnea improved within 4 days. After 3 days, the patient discharged with good general condition.