COVID-19 and Kawasaki Disease: Novel Virus and Novel Case - Portal de Boas Práticas
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
CASE REPORT
COVID-19 and Kawasaki Disease: Novel Virus and
Novel Case
Veena G. Jones, MD,a,b,* Marcos Mills, MD,c,d,* Dominique Suarez, MD,a Catherine A. Hogan, MD,e Debra Yeh, MD,d J. Bradley Segal, MD,d Elizabeth L. Nguyen, MD,d
Gabrielle R. Barsh, MD, PhD, MD,d Shiraz Maskatia, MD,c,d Roshni Mathew, MDd,f
ABSTRACT In the midst of the coronavirus disease 2019 (COVID-19) pandemic, we are seeing widespread disease
burden affecting patients of all ages across the globe. However, much remains to be understood as
clinicians, epidemiologists, and researchers alike are working to describe and characterize the disease
process while caring for patients at the frontlines. We describe the case of a 6-month-old infant admitted
and diagnosed with classic Kawasaki disease, who also screened positive for COVID-19 in the setting of
fever and minimal respiratory symptoms. The patient was treated per treatment guidelines, with
intravenous immunoglobulin and high-dose aspirin, and subsequently defervesced with resolution of her
clinical symptoms. The patient’s initial echocardiogram was normal, and she was discharged within
48 hours of completion of her intravenous immunoglobulin infusion, with instruction to quarantine at
home for 14 days from the date of her positive test results for COVID-19. Further study of the clinical
presentation of pediatric COVID-19 and the potential association with Kawasaki disease is warranted, as
are the indications for COVID-19 testing in the febrile infant.
www.hospitalpediatrics.org
a
DOI:https://doi.org/10.1542/hpeds.2020-0123
Division of Pediatric
Copyright © 2020 by the American Academy of Pediatrics
Hospital Medicine, Palo
Alto Foundation Medical Address correspondence to Veena G. Jones, MD, Division of Pediatric Hospital Medicine, Palo Alto Foundation Medical Group, Palo Alto
Group and bPalo Alto Medical Foundation, 795 El Camino Real, Palo Alto, CA 94304. E-mail: jonesvg@sutterhealth.org
Medical Foundation
Research Institute, Palo HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154-1663; Online, 2154-1671).
Alto Medical Foundation, FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
Sutter Health, Palo Alto,
California; and cDivisions FUNDING: No external funding.
of Pediatric Cardiology POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
and fPediatric Infectious
Disease and eClinical *Contributed equally as co-first authors.
Virology Laboratory,
Dr Jones provided direct care to the patient in this report, conceptualized and outlined the manuscript, reviewed existing literature, and
Department of Pathology
and dDepartment of
drafted the initial manuscript; Dr Mills reviewed existing literature and drafted the initial manuscript; Dr Suarez provided direct care to
Pediatrics, Stanford the patient in this report and contributed to the drafting of the initial manuscript; Dr Hogan contributed to the drafting of the initial
Medicine, Stanford manuscript; Drs Yeh, Segal, Nguyen, and Barsh provided direct care to the patient in this report; Dr Maskatia is providing ongoing care
University, Stanford, to the patient; Dr Mathew conceptualized and outlined the manuscript; and all authors reviewed and revised the manuscript, approved
California the final manuscript as submitted, and agree to be accountable for all aspects of the work.
HOSPITAL PEDIATRICS Volume 10, Issue 6, June 2020 537
Downloaded from www.aappublications.org/news by guest on August 20, 2020
The rapid spread of coronavirus disease normal extremities. She had mild subcostal the hands (Fig 3) and lower extremities
2019 (COVID-19) caused by severe acute retractions, although she had normal (thus meeting classic criteria for KD). She
respiratory syndrome coronavirus 2 has led breath sounds. Laboratory testing revealed was treated with a single dose of 2 g/kg
to a global pandemic, with infected a left-shifted white blood cell count with intravenous immunoglobulin and high-dose
individuals of all ages residing in almost bandemia, normocytic anemia, normal acetylsalicylic acid (20 mg/kg 4 times daily),
every country in the world. The pediatric platelets, markedly elevated C-reactive according to treatment guidelines.3 Her last
population appears to be affected in much protein of 13.3 mg/dL, and erythrocyte elevated temperature was 38.3°C, just after
smaller proportions than adults, with only sedimentation rate of 118. She had completing intravenous immunoglobulin. An
2% of cases described in patients younger hyponatremia (sodium at 133) and echocardiogram was normal without any
than age 20.1 In an epidemiological report, hypoalbuminemia (albumin at 2.8), with evidence of coronary dilation or aneurysm,
authors described 731 confirmed COVID- otherwise normal chemistries, including no pericardial effusion, and with normal
19 cases in the pediatric population, with liver function tests. Results from respiratory valvar and ventricular function.
.90% of patients characterized as pathogen testing by reverse transcription The evening before discharge, RT-PCR
asymptomatic, mild, or moderate cases.2 polymerase chain reaction (RT-PCR) test and testing for COVID-19 resulted positive from
The authors looked at a total of blood culture were negative. A chest the Stanford Health Care Clinical Virology
2143 patients, 1412 of whom had suspected radiograph revealed a faint opacity in the Laboratory. The public health department
but unconfirmed COVID-19 infection, but left midlung zone. Throughout this period of was notified, and the family was instructed
there was little description of co-incidence illness, she had no sick contacts. Her 9-year- to quarantine at home for 14 days from the
with other clinical conditions and no cases old sibling had upper respiratory symptoms positive test result date. She was
reported of concurrent Kawasaki disease 3 weeks before. The family had self-isolated discharged on low-dose acetylsalicylic acid
(KD). because of the COVID-19 pandemic for the (3 mg/kg daily), with plans to follow-up with
We describe here the case of a pediatric week before, without leaving home for pediatric cardiology for repeat
patient diagnosed and treated for classic KD school or work. There was no history of echocardiographic evaluation 2 weeks after
in the setting of confirmed COVID- recent travel. discharge, timed to occur after the
19 infection, published with parental The patient was referred for admission for mandated 14-day quarantine.
permission. KD evaluation. Given her fever, possible mild
DISCUSSION
congestion, and chest radiograph findings,
CASE DESCRIPTION To our knowledge, this is the first described
she was sent to the emergency department
The patient is a 6-month-old, term, for COVID-19 testing before admission to the case of KD with concurrent COVID-
previously healthy and fully immunized girl pediatric floor. On arrival, the patient was 19 infection. KD is an acute vasculitis of
who initially presented to pediatric urgent on day 5 of fever and had limbic sparing childhood and the leading cause of acquired
care with 1 day of fever, fussiness, and conjunctivitis (Fig 1); prominent tongue heart disease in children in developed
refusal to eat. She did not exhibit cough, papilla; a blanching, polymorphous,
congestion, or rhinorrhea. Examination maculopapular rash (Fig 2); and swelling of
revealed a fussy infant with a temperature
of 38.8°C, with no focal signs of infection.
Laboratory evaluation included a rapid
influenza swab and a catheterized urinalysis
with urine culture, all of which had negative
results. She was diagnosed with a viral
infection.
On day 2 of fever, she developed an
erythematous, seemingly nonpruritic,
blotchy rash. She re-presented to care
on day 4 of fever with persistent rash.
Although she remained free of cough, there
was possible mild congestion. Vital signs
revealed a temperature of 38.3°C, sinus
tachycardia (200 beats per minute), and
tachypnea with an oxygen saturation of
100%. Examination was notable for
irritability, limbic sparing conjunctivitis, and FIGURE 1 Bulbar conjunctival injection. The
dry cracked lips. There was no appreciable image is shared with parental FIGURE 2 Maculopapular rash. The image is
lymphadenopathy, and, at the time, she had permission. shared with parental permission.
538 JONES et al
Downloaded from www.aappublications.org/news by guest on August 20, 2020
serves pediatric and adult tertiary-care contact with the infant throughout
hospitals and affiliated clinics in northern hospitalization and has no respiratory
California. In early January 2020, 2 multiplex symptoms as of 2 weeks after hospital
RT-PCR assays were validated on the basis discharge. When coronary involvement
of a modified published protocol.8 These appears with KD, it typically occurs after the
assays are used to target the envelope and initial presentation. As such,
RNA-dependent RNA-polymerase genes, recommendations for monitoring include
respectively. Analytical sensitivity from echocardiography in 1 to 2 weeks and 4 to
nasopharyngeal swabs eluted in viral 6 weeks after treatment.3
transport medium was shown to be good, As we continue to see the spread of COVID-
with a lower limit of detection ranging 19 and increase in cases worldwide, clinical
between 500 and 700 copies per mL. criteria for testing for COVID-19 may be
Furthermore, analytical specificity was high, restricted to those with respiratory
with no cross-reactivity observed in symptoms because of constraints such as
.50 tested samples with seasonal testing availability. In pediatrics, with the
coronaviruses or other respiratory viruses. clinical spectrum yet to be clearly defined,
Samples revealing late cycle threshold patients presenting with fever alone or
FIGURE 3 Upper extremity erythema and values (cycle threshold $40) are repeated primarily with other organ system
edema. The image is shared with for confirmatory testing to prevent false- involvement such as gastrointestinal
parental permission. positive results. Although direct comparison symptoms may be missed if testing is
data between this assay and the Centers for restricted to those with respiratory
countries, with 50% of cases occurring in Disease Control and Prevention’s assay complaints alone.
those ,2 years of age and 80% in those (which targets 2 regions of the
,5 years of age.4 The diagnosis of “classic” nucleocapsid gene) have not yet been CONCLUSIONS
KD is considered in patients presenting with published, preliminary data suggest similar This case report may serve as a useful
fever for 5 days together with at least 4 out analytic performance.8,9 reference to other clinicians caring for
of 5 clinical criteria in the absence of an At the time of this patient’s hospital pediatric patients affected by COVID-19 as
alternate diagnosis. discharge, the World Health Organization understanding of the clinical presentation
The cause of KD remains unknown despite reported almost 180 000 global cases of patterns continues to evolve. Further
several decades of investigation. Some confirmed COVID-19, with 7426 deaths.10 description of the clinical course of
evidence suggests an infectious trigger, with Despite the growing number of reported pediatric patients diagnosed with COVID-
winter to spring seasonality of the disease, cases, there remains a knowledge gap 19 remains necessary, particularly
and wavelike spread of Japanese epidemics regarding the infectious, epidemiological, regarding the potential association with KD.
of KD.4 In various studies, authors have and clinical features associated with COVID- Acknowledgments
described an association between viral 19 illness, particularly in the pediatric We thank the patient and her family for
respiratory infections and KD, ranging from population. To date, the most common their willingness to share this case and the
9% to as high as 42% of patients with KD pediatric presentation of COVID-19 is an images. We also thank all the members of
testing positive for a respiratory viral array of signs and symptoms including the health care team who contributed to the
infection in the 30 days leading up to completely asymptomatic to symptoms of care of the patient discussed in this case
diagnosis of KD.5–7 Interestingly, Turnier acute upper respiratory tract infection such report. In particular, we thank Dr Katherine
et al5 in 2015 described that 28% of positive as fever, fatigue, cough, sore throat, Fry (Palo Alto Medical Foundation pediatric
results were attributable to rhinovirus and/ rhinorrhea and congestion, and shortness hospitalist).
or enterovirus, and 8.7% were due to of breath. In more severe cases, symptoms
parainfluenza; results for the remaining can include gastrointestinal symptoms and REFERENCES
pathogens (respiratory syncytial virus, patients can progress to respiratory failure, 1. Wu Z, McGoogan JM. Characteristics of
influenza, adenovirus, and human shock, coagulation dysfunction, and renal and important lessons from the
coronavirus [strains 229E, HKU1, NL63, injury.2 coronavirus disease 2019 (COVID-19)
OC43]) were each positive ,5% of the time. With regard to her COVID-19 infection, our outbreak in China: summary of a report
Although the clinical significance of our patient’s clinical course and presentation of 72 314 cases from the Chinese Center
patient’s positive COVID-19 test result in the were mild. Throughout her hospitalization, for Disease Control and Prevention.
setting of her KD is not clear, her testing for she did not have any notable respiratory JAMA. 2020;323(13):1239–1242
COVID-19 appears accurate. The Stanford symptoms, and repeat chest radiograph 2. Dong Y, Mo X, Hu Y, et al. Epidemiology of
Health Care Clinical Virology Laboratory was not obtained. Her mother was in close COVID-19 among children in China
HOSPITAL PEDIATRICS Volume 10, Issue 6, June 2020 539
Downloaded from www.aappublications.org/news by guest on August 20, 2020[published online ahead of print March 4. Rowley AH, Shulman ST. The epidemiology 8. Corman VM, Landt O, Kaiser M, et al.
16, 2020]. Pediatrics. doi:10.1542/ and pathogenesis of Kawasaki disease. Detection of 2019 novel coronavirus
peds.2020-0702 Front Pediatr. 2018;6:374 (2019-nCoV) by real-time RT-PCR. Euro
3. McCrindle BW, Rowley AH, Newburger JW, 5. Turnier JL, Anderson MS, Heizer HR, Jone Surveill. 2020;25(3):2000045
et al; American Heart Association P-N, Glodé MP, Dominguez SR. 9. Centers for Disease Control and
Rheumatic Fever, Endocarditis, and Concurrent respiratory viruses and Prevention. CDC 2019-novel coronavirus
Kawasaki Disease Committee of the Kawasaki disease. Pediatrics. 2015; (2019-nCoV) real-time RT-PCR diagnostic
Council on Cardiovascular Disease in the 136(3). Available at: www.pediatrics.org/ panel. Available at: https://www.fda.gov/
Young; Council on Cardiovascular and cgi/content/full/136/3/e609 media/134922/download. Accessed
Stroke Nursing; Council on Cardiovascular March 20, 2020
6. Kim JH, Yu JJ, Lee J, et al. Detection rate
Surgery and Anesthesia; and Council on
and clinical impact of respiratory viruses
Epidemiology and Prevention. Diagnosis, 10. World Health Organization. Coronavirus
in children with Kawasaki disease.
treatment, and long-term management of disease 2019 (COVID-19). Situation
Korean J Pediatr. 2012;55(12):470–473
Kawasaki disease: a scientific statement report – 57. Available at: https://
for health professionals from the 7. Jordan-Villegas A, Chang ML, Ramilo O, www.who.int/docs/default-source/
American Heart Association [published Mejías A. Concomitant respiratory viral coronaviruse/situation-reports/
correction appears in Circulation. 2019; infections in children with Kawasaki 20200317-sitrep-57-covid-19.pdf?
140(5):e181–e184]. Circulation. 2017; disease. Pediatr Infect Dis J. 2010;29(8): sfvrsn5a26922f2_2. Accessed March 17,
135(17):e927–e999 770–772 2020
540 JONES et al
Downloaded from www.aappublications.org/news by guest on August 20, 2020COVID-19 and Kawasaki Disease: Novel Virus and Novel Case
Veena G. Jones, Marcos Mills, Dominique Suarez, Catherine A. Hogan, Debra Yeh, J.
Bradley Segal, Elizabeth L. Nguyen, Gabrielle R. Barsh, Shiraz Maskatia and Roshni
Mathew
Hospital Pediatrics 2020;10;537
DOI: 10.1542/hpeds.2020-0123 originally published online April 7, 2020;
Updated Information & including high resolution figures, can be found at:
Services http://hosppeds.aappublications.org/content/10/6/537
Supplementary Material Supplementary material can be found at:
References This article cites 6 articles, 1 of which you can access for free at:
http://hosppeds.aappublications.org/content/10/6/537#BIBL
Subspecialty Collections This article, along with others on similar topics, appears in the
following collection(s):
Infectious Disease
http://www.hosppeds.aappublications.org/cgi/collection/infectious_d
iseases_sub
Public Health
http://www.hosppeds.aappublications.org/cgi/collection/public_healt
h_sub
Permissions & Licensing Information about reproducing this article in parts (figures, tables) or
in its entirety can be found online at:
http://www.hosppeds.aappublications.org/site/misc/Permissions.xht
ml
Reprints Information about ordering reprints can be found online:
http://www.hosppeds.aappublications.org/site/misc/reprints.xhtml
Downloaded from www.aappublications.org/news by guest on August 20, 2020COVID-19 and Kawasaki Disease: Novel Virus and Novel Case
Veena G. Jones, Marcos Mills, Dominique Suarez, Catherine A. Hogan, Debra Yeh, J.
Bradley Segal, Elizabeth L. Nguyen, Gabrielle R. Barsh, Shiraz Maskatia and Roshni
Mathew
Hospital Pediatrics 2020;10;537
DOI: 10.1542/hpeds.2020-0123 originally published online April 7, 2020;
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://hosppeds.aappublications.org/content/10/6/537
Hospital Pediatrics is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. Hospital Pediatrics is owned,
published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca,
Illinois, 60143. Copyright © 2020 by the American Academy of Pediatrics. All rights reserved.
Print ISSN: 1073-0397.
Downloaded from www.aappublications.org/news by guest on August 20, 2020You can also read
