Weekly Update May 15-22

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More cases of a COVID-19 associated systemic inflammatory syndrome have been reported in children

The CDC has advised being on the lookout for the increasingly reported Multisystem Inflammatory Syndrome in Children (MIS-C). Any such cases should be reported to the CDC. The case definition (verbatim from the CDC) is as follows:

  • An individual aged <21 years presenting with fever, laboratory evidence of inflammation, and evidence of clinically severe illness requiring hospitalization, with multisystem (>2) organ involvement (cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic or neurological); AND
  • No alternative plausible diagnoses; AND
  • Positive for current or recent SARS-CoV-2 infection by RT-PCR, serology, or antigen test; or COVID-19 exposure within the 4 weeks prior to the onset of symptoms
  • Fever >38.0°C for ≥24 hours, or report of subjective fever lasting ≥24 hours
  • Including, but not limited to, one or more of the following: an elevated C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), fibrinogen, procalcitonin, d-dimer, ferritin, lactic acid dehydrogenase (LDH), or interleukin 6 (IL-6), elevated neutrophils, reduced lymphocytes and low albumin
  • Additional Considerations (per CDC)
    Some individuals may fulfill full or partial criteria for Kawasaki Disease, but should be reported if they meet the case definition for MIS-C.
    Consider MIS-C in any pediatric death with evidence of SARS-CoV-2 infection

Additional information can be found here: Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with Coronavirus Disease 2019 (COVID-19)

BCG vaccine does not seem to protect against COVID-19

There was some speculation early in the COVID-19 pandemic that patients were protected against COVID-19 if they had had bacille Calmette-Guerin (BCG) immunization against tuberculosis. Unfortunately, a new study seems to refute this. 

This was a retrospective study of 3064 Israelis born between 1979-1981 who got BCG and 2869 born between the years of 1983 and 1985 who did not (after universal vaccine was halted). No difference in COVID-19 infection was found between the two groups (vaccinated: 11.7%, unvaccinated: 10.4%). The study was unable to measure the severity of disease vs. immunization status because there were few patients with severe illness in this cohort.

SARS-COV-2 Rates in BCG-Vaccinated and Unvaccinated Young Adults. JAMA. Published online May 13, 2020

 

Guillain-Barre Syndrome joins encephalopathy as an additional possible result of COVID-19

It is known that COVID-19 can cause an encephalopathy which can then take months to resolve. A new paper reports five cases of a Guillain-Barre-like syndrome occurring in relation to COVID-19.

This is a report from Italy of five patients with COVID-19 who had an associated Guillain-Barre syndrome. Of these five, four had onset presenting as lower limb weakness and facial diplegia. The syndrome progressed to include flaccid paralysis, but not dysautonomia. Cerebrospinal fluid (CSF) polymerase chain reaction (PCR) in all patients was negative for COVID-19. Electromyogram (EMG) showed axonal Guillain-Barre in three patients and demyelination in two.  Treatment was with plasma exchange and intravenous immunoglobulin (IVIG). As with many other COVID-19 patients, three members of the study were placed on ventilation.

Toscano G et al. Guillain–Barré syndrome associated with SARS-CoV-2. N Engl J Med 2020 Apr 17; [e-pub]. (https://doi.org/10.1056/NEJMc2009191)

 

New Online Risk Calculator Available

A group out of China has developed a risk calculator for predicting the severity of illness in those with COVID-19.  They initially observed 1,590 patients and found that 10 risk factors seem to change the outcome of those with COVID-19 (derivation set). 

These risk factors include:

  • X-ray Appearance
  • Age
  • Hemoptysis
  • Dyspnea
  • Unconsciousness
  • Number of comorbidities (defined on the calculator link)
  • History of cancer
  • Neutrophil to lymphocyte ratio
  • Lactate dehydrogenase (LDH)
  • Direct bilirubin

The group then applied their rule to another 710 patients (validation set). Using this tool, the group was able to categorize patients as low, medium or high risk for progressive disease.  The probability for adverse events (invasive ventilation/ICU admission/death) in the various groups is as follows: low-risk group 0.7% (e.g. 0.7% with a low risk score went on to have an adverse event); medium-risk score group 7.3% had an advrese event;high-risk group score 59.3% had an adverse event.  The calculator can be found here.

JAMA Intern Med. Published online May 12, 2020. doi:10.1001/jamainternmed.2020.2033

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