1186: MEASLES-ASSOCIATED MYOCARDITIS: A CASE REPORT

Vaccinations have been incriminated in the increase of atopic disorders. Especially the measles-mumps-rubella (MMR) vaccination is often refused by people having a notion that these infectious diseases are beneficial for a healthy development of a child's immune system. This practice endangers herd immunity and is the cause of repeated outbreaks. As the clinical course of infections and also its possible impact on the development of atopy may be different in vaccinated and unvaccinated individuals, we explored in vaccinated and unvaccinated children associations of MMR infection with atopic disorders. Using data from a previously conducted study on the relationship between the diphtheria-tetanus-pertussis-(inactivated) poliomyelitis vaccination in the first year of life and atopic disorders, the study population of 1872 8-12-yr-old was divided as children MMR-unvaccinated and children MMR-vaccinated in the first year of life. Within each group the association between MMR infections and atopic disorders (both as reported by the parents) was assessed. We found a statistically significant positive association between measles infection and 'any atopic disorder' [adjusted odds ratio, OR (95% confidence interval, CI): 1.77 (1.20-2.61)] in the MMR-vaccinated group, mainly because of the relationship with eczema. For rubella there was a negative association with eczema and food allergy in the unvaccinated group: adjusted OR (95% CI): 0.57 (0.38-0.85) and 0.23 (0.07-0.76), respectively. All other associations were not statistically significant. We found a positive relationship between measles infection and any atopy in a group of MMR-vaccinated children and a negative association between rubella infection and eczema and food allergy in unvaccinated children. However, we cannot conclude that these relationships are causal. The negative association with rubella may be an artefact. This study shows no evidence for any protective effects from MMR diseases for the development of atopy and therefore supports conclusions found elsewhere that childhood vaccinations do not cause atopy.

Exercise elicits dynamic changes in extravascular lung water and haemodynamic congestion in heart failure patients with preserved ejection fraction.

We describe the case of a 3-year child in which pancreatic and parotid gland involvement preceded the development of the classical clinical phenotype of a typical Kawasaki disease (KD). The child was referred to the Emergency Department with a story of 3 days of continuous fever associated with abdominal pain and bilaterally swelling in the parotid regions; laboratory evaluation identified markedly increased levels of total amylase, pancreatic amylase, lipase, and transaminase, and diagnosis of pancreatitis was posed. After 9 days of fever and persistence of the clinical features, the classical signs of KD appeared, and the child was treated with intravenous immunoglobulins (IVIG), showing a dramatic response with complete resolution of the clinical picture. In this work, we reviewed the literature about gastrointestinal (GI) symptoms in KD, focusing on pancreatic and hepatic involvement. This analysis highlighted that, in case of fever associated with pancreatic inflammation, KD must be considered in the spectrum of differential diagnosis, and that GI involvement in KD is frequently associated with an incomplete response to IVIG treatment.

Severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV-2) is associated with multisystem inflammatory syndrome in children (MIS-C) that ranges from mild symptoms to cardiopulmonary collapse. A 5-year-old girl presented with shock and a rapid decline in left ventricular function requiring intubation. SARS-CoV-2 was diagnosed by viral Polymerase Chain Reaction (PCR), and she received remdesivir and COVID-19 convalescent plasma. Initial echocardiogram (ECHO) demonstrated low normal left ventricular function and mild left anterior descending coronary artery dilation. She remained hypotensive, despite high-dose epinephrine and norepinephrine infusions as well as stress-dose hydrocortisone. Admission SARS-CoV-2 IgG assay was positive, meeting the criteria for MIS-C. An ECHO 9 hours after admission demonstrated a severe decline in left ventricular function. Due to severe cardiogenic shock, she was cannulated for venoarterial extracorporeal support (ECMO). During her ECMO course, she was treated with remdesivir, intravenous methylprednisolone, intravenous immunoglobulin, and anakinra. She was decannulated on ECMO day 7, extubated the following day, and discharged home 2 weeks later without respiratory or cardiac support. The use of ECMO for cardiopulmonary support for pediatric patients with MIS-C is feasible and should be considered early as part of the treatment algorithm for patients with severe cardiopulmonary dysfunction.

As outlined in the 2004 American Heart Association guidelines, the diagnosis of Kawasaki disease (KD) is supported by results of clinical laboratory studies. However, detailed information regarding the evolution of these results during illness has not been previously reported. The goals of this project were to characterize the evolution of clinical laboratory values in KD before and after treatment with intravenous immunoglobulin (IVIG). Laboratory values from 380 unselected, consecutive KD patients were analyzed at 3 times: acute (illness day, 2-10; illness day 1 = first day of fever and before IVIG), subacute (illness day, 11-21), and convalescent (illness day, 22-60). Results were stratified by IVIG response and coronary artery outcome. Although white blood cell count, percentage bands, erythrocyte sedimentation rate, and C-reactive protein values were highest and age-adjusted hemoglobin was lowest in the acute phase before IVIG, platelet count was highest in the subacute phase, and percentage lymphocytes and eosinophils were highest in the convalescent phase after IVIG. KD patients with coronary artery aneurysms had a higher white blood cell count in the subacute phase and higher erythrocyte sedimentation rate in the subacute and convalescent phases compared with those with dilated or normal coronary arteries. A consistent evolution of laboratory values is associated with KD before and after treatment. Understanding the dynamic changes in laboratory values can assist physicians in using laboratory criteria to diagnose KD following the American Heart Association guidelines.

Intravenous Immunoglobulin and Favipiravir treatment for A Kidney Transplant Patient with Severe Covid-19 Pneumonia

We have lately documented the importance of N-terminal pro-brain natriuretic peptide in aiding the diagnosis of Kawasaki disease. We sought to investigate the potential value of N-terminal pro-brain natriuretic peptide pertaining to the prediction of coronary artery dilatation (Z-score>2.5) and/or of resistance to intravenous immunoglobulin therapy. We hypothesised that increased serum N-terminal pro-brain natriuretic peptide level correlates with increased coronary artery dilatation and/or resistance to intravenous immunoglobulin. We carried out a prospective study involving newly diagnosed patients treated with 2 g/kg intravenous immunoglobulin within 5-10 days of onset of fever. Echocardiography was performed in all patients at onset, then weekly for 3 weeks, then at month 2, and month 3. Coronary arteries were measured at each visit, and coronary artery Z-score was calculated. All the patients had N-terminal pro-brain natriuretic peptide serum level measured at onset, and the Z-score calculated. There were 109 patients enrolled at 6.58±2.82 days of fever, age 3.79±2.92 years. High N-terminal pro-brain natriuretic peptide level was associated with coronary artery dilatation at onset in 22.2 versus 5.6% for normal N-terminal pro-brain natriuretic peptide levels (odds ratio 4.8 [95% confidence interval 1.05-22.4]; p=0.031). This was predictive of cumulative coronary artery dilatation for the first 3 months (p=0.04-0.02), but not during convalescence at 2-3 months (odds ratio 1.28 [95% confidence interval 0.23-7.3]; p=non-significant). Elevated N-terminal pro-brain natriuretic peptide levels did not predict intravenous immunoglobulin resistance, 15.3 versus 13.5% (p=1). Elevated N-terminal pro-brain natriuretic peptide level correlates with acute coronary artery dilatation in treated Kawasaki disease, but not with intravenous immunoglobulin resistance.

Background: Despite widespread availability of a safe and cost-effective vaccine, Measles outbreak is reported from different regions of Bangladesh in the recent past. This study was aimed to Identify the related features of Measles infection in children during the upsurge of Measles infection in Chattogram during 2019-2020, when Bangladesh was about to achieve Measles elimination.
 Materials and methods: This prospective observational study included all the Measles infected children admitted in the Pediatric Ward of Chittagong Medical College Hospital, Chattogram during the period from September 2019-February 2020. In this hospital patients up to 12 years after neonatal period are admitted. Patients whose guardian did not give consent were excluded. Measles cases were diagnosed clinically according to case definition criteria by WHO. Demographic, clinical features, Measles vaccination status of both affected children & their mother and associated complications were recorded in a predesigned form. Data were analyzed and results were given in a tabulated form. The aim of this study was to evaluate the characteristics of Measles infection and their vaccination status in children during its upsurge in 2019-2020.
 Results: Affected children 13(20%) were suffered in spite of vaccination. Among the 65 affected children 44 (67.6%) were below one year of age, youngest one was 2 months old. Male to female ratio was 1.8:1. 80% (n=52) children were not vaccinated, 35 of them not yet attained the age of vaccination. 17 children attained the age but vaccination was delayed due to cough and cold, fever, bronchopneumonia or Measles itself. Complications were common among them, Bronchopneumonia 47 (72.3%) and Purulent conjunctivitis 38 (58.5%). There was no case fatality.
 Conclusion: Children are being affected by Measles before attaining the age of first dose of vaccination and incompletely vaccinated or unvaccinated children have a role in the upsurge of Measles.
 Chatt Maa Shi Hosp Med Coll J; Vol.22 (1); January 2023; Page 33-37

BackgroundKawasaki disease (KD) is an acute self-limited systemic vasculitis of unknown etiology affecting mainly children less than 5 years of age. Risk factors for cardiac involvement and resistance to treatment are insufficiently studied in non-Japanese children.ObjectiveThis study aimed to investigate the epidemiology, clinical features and risk factors for resistance to treatment and coronary artery lesions (CAL) in KD in Spain.MethodsRetrospective study (May 2011-June 2016) of all patients less than 16 years of age diagnosed with KD included in KAWA-RACE network (84 Spanish hospitals).ResultsA total of 625 cases were analyzed, 63% were males, 79% under 5 year-olds and 16.8% younger than 12 months. On echocardiographic examination CAL were the most frequent findings (23%) being ectasia the most common (12%). Coronary aneurysms were diagnosed in 9.6%, reaching 20% in infants under 12 months (p<0.001). A total of 97% of the patients received intravenous immunoglobulin (IVIG) with a median number of days from fever onset to IVIG administration of 7.2. A second dose was given to 15.7% and steroids to 14.5% patients. Only 1.4% patients received infliximab. No deaths were reported. A multivariate analysis identified anemia, hypoalbuminemia, hyponatremia, higher creatinine and procalcitonin as independent risk factors for treatment failure and length under 103 cm, hemoglobin < 10.2 mg/dL, platelets > 900,000 cells/mm3, maximum temperature < 39.5°C, total duration of fever > 10 days and fever before treatment ≥ 8 days as independent risk factors for developing coronary aneurysms.ConclusionsIn our population, children under 12 months develop coronary aneurysms more frequently and children with KD with anemia and leukocytosis have high risk of cardiac involvement. Adding steroids early should be considered in those patients, especially if the treatment is not started before 8 days of fever. A score applicable to non-Japanese children able to predict the risk of aneurysm development and IVIG resistance is necessary.

Early recognition and treatment of Multisystem Inflammatory Syndrome in Children (MIS-C) within the context of COVID-19 infection is crucial for improved outcomes. Prompt intervention with IVIG and steroids leads to significant improvement in a severe case of MIS-C. Clinicians should be vigilant for MIS-C symptoms and initiate timely management. We report a case involving a fourteen-year-old male with COVID-19 infection who developed multisystem inflammatory disease. A previously healthy child presented with a history of 10 days of fever and cough, along with diarrhea, and vomiting for 3 days. His COVID-19 infection was confirmed through Polymerase Chain Reaction (PCR), and the laboratory values were remarkable for high levels of C-reactive protein, D-dimers, B-type natriuretic peptide (BNP), and troponin I. He developed circulatory shock on the second day of the presentation and needed inotropic support. Steroids and intravenous immunoglobulin (IVIG) were started in light of Multisystem Inflammatory Syndrome in Children (MIS-C), which improved his condition. Thus, during the management of COVID-19 infection, early detection and a careful clinical characterization for MIS-C are essential.

Noninvasive cardiac output monitoring during anaesthetic management for caesarean delivery in parturient with severe mitral stenosis: A more relaxed look.

The present article describes three cases of patients in cardiogenic shock (CS) with previous cardiac surgery that made them initially inoperable. Perioperative support with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) improved haemodynamic status and results in these high-risk patients. Case 1 is a 57-year-old male morbidly obese with previous aortic valve replacement (AVR) who presented with chest pain and developed cardiac arrest. Cardiopulmonary resuscitation and femoral VA-ECMO were initiated. Three days later, a redo AVR was performed. Veno-arterial extracorporeal membrane oxygenation was maintained for 12 days, followed by 7 days of veno-venous ECMO for complete recovery. Case 2 features a 39-year-old male with two previous mitral valve replacements (MVRs). The first is due to papillary muscle rupture, and the second is due to endocarditis of the mitral prosthesis. He presented with CS and pulmonary oedema. Emergency surgery was performed and the patient was then placed in VA-ECMO. Weaning off was achieved 3 days after surgery. Case 3 is a 21-year-old female with a previous MVR due to rheumatic disease. She presented with CS, severe mitral prosthesis stenosis, and a pulmonary embolism. Femoral VA-ECMO was initiated, and one day later, she underwent a redo MVR operation. Extracorporeal membrane oxygenation was discontinued 4 days later. Dysfunctional prosthetic valves leading to CS may benefit from a redo cardiac operation supported by a perioperative VA-ECMO to optimize haemodynamic status. Despite the results from risk prediction scores, this approach has the potential to reduce operative mortality in initial inoperable patients and allow a definitive redo cardiac surgery.

Measles is a highly contagious disease characterized by fever, malaise, coryza, conjunctivitis, cough and maculopapular rashes. Although it is a vaccine preventable disease, it however continues to be one of the present day scourges of the developing world The study is a cross sectional involving children 10 years and below who were randomly selected by multistage cluster sampling from hospital each in local government areas from the three geopolitical zones of Zamfara state, Nigeria to determine the seroprevalence of measles specific IgM antibodies and the possible risk factors associated with the acquisition of the infection. Following informed consent a total of two hundred and twenty four (224) blood sample was collected. Study subjects were interviewed using self-structured questionnaires. Serum samples were analyzed using ELISA IgM kit (Diagnostic Automation and Cortez, Calabasas, CA, USA), in accordance with the manufacturer’s guidelines. Of the 224 serum samples screened 43.3% were positive for measles virus specific IgM antibodies indicating an active infection. The results shows decrease in sero-positivity with age, with the highest prevalence recorded in age group 0-2years (49.1%) and lowest among 8-10 years (25.0%). Males had slightly higher prevalence 44.2% compared to females 42.3%, though the result was not statistically significant, (P&gt;0.05). Previous exposure to measles and crowded environment revealed significant association (P&lt; 0.05).However no association was observed in relation to vaccination status and contact with infected individuals (P&gt;0.05). This study confirms the presence of measles and indicate measles endemicity in the study area. However the study shows a reduction in measles burden among vaccinated children. Its presence among unvaccinated children might be an indication of insufficientKEY WORDS: Measles, IgM, Antibody, Elisa, Prevalence, Zamfara.

Kawasaki disease (KD) represents one of the most common types of pediatric vasculitis. To date, there has been one case that is associated with abducens palsy.1 Here, we present a case of classic KD with right abducens palsy that developed during the subacute phase of the illness. A 12-year-old Caucasian girl with an unremarkable medical history was referred to our hospital with a 4-day history of fever, weakness and a rash. On the second day of fever, she developed rash in the lower extremities, vomiting, headache and complete blood count revealed leukocytosis (19 000/mm3). Physical examination revealed a maculopapular rash that blanched with central clearing over her trunk and lower extremities, unilateral lymphadenopathy, bilateral conjunctival injection, oropharynx hyperemia and strawberry tongue. There was no organomegaly, costovertebral tenderness or meningeal findings. Complete blood count and biochemical parameters were non-specific. Diagnosis of KD was made and 2D-echocardiography was performed, which showed a dilated proximal left coronary artery measuring 5.6–5.8 mm. Intravenous immunoglobulin (IVIG) and high-dose acetylsalicylate (80 mg/kg) were given. By her 4th hospital day, 2 days after IVIG therapy, she complained of double vision and lateral rectus palsy. There were no characteristic findings on computed cranial tomography. Lumbar puncture was not abnormal. Her cranial magnetic resonance imaging study was normal. Neurological exam and laboratory findings were consistent with right abducens palsy (Fig. 1). Oral dexamethasone 0.5 mg/kg/dose was started twice a day on her 5th hospital day. On the seventh hospital day the patient was afebrile and her general status was improved, but cranial nerve palsy persisted. Her erythrocyte sedimentation rate was relatively decreased to 40 mm/h. After her 13th hospital day, a dose of steroid treatment was decreased to a half-dose and after another week steroid treatment was ceased. The patient was discharged on the 20th day of hospitalization with acetylsalicylate therapy. A follow-up examination 4 weeks later presented resolution of right abducens palsy and disappearance of coronary involvement. Loss of abduction of the right eye is seen, demonstrating isolated sixth-nerve palsy. The diagnosis of KD can be made when there are fewer than four clinical features if coronary artery involvement is documented.2 Our case had four of the five criteria at the time of presentation (conjunctivitis, mucosa changes, lymphadenopathy and rash). Although the coronary artery involvement of KD is the most important cause of morbidity and mortality, neurological findings can be expected as KD has a multisystemic nature. Irritability and lethargy are common features during the clinical course of KD due to aseptic meningitis.3,4 Nevertheless, cranial nerve palsy associated with KD has rarely been seen and the mortality rate is higher in KD associated with facial nerve palsy, as compared with KD without facial nerve palsy.1 Although this single case is not enough to be evidence, we suggest that recovery of the neurological finding may be related with acetylsalicylate and steroid treatment. This report reinforces the need to be aware of various manifestations of KD beside coronary artery involvement. It is also helpful to keep in mind the diagnosis of KD in any child with high fever and without cranial palsy.

Immune Thrombocytopenia during Childhood: New Approaches to Classification and Management