Carolinas Research Day 2021

Bhuvna Mahajan, OMS-II; Nicole Rosenberg, OMS-III; Hanna Sahhar, MD Edward Via College of Osteopathic Medicine-Carolinas Campus, Pediatrics Dept, Spartanburg, SC

CLIN-4

RESULTS

ABSTRACT

RESULTS

Our study included three males and three females with ethnically diverse backgrounds [41.6% Caucasian, 58.4% African American, 16.7% Hispanic, 83.3% non-Hispanic] and had no pertinent previous medical history. The most common clinical symptoms amongst all six patients included conjunctival injection, thrombocytopenia, abdominal pain, and rash. Average inflammatory markers for KD patients noted elevated BNP [1347.2], CRP [18.8], ferritin [829], d -dimer [3.08], IL- 6 [245.7], and lymphopenia [9%] (Figure 6). In comparison with KD patients, KLS patients showed notably elevated BNP [236.9], CRP [20.3], ferritin [863.9], d- dimer [6.71], troponin [1.41], and lymphopenia [5.3%]. Multi -system organ involvement includes evidence of clinically severe illness in 4.3 organ systems per true KD patient on average and 5.3 per KLS patient.

Per the World Health Organization, Multisystem Inflammatory Syndrome in Children (MIS-C) has been identified as a priority disease that must be further characterized. On May 14th, 2020, The Center for Disease Control and Prevention (CDC) defined the case criteria for MIS-C to characterize this newfound spectrum of illness, though much remains unknown. All patients involved in our study present with qualifying criteria for MIS-C based on the CDC definition. This definition includes: less than 21 years of age, fever of 38.0°C, positive lab markers for inflammation, multisystem organ involvement, no alternative diagnosis, a confirmed SARS-COV-2 Infection (COVID-19) or exposure within 4 weeks prior to symptom onset. Patients presenting with MIS-C develop a multitude of symptoms similar to Kawasaki’s Disease (KD). The criteria includes: ≥5 days of fever and the presence of at least 4 of the 5 following clinical criteria: oral/pharyngeal mucosal changes (Figure 1), bilateral conjunctival infection without exudate (Figure 2), rash (Figure 3), edematous extremity changes (Figure 4), and cervical lymphadenopathy (Figure 5). Patients with ≥5 days of fever and fewer clinical symptoms are defined as Kawasaki like Syndrome (KLS). Our project aims to differentiate the characteristics of True Kawasaki Disease (KD) and Kawasaki-like Syndrome (KLS) in children presenting with MIS-C. Out of the 6 patients with MIS-C, 3 were diagnosed with true KD presenting with all 5 criteria, while the remaining 3 were diagnosed with KLS, presenting with less than 4 criteria defined for KD. All patients with MIS-C are exhibiting clinical findings of KD, an acute febrile vasculitis caused by an unknown etiology. Conversely, other patients do not demonstrate the full criteria of KD, and are thus defined as patients with Kawasaki-Like Syndrome (KLS). METHODS A retrospective analysis of six pediatric patients was performed to determine who presented with criteria for MIS-C. Qualifying criteria includes: less than 21 years of age, fever of 38.0°C, positive lab markers for inflammation, multisystem organ involvement, no alternative diagnosis, a confirmed COVID-19 infection or exposure within 4 weeks prior to symptom onset. Data was collected from all MIS-C patients to determine if each patient fit all criteria of KD or partial criteria (KLS). INTRODUCTION

DEMOGRAPHICS

KAWASAKI DISEASE (KD)

KAWASAKI LIKE SYNDROME (KLS)

4.6

9.4

AGE [years]

1 2 2 1 1 2

2 1 1 3 0 3

MALE

FEMALE

CAUCASIAN

AFRICAN AMERICAN

HISPANIC

NON-HISPANIC Table 1: Average population demographics

COVID-19 Exposure (all 6 cases)

Multisystem Inflammatory Syndrome in Children (MIS-C) (all 6 cases)

Kawasaki Disease (KD) (3 cases) ≥5 days of fever + ≥4 of the 5 following clinical criteria:

Kawasaki Like Syndrome (KLS) (3 cases) ≥5 days of fever + ≤3 of the 5 following clinical criteria:

Figure 6: Average inflammatory markers

CONCLUSIONS

• MIS-C is a disease not yet described in literature. It is affecting children with previous COVID-19 exposure and can present with a spectrum of severe symptoms qualifying for either true KD or KLS. • One patient tested positive for COVID-19 via polymerase chain reaction (PCR) and three patients have positive COVID-19 I gG/IgM . • This study identified appreciable differences in common laboratory studies allowing for early differentiation between KD and KLS including BNP, platelet count, and IL-6. • Future studies should be done to further define KD and KLS as separate disease states based on their cytokine profiles. • We believe clarifying and exploring the differences in clinical and molecular pathology of MIS-C may optimize treatment algorithms and positive outcomes.

Figure 1: Erythema and cracking of lips, strawberry tongue, and/or erythema of oral and pharyngeal mucosa

REFERENCES

Figure 2: Bilateral bulbar conjunctival injection without exudate

Diorio C, Henrickson SE, Vella LA, et al. Multisystem inflammatory syndrome in children and COVID-19 are distinct presentations of SARS–CoV- 2. The Journal of Clinical Investigation. 2020;130(11):5967 - 5975. doi:10.1172/JCI140970

Figure 3: Rash: maculopapular, diffuse erythroderma, or erythema multiforme

ACKNOWLEDGEMENTS

I would like to thank my co-author Nicole Rosenberg for her commitment to this project. I would like to thank Dr. Sahhar for his unwavering support as a mentor and his dedication to his patients. I would like to thank Spartanburg Regional and Prisma Health for providing access to the patient files.

Figure 4: Erythema/edema of the hands/feet in acute phase ± periungual desquamation in subacute phase

Figure 5: Cervical lymphadenopathy (≥1.5 cm diameter), usually unilateral

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