Saturday, May 23, 2020

Coronavirus: What is Kawasaki Disease and its Possible Link with COVID-19 in Children?
By Lauren Chadwick  & Alice Tidey

A mysterious condition affecting children that could be linked to COVID-19 has been reported in several European countries and North America.

The World Health Organization (WHO) put out a scientific brief on Friday describing "clusters of children and adolescents requiring admission to intensive care units with a multisystem inflammatory condition with some features similar to those of Kawasaki disease and toxic shock syndrome."

England's health service had alerted at the end of April that cases of children in intensive care with "a multi-system inflammatory state" were rising.

Children were displaying overlapping symptoms of severe COVID-19, toxic shock syndrome and Kawasaki disease.

The UK, France, Italy, Spain, and the US have all reported cases with some children testing positive for COVID-19 or coronavirus antibodies, meaning they were previously exposed to the virus.

A nine-year-old in France recently died due to complications from cardiac arrest. The child had tested positive for coronavirus antibodies.

At least three children have died in New York from this "new emerging syndrome".

What are the symptoms to look out for?

The WHO says to look out for fever, inflammation, hypotension, and shock and New York City's department of health warned to look for signs of fever, prolonged abdominal pain, skin rash, bloodshot eyes, racing heart among other symptoms.

The symptoms reported are similar to Kawasaki Disease, which primarily affects children under the age of five and can cause blood vessels to become inflamed and swollen and lead to complications such as the swelling of the arteries.

“The characteristics of it are fever, red eyes, red lips, red tongue, a rash, there can be swelling and redness of the hands and feet and there can also be swelling of the lymph nodes and neck,” said Adriana Treboulet, associate director of the Kawasaki Disease Research Centre at the University of California, San Diego.

“It can cause swelling of the arteries of the heart and that can be lifelong and it can lead to things such as a heart attack,” Treboulet added.

The disease can be mild but about a quarter of children will have coronary artery aneurysms or swelling of the heart arteries, experts say.

"So Kawasaki disease has been recognised for a long time and it really is as horrible as it sounds," Kate Sullivan, a professor of paediatrics at The Children's Hospital of Philadelphia. "There's inflammation of every organ of the body.

"Usually what people see first is the skin but the thing that we are most afraid about is it affects the heart and an inflammation of the heart is always dangerous."

What is the reported link between these symptoms and COVID-19?

In countries with large outbreaks of coronavirus, there have been more reported cases of paediatric shock and Kawasaki disease-like symptoms. Some of these children have tested positive for COVID-19 or coronavirus antibodies.

France’s public health agency said they have had reports of at least 144 children with atypical paediatric diseases since March 1.

Some children between the ages of 5 and 20 have presented Kawasaki Disease like symptoms that the agency has been calling "pseudo Kawasaki Disease".

NHS England first warned in April that some children have shown symptoms of toxic shock syndrome — which is caused by a bacteria getting into the body and releasing harmful toxins — and atypical Kawasaki disease "with blood parameters consistent with severe COVID-19 in children".

Spain’s paediatric association put out a similar warning in April, stating that there were cases of paediatric shock but telling parents not to be alarmed.

“Cases of shock in children that are temporarily coinciding with the COVID-19 epidemic are very rare,” the association explained.

Prof Simon Kenny, NHS national clinical director for children and young people, said in a statement that it was "important that clinicians [were] made aware of any potential emerging links so that they are able to give children and young people the right care fast".

Experts say it is too early to determine whether or not there is a direct link between the virus that causes COVID-19 (SARS-CoV-2) and Kawasaki disease.

How could it be linked to COVID-19 and when will we know?

"Initial hypotheses are that this syndrome may be related to COVID-19 based on initial laboratory testing," the WHO said on Friday.

"It is essential to characterise this syndrome and its risk factors, to understand causality, and describe treatment interventions."

The early NHS warning suggested that "there may be another, as yet unidentified, infectious pathogen associated with these cases."

Professor Robert Tulloh, a cardiologist at Bristol Royal Hospital for Children, told Euronews last month: “There might be worse cases of [Kawasaki disease] because they are presenting late - since they were mistakenly thought to be COVID-19 until too late. Or there might actually be more cases of Kawasaki disease triggered by COVID-19, masquerading as COVID-19 or actually COVID-19-related."

“​It will take many months before the epidemiologists can let us know whether there is a link. It will be complicated and not a simple answer,” Tulloh added.

Tulloh says there was thought to be a link between Kawasaki disease and SARS (Severe Acute Respiratory Syndrome) during the 2003 outbreak, but that theory has since been disproven.

"As with COVID-19, Kawasaki disease can be mild in most cases and we would not want to cause alarm or panic among parents of young children," added Tulloh.

"However, about a quarter of children with Kawasaki disease will get coronary artery aneurysms (swelling of the heart arteries) if they are not treated at the correct time, which is about 5 days into the illness.

Professor Russell Viner, President of the Royal College of Paediatrics and Child Health, stressed that instances of children falling severely ill with COVID-19 have been "very rare".

"Evidence from throughout the world shows us that children appear to be part of the population least affected by this infection.”

What does the WHO say?

WHO confirmed in late April that it was investigating the rare inflammatory condition.

"So they [children] tend to have overwhelming mild disease," said Dr Maria Van Kerkhove, COVID-19 technical lead at WHO's health emergencies programme.

"But there are some children who have developed severe disease and some children who have died.

"There are some recent rare descriptions of children in some European countries that have had this inflammatory syndrome, which is similar to Kawasaki's syndrome."

The WHO asked for clinicians to be alert to this possibility and since then, more cases of the disease have been reported in several countries.

"There is therefore an urgent need for collection of standardised data describing clinical presentations, severity, outcomes, and epidemiology," the WHO said on Friday (May 15).

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