KAWASAKI – In a study published by a group of physicians from the public Assistance-Hospitals of Paris (AP-HP), the new syndrome that affects children, close to the Kawasaki disease, is very serious, but it is also very rare and non-fatal if it is treated well…
Contents 1 – Symptoms of “SET-C” • Syndrome Kawasaki • toxic Shock 2 – Number of cases in France 3 – the Severity of the MIS-C • Risk of death • genetic Factors 4 – Link with the coronavirus 5 – An increase in cases ?
[updated on may 20, 2020 at 15h53] The “pseudo-Kawasaki disease”, also called “SET-C” (for Multisystem inflammatory syndrome in children), which are on the increase among children in the wake of the outbreak of coronavirus, continues to reveal its secrets to the medical world. A study on the subject has just been published by doctors of the public Assistance-Hospitals of Paris (AP-HP). This study was conducted on 35 children with this syndrome multi-systemic, in other words, resulting in an infection in multiple symptoms ranging from digestive problems and diarrhea to breathing and heart problems, by way of a high fever and rash. A short text was published Tuesday 19 may on the site of the AP-HP and conclusions in greater detail in the journal Circulation. In summary, this new study shows the efficacy of treatments with immunoglobulin for these cases, the particularly serious but non-fatal if they are taken on time.
“most of these children needed to receive treatments that support the function of the heart that was corrupted and is being mechanically ventilated”, write for example, physicians who indicate that ten patients on 35 “has been placed temporarily in circulatory support”. “This publication clearly shows that this rare complication of COVID-19 in children and exceptional in the young adult can be a very great seriousness. The entire community of pediatric cardiology agrees to identify an emerging disease that it would be appropriate to call inflammation multisystem of the child associated with the SARS-CoV-2 in which the achievement of the heart muscle is in the foreground,” continue the authors. “Treatment, identical to that of the Kawasaki disease, is apparently effective in most children,” they concluded, stating that all children were treated “by immunoglobulins associated sometimes with corticosteroids”.
dr. Jimmy Mohamed of the AP-HP has stated on Europe 1 that these children “had an average of ten years” and “in one third of cases, they had comorbidities, such as overweight or asthma.” He calls the parents noting of the digestive symptoms to consult their doctor, especially as the epidemic of gastro-enteritis is complete. “He will be able to reassure you or refer you to a specialist”, he adds. While coronavirus has been known as little developed and little dangerous for the children since the beginning of the epidemic, this new infection is concerned in any case a little everywhere in the world. Here are five key questions about this mysterious disease :
1 – What are the symptoms of the MIS-C, new infections in children ?
This inflammation is multi-systemic in children (SET-C) would be unusual and completely new. It causes symptoms corresponding to certain infections known, but not all, which urges physicians to describe an “overlap” between a toxic shock – “normal” and a syndrome of Kawasaki typical.
The syndrome of Kawasaki has been known since 1967 and its discovery in Japan. It is a disease of the blood vessels mysterious striking more young people, generally from 1 to 8 years of age, and is characterized by a “vasculitis febrile”, affecting the veins and small arteries. The cause of this syndrome vascular affecting young children remains undetermined. Shock toxic commonly seen in children have several characteristics in common with the storm cytokinique, a runaway of the immune system observed in the most severe cases of the coronavirus and that leads to a reaction to a hyper-inflammatory that can become deadly
The symptoms of the MIS-C borrow so in the one and the other and, moreover, are many : rash, high fever of around 39-40°, lymph nodes, abdominal pain, vomiting or diarrhea, sometimes think of appendicitis, but also breathing and heart problems. The symptoms begin with digestive disorders and are in a state of shock respiratory. Myocarditis, that is to say, an inflammation of the muscle tissue of the heart, may ensue and lead to heart failure. In summary, “the immune system reacts too strong and creates damage,” says Véronique Hentgen, infectious diseases physician and pediatrician in Paris.
Dr. Liz Whittaker, of the faculty of medicine, Imperial College London, infectious disease specialist, validates this thesis with an over-immune reaction. It delivered Thursday, may 13 more details on the symptoms of the MIS-C. On Channel 4, it indicates that a significant proportion of sick children have suffered from “abdominal pain and diarrhea”. Among them, “a very small group has developed a shock at the level of the heart”. “These children can become very ill, they have cold hands, feet and breathe very quickly”, she adds referring to as skin rashes, “eyes and mouth red, as well as fever. It ensures that these children require intensive care treatment urgent. “Most of the children are very sick for four to five days, but their condition is improving then.”
2 – How many cases have been reported in children in France ?
The multiple infection called “SET-C” has been the subject of an alert in France as early as the 27th of April. Several doctors have since climbed their observations to public Health in France. During his press conference, Tuesday, may 19, 2020, the director-general of Health Jerome Solomon, has indicated that 152 cases had been listed since 1 march, of which 98 cases with “possible ties with the coronavirus”. The Friday, may 15, a press release of public Health France was 144 and the number of reports of systemic diseases atypical pediatric” in the country. In a separate release, the health agency stated that 67 cases (54%) were girls. 72 young patients were suffering from myocarditis, the most serious complication, 47 patients were spared (6 were awaiting classification). A stay in intensive care was required for 65 children and in the critical care unit for 25. The other children have been hospitalized in the department of pediatrics.
After a peak observed in week 17 (20-26 April), the number of new reported cases has declined since important still indicated a public Health France. According to other figures reported by Le Figaro on Friday, may 15, 50% of affected children would have ended up in the icu with a severe inflammation. Most of the cases are concentrated in the Île-de-France (72 cases, including 42 at the Necker hospital), but 12 were also counted in the Big East and 11 in the PACA region”, writes the daily.
the rapid growth
The number of cases of this new infection was rapidly multiplied in France. A document submitted on 29 April by the Centre for rare diseases, congenital heart defects first identified at least 25 cases in three weeks in the réanimations in paris, said BFMTV. In these patients aged mostly between 8 and 15 years, there were fifteen cases of myocarditis. Professor Pierre-Louis Leger, department head of the pediatric intensive care unit of the hospital Trousseau (AP-HP), admitted to the string of info at the end of April have recorded three cases of this form of toxic shock in ten days at the Trousseau hospital, three or four at the Robert Debré hospital and it was estimated that the ten cases had been taken to Necker, a balance sheet already “totally abnormal in this period.”
The professor Damien Bonnet, a rare disease specialist at the parisian hospital Necker-Sick Children, told the weekly Marianne, may 5, that Necker had a quarantine of the affected children even if not all of them have been conducted in the intensive care unit. “Has Necker-Sick Children, there are about three children hospitalized per day for this new form of Kawasaki disease, was admitted into sectors of intensive care, but not all in the icu”, said the doctor. In a note on the coronavirus in the child, published on the same day and on the reopening of schools, public Health France, stated that forty of the cases were known in france, which suggests that the number of cases has more than tripled in ten days.
3 – The children are they in danger ?
The concern is first world. The british society of pediatric intensive care (PICS) and the National Health Service (NHS), the health authority, uk, published on Monday, April 27, a first alert that was immediately a concern to health authorities in europe. Their communication was originally published in the Health Service Journal, for health professionals, who they were asking to raise the case of “Kawasaki-like”, expressing their fear that a rapprochement with the Covid-19. This type of internal reporting to the network medical is current. But since then, the Uk has reported a hundred cases in total, striking mostly young children between the ages of 5 and 16 years old and have no health issue, as well as the suspicious death of a baby of 8 months. “This is something that concerns us,” assured at the end of April the minister of Health in the uk, Matt Hancock, to the radio LBC. And it is not the only one. “We are monitoring this issue very carefully,” said to AFP a spokesman for the swiss federal Office of Health. Dozens of cases of MIS-C have also been reported in Spain, in Belgium or in the north of Italy, where the epidemic of Covid-19 has been devastating.
The new infection symptoms multiple has also been the subject of an alert of authorities american this Thursday, may 14, at the destination of health professionals. Called syndrome multi-inflammatory in children (SET-C) by the u.s. Centers for prevention and disease control, it affects already a hundred cases in addition to-Atlantic, and has already killed at least three children in the State of New York. The american authorities have called for vigilance and require physicians to report “any infant death with evidence of infection with SARS-CoV-2”. “Care providers who have treated or are treating patients under the age of 21 years, corresponding to the criteria (the disease) MIS-C dmust report suspected cases to their local health department”, have also indicated the Centres of prevention american.
Of France to the WHO, authorities in the alert
The world Health Organization (WHO), for its part, evoked early may “a few cases of children with down syndrome and inflammatory”, but observed how “really rare”. Reassuring, WHO recalled that “the vast majority of children with Covid-19 have only a mild infection and recover completely”. In a note published in mid-may (and available here), the organization has however called on the health authorities to make up any cases that would be recognized in other countries. It announced it had begun a study to determine the link between this new infection and the Covid-19.
The 152 cases) also allude to in France. But all these cases are still presented as exceptions by the health authorities as well as by many doctors. Since its first intervention on the subject, April 29, on France info, the minister of Health Olivier Véran wants to reassure, evoking “diseases are quite rare,” and focusing primarily on the state of alert of the health services on the issue. “All réanimations pediatric of France are on alert for getting alerts that I am day-to-day,” he said again to the deputies on 2 may last. The death of a child in Marseille, has not really changed the discourse : we talk about a resurgence of the “exceptional cases” that need to be closely monitored, but not a new “epidemic”, as indicated, in particular, Damien Bonnet, chief of service at the Centre for rare diseases the Necker hospital.
The risk of death in affected children is it high ?
In France, out of the 152 cases identified, we account at this stage only one death from this infection multi-systemic. A boy aged 9 years died in Marseille on Saturday, may 9, 2020. The latter was part of a group of five children admitted to the hospital la Timone for the suspicion of the syndrome of Kawasaki, instead of the three annual cases generally identified, indicates The Provence. Professor Fabrice Michel, head of the pediatric intensive care unit of the Timone, clarified that the child died after seven days of care in their services. He had been rushed to hospital after a “severe discomfort with a heart attack at his home, located in Marseille. The doctors of la Timone, as well as the AP-HM in a press release, have given other details on this case dramatic. The heart attack would be well and truly “connected” to this” syndrome called “post-infection Covid”. The serological analysis showed that the child had been “in contact” with the coronavirus, but had not developed symptoms.
it Remains to determine if the young victim had “co-morbidities”. “It will be necessary to exploit his or her medical record, in order to understand if there had been no pre-existing medical condition,” says Fabrice Michel, while public Health France wrote that it was “of a co-morbid neuro-developmental”. The father of the child about him, has assured on BFMTV on Monday 18 may that his son was “in excellent health”. It considers that the tragedy “could have been avoided” and plans to lodge a complaint against the hospital of la Timone in Marseille. Presented to the emergency room for the first time, the child would have been under him returned home, with a prescription of antibiotics for a suspicion of scarlet fever, before a serious worsening of her condition and his / her admission in the pediatric intensive care unit of the Timone on 2 may.
another suspicious death in the United Kingdom has puzzled health authorities in europe. A baby of 8 months died last April at the hospital Derriford Plymouth, probably this mysterious infection. The mother of the infant has launched an appeal to the british authorities as “insane” the fact that the children return to school on the 1st of June in the uk. “Other children are going to die. Other parents will be in the same situation unimaginable, unless the government starts to listen to the advice of scientists”, she said to the Mirror.
To professor Fabrice Michel de la Timone in Marseille, which is responsible for the first fatal case in France, instead, we must continue to “reassure parents”. “All the other cases of which we are aware were delivered in just a few days after treatment immuglobuline”, he says with The Provence. “We talk a lot about us from this syndrome, because it takes very different forms, thus we are very attentive”, but the cases “should not worry”, he assured, attentive, all the same parents that it is necessary “to consult when children have fever for more than two days and signs associated with them”. “What is certain is that this disease is fortunately very rare. It can be serious but evolves in the majority of cases”, is full of the AP-HM. “In the case of a high fever and durable, inflammatory manifestations (lymph nodes, rash) in children, it is appropriate to promptly obtain a medical opinion”, called also public Health France on the 15th of may.
The disease strikes the children as a function of genetic factors ?
Among the questions that arise on the multiplication of these cases, the category of children affected emerges it also. According to the medical journal the Lancet, genetics may be the determining factor, the first observed cases in England being predominantly “afro-caribbean”. The people of africa and the west indies seem to be particularly exhibited in France also and it is in these populations that we would find the most severe cases. The child died at Marseilles was of “african descent” is simply to indicate the Pr Michel de La Timone, without extrapolate. While in France, ethnic statistics are forbidden, an exception could be made for reason of health. A request to the Commission nationale de l’informatique et des libertés (Cnil) is being considered for a better understanding of this infection.
4 – Is there really a link with the coronavirus ?
The link between the SET-C and the outbreak of coronavirus seems to be now established. In the recent study of the AP-HP, mentioned at the top of this article, nearly 90% of the 35 treated children had had a PCR or a positive serology at Covid-19. “The link with the infection by the coronavirus SARS-CoV-2 is found in 88% of them who have developed antibodies against it,” writes the AP-HP on his site. The coronavirus is suspected since the start, at least as a trigger of this infection that hits some of the children.
professor Alexandre Belot, a pediatrician at the hospital Woman-mother and child Lyon, who led an epidemiological study to identify all cases with public Health in France, stated bluntly in Paris on 15 may that “the link between the virus and the syndrome of Kawasaki” was now “confirmed”. “We have noted a significant increase in the number of cases four weeks after the epidemic wave that has crossed the country, and then an important decrease. They were concentrated in the areas where the virus was strongly present : the greatest (9.6%), the Ile-de-France (58.4 per cent) and, to a lesser extent, Auvergne-Rhône-Alpes”, explains the scientist.
According to the press release of public Health France dated may 14, and about 125 cases observed, 52% had a PCR and/or serology for SARS-CoV-2. The link to the virus was “likely” in 15 other children analyzed (12%). For 29 patients (23%), the results were still pending, and the status was unknown for the other 16. “These results are very much in favor of a link between infection by the SARS-CoV-2, and this condition,” concluded the statement, which also reiterated that the young victim died at Marseille was also also a serology “positive” vis-à-vis the Covid-19.
The French speaking Society for rheumatology and inflammatory diseases in pediatrics (SOFREMIP) was issued as early as April 29, a letter, still available on the website of the French Society of paediatrics. Its experts said they were “questioned for several weeks by the description of pediatric cases in the resuscitation of myocarditis with failure of the circulatory system”. “In the context of the current pandemic of COVID-19 the association of these cases to the SARS-CoV2 is possible, even if it could not be proven for all patients,” wrote already to the members felt was “essential not to forget to search for other viruses that are typically associated with Kawasaki disease atypical and that are expected to circulate this season : adenovirus, enterovirus, coxsackie”.
70% to 75% of affected children have been “in contact” with the coronavirus
Among the different doctors, researchers, and pediatricians surveyed, much emphasize has been weeks since the concomitance quite disturbing between new infections and the epidemic of SARS-CoV-2. A Necker, Damien Bonnet is estimated that usually, there is a severe form of Kawasaki disease by month, then in three weeks, a score has been recorded. A part or a “majority” of children struck by this new form on syndrome Kawasaki have been tested positive Covid-19 according to the european data. “It is the case of more than half of them (70%). The other children have been in contact with a person infected with the coronavirus”, still indicated in Marianne professor Bonnet recently, which stated that “the probability of a link between the two is high.”
Asked for her hand on BFMTV, the Pr Ricardo Carbajal, chief of pediatric emergencies of the Trousseau hospital in Paris, ensured that “75% of the cases” observed in these children have had a “family contact proven” with the coronavirus. “We conducted a survey very in-depth with families who we contacted to find out if these children had been in contact with patients shown to during the containment and was found for 75% of them, at least one contact occurred between 3 and 5 weeks before the onset of symptoms”. Professor Fabrice Michel de la Timone in Marseille, which has reported the first death of a child due to an infection in the MIS-C, the link with the coronavirus is also “difficult to deny”. Many patients marseillais have antibodies in their body, a sign of a contamination Covid-19.
A reaction subsequent to the coronavirus ?
Remains that this influx of pediatric patients is delayed in comparison to the epidemic of coronavirus. According to the first hypothesis, the disease is multi-systemic may in fact be a collateral damage ticking. “We do not say that there are uno causal relationship between the infection by the Covid-19 and these clinical pictures. But a hypothesis would be a secondary disease to the Covid-19, as a consequence of infection often go unnoticed. An inflammatory phenomenon is ticking,” said Pierre-Louis Leger on BFMTV early may.
The thesis of the disease, post-infectious, “with a secondary reaction to the infection,” is echoed by Damien Bonnet of the Necker. According to him, the runaway of the immune system observed in children affected could be a result of infection with the coronavirus. Young patients may have, in a first time, developed “good antibodies” to get rid of the coronavirus, before that”a number of cells begin to put on excessive”. Infections could be linked to the production of toxins in response to a bacterial infection.
In the Paris on Friday, may 15, professor Alexandre Belot posited two hypotheses : “either the development of the disease is favored by an excess of the immune response in some children, on a background of genetic factors. Either it is linked to mutations of the virus itself which would result in younger patients this type of response”.
“We have absolutely no medical explanation at this point. Is it that it is an inflammatory response that comes to trigger a pre-existing disease in children affected by this virus or another infectious disease ? There are a lot of questions”, said the minister of Health Olivier Véran at the end of April showing more or less the same assumptions. The minister said then don’t have an answer at this stage and stated that “some of the children affected, but not all, have proven to be carriers of the coronavirus”. “I would mobilizes the community’s health care, the scientific community in France and internationally to have the maximum amount of data possible, to see if there is a link between the coronavirus and this form, which, until now, had not been observed anywhere”, he summarized.
A track followed abroad
outside the track, with a reaction post-coronavirus is followed, as indicated by the american pediatrician Sunil Sood, the children’s medical center Cohen in New York, questioned by the AFP. “They had the virus, their body has fought. But now there is this immune response is delayed and excessive,” according to this specialist. But as to thicken a bit, the fog that prevails at both the coronavirus and on these new infections, the AFP makes it clear that no similar case has been reported in children in Asia, including in China, where the virus appeared in December. It is at this level that the genetic factors and that a possible mutation of the virus are discussed.
The highly respected medical journal The Lancet has published this Thursday, 13 may 2020 an article that quite clearly the link between the SARS-CoV-2 and SET-C, which strikes children. The study is based on the observed cases in Bergamo, one of the epicenters of Covid-19 in Italy. While the hospital of the city lombard deals, on average, a case of syndrome of Kawazaki per quarter, it has listed ten between February 18 and April 20, 2020, or thirty times more than usual. The researchers cited by The Lancet, also indicate that eight out of ten children in hospital had tested positive for the coronavirus.
5 – Should we fear an upsurge in cases of PUT-C at the déconfinement ?
If these mysterious infections are really a reaction after an infection with the coronavirus, should we fear an upsurge of cases with the déconfinement ? It is a likely scenario according to several researchers around the world. “The comparison of the curves of hospitalization for COVID-19 and for this pathology is in favour of a average time of occurrence of these systemic inflammatory diseases by 4 weeks after infection with the SARS-CoV-2”, showed public Health France on may 14. A period of time confirmed greater or lesser extent by the u.s. health authorities, who estimate that the occurrence of these inflammatory symptoms seems to intervene in “four to six weeks after the child has been infected with the virus, while it has already developed antibodies,” writes the AFP.
in The United Kingdom, Dr. Liz Whittaker confirms it too : “the syndrome occurs in a minimum of three weeks after an infection with the coronavirus, although the affected children in all have been asymptomatic carriers”. It actually estimates a possible increase in cases during or after the déconfinement. “It is a possibility”, she said to Channel 4. Professor Russell Viner, president of the Royal College of Paediatrics and Child Health (RCPCH), also believes that “if there is a phenomenon of post-infectious, we could see other people, but the important thing is that it can be avoided.” It therefore calls to inform parents to ensure that they can recognize the syndrome and seek help early”.
