Features of COVID-19 post-infectious cytokine release syndrome in children presenting to the emergency department

Abstract

The 2019 coronavirus disease (COVID-19) has not appeared to affect children as severely as adults. However, approximately 1 month after the COVID-19 peak in New York City in April 2020, cases of children with prolonged fevers abruptly developing inflammatory shock-like states have been reported in Western Europe and the United States. This case series describes four previously healthy children with COVID-19 infection confirmed by serologic antibody testing, but negative by nasopharyngeal RT-PCR swab, presenting to the Pediatric Emergency Department (PED) with prolonged fever (5 or more days) and abrupt onset of hemodynamic instability with elevated serologic inflammatory markers and cytokine levels (IL-6, IL-8 and TNF-α). Emergency physicians must maintain a high clinical suspicion for this COVID-19 associated post-infectious cytokine release syndrome, with features that overlap with Kawasaki Disease (KD) and Toxic Shock Syndrome (TSS) in children with recent or current COVID-19 infection, as patients can decompensate quickly.

Keywords: COVID-19; Children; Cytokine storm; Kawasaki Disease.

Fig. 1

Patient 1's progression of consecutive portable chest radiographs interpreted by radiologists. A. In ED, “No acute pulmonary disease.” B. 17 h later, “New hazy opacities in both lower lungs concerning for atypical viral pneumonia.” C. Hospital Day 2, “Hazy bilateral opacities predominantly in the mid to lower lungs concerning for atypical viral pneumonia.” Patient 2's portable chest radiograph interpreted by radiologists. D. “Peribronchial thickening with ill-defined airspace opacities in the right mid to lower lung, concerning for atypical viral pneumonia.”