The impact of the COVID-19 pandemic on the field of pediatric rheumatology

Abstract

Purpose of review: The purpose of this review is to discuss the clinical management of children with pediatric rheumatic disease (PRD) during the Coronavirus disease of 2019 (COVID-19) pandemic, as well as the unique role of the pediatric rheumatologist during a time of emerging post-COVID inflammatory sequelae including, multisystem inflammatory syndrome in children (MIS-C).

Recent findings: To date, there has been little evidence to suggest that children with PRD, including those on immunomodulatory therapies, are at increased risk for severe COVID-19. Clinical guidance statements have been created to support clinical providers in providing care to children with PRD during the COVID-19 pandemic. Pediatric rheumatologists have also been called upon to assist in the identification and management of post-COVID sequelae, including the rapidly emerging inflammatory illness, MIS-C.

Summary: The COVID-19 era has been defined by a rapid expansion in scientific knowledge and a time of extraordinary local and worldwide collaboration, both within the pediatric rheumatology community, as well as across multiple disciplines. Through collective efforts, we have learned that children with PRD, including those on immunomodulatory therapies, are not at increased risk for severe COVID-19. Pediatric rheumatologists have also worked alongside other disciplines to develop guidance for the management of MIS-C, with the majority of patients experiencing excellent clinical outcomes.

Box 1

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FIGURE 1

Summary figure of main clinical and laboratory findings in pediatric acute severe COVID-19 disease, MIS-C and Kawasaki disease. CRP, C reactive protein; ESR, erythrocyte sedimentation rate; IL-6, interleukin-6; LVEF, left ventricular ejection fraction.

FIGURE 2

American College of Rheumatology (ACR) algorithm initial immunomodulatory treatment in MIS-C (original legend included in image). Algorithm for initial immunomodulatory treatment of multisystem inflammatory syndrome in children (MIS-C). Moderate-to-high consensus was reached by the Task Force in the development of this treatment algorithm for MIS-C associated with severe acute respiratory syndrome coronavirus 2. ¹Intravenous immunoglobuin (MG) dosing is 2 gm/kg based on ideal body weight. Cardiac function and fluid status should be assessed before MG is given. In some patients with cardiac dysfunction, MG may be given in divided doses (1 gm/kg da1y over 2 days). ²Methylpremisolone or another steroid at equivalent dosing may be used. ³Refractorry disease is defined as persistent fevers and/or ongoing and significant end-organ involvement. ⁴Low-to-moderate-dose glucocorticoids (methylprednisolone 1-2 mg/kg/day) may be considered for first-line therapy in some MIS-C patients with concerning features (ill appearance, highly elevated B-type natriuretic peptide levels, unexplained tachycardia) who have not yet developed shock or organ-threatening disease. ⁵If the patient was given Iow-to-moderate-dose glucocorticoids as first-line therapy, methylprednisolone IV dosing should be 10–30 mg/kg/day for intensification treatment. Reproduced with permission from Henderson et al. [^▪▪].

FIGURE 3

Clinical presentations of chilblains in an otherwise healthy young boy, presenting with pain and swelling in affected toes.