Hemoadsorption for severe MIS-C in critically ill children, should we consider it as a therapeutic opportunity?

Abstract

Multisystem inflammatory syndrome (MIS-C) is a new severe clinical condition that has emerged during the COVID-19 pandemic. MIS-C affects children and the young usually after a mild or asymptomatic COVID-19 infection. MIS-C has a high tropism for the cardiovascular system with need for inotropes and vasopressor support in 62% of cases. As of today a mortality from 1.5% to 1.9% related to MIS-C is reported. Hemoadsorption via the inflammatory mediator adsorber CytoSorb (CytoSorbents Europe, Berlin Germany) has been used as adjunctive therapy with the aim to restore the host response in septic shock and other hyper-inflammatory syndromes. We present the clinical experience of an adolescent boy with a refractory shock secondary to left ventricular dysfunction (LVD) in the context of MIS-C, treated with hemoadsorption, and continuous kidney replacement therapy (CKRT) in combination with immunomodulatory therapies. The therapeutic strategy resulted in hemodynamic and clinical stabilization as well as control of the hyperinflammatory response. Treatment appeared to be safe and feasible. Our findings are in line with previously published clinical cases on Cytosorb use in MIS-C showing the beneficial role of the hemoperfusion with Cytosorb in severe MIS-C to manage the cytokine storm. We provide an analysis and comparison of recent evidence on the use of hemoadsorption as an adjuvant therapy in critically ill children with severe forms of MIS-C, suggesting this blood purification strategy could be a therapeutic opportunity in severe LVD due to MIS-C, sparing the need for extracorporeal membrane oxygentation (ECMO) and other mechanical cardiocirculatory supports.

Keywords: Coronavirus; cytokines; left venticular failure (LVEF); multisystem inflammatory syndrome in children (MIS-C); myocarditis; pediatric critical care; shock.

Figure 1.

(a) Endomyocardial biopsy (EMB) histology shows a mononuclear, predominantly lymphocytic, inflammatory infiltrate, and myocardial injury with necrosis (HE, 40×). (b) Immunohistochemistry with anti-CD3 revealed a rich T-lymphocytic component (CD3, 40×).

Figure 2.

Upper section: time course of N-terminal (NT)-pro hormone brain natriuretic peptide (BNP) (NT-proBNP) and Troponin I (high sensivity troponin hs-TnI) during extracorporeal blood purification treatment (EBPT). Lower section: time course of the ejection fraction during EBPT.

Figure 3.

Upper section: time course of White Blood Cells (WBC), D-dimers, and C-reactive protein (CRP) during extracorporeal blood purification treatment (EBPT). Lower section time course of Ferritin, Interleukin 6, Interleukin 10 during EPBT.

Figure 4.

Time course of Lymphocytes, Lactate Dehydrogenase (LDH), Creatinine, aspartate aminotransferase AST, alanine aminotransferase ALT during Extracorporeal Blood Purification Treatment (EBPT).