Neurological manifestations of pediatric multi-system inflammatory syndrome potentially associated with COVID-19
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LETTER TO THE EDITOR
Neurological manifestations of pediatric multi-system inflammatory syndrome potentially associated with COVID-19 Alexander J. Schupper 1
&
Kurt A. Yaeger 1 & Peter F. Morgenstern 1
Received: 12 June 2020 / Accepted: 16 June 2020 # Springer-Verlag GmbH Germany, part of Springer Nature 2020
There has been significant media attention and a New York City Health Alert [1] surrounding “Pediatric Multi-System Inflammatory Syndrome Potentially Associated with COVID-19.” As of May 18, 2020, there were 145 suspected cases of this syndrome in New York City [2]. While this disease has been outlined as having components shock and similarities to Kawasaki disease, associated neurologic manifestations have not been described (https://www.rcpch.ac.uk/ sites/default/files/2020-05/COVID-19-Paediatricmultisystem-%20inflammatory%20syndrome-20200501.pd). We have encountered several children with this condition and highlight two with major neurological complications. A 5-year-old boy with no significant past medical history presented with several days of fever, cough, and abdominal pain. He progressed to cardiogenic shock and transfer to our institution, where he tested positive for COVID-19 antibodies and had high IL-6 levels. He developed cardiopulmonary failure requiring extracorporeal membrane oxygenation (ECMO). After 5 days of ECMO, he was found to have a fixed and dilated right pupil. His heparin was emergently reversed, he was decannulated, and emergent CT head revealed a right middle cerebral artery (MCA) infarction, cerebral edema, and diffuse contralateral subarachnoid hemorrhage (Fig. 1a). Following the CT scan, his left pupil became fixed and dilated. The reversal of his paralytic revealed absent brainstem reflexes and movement. Brain death was confirmed 3 days later following normalization of his electrolytes. The second patient is a 2-month-old boy with a history of tracheomalacia requiring tracheostomy. He presented with respiratory failure, pneumomediastinum, and bilateral
* Alexander J. Schupper [email protected] 1
Department of Neurosurgery, Mount Sinai Health System, 1468 Madison Avenue, Annenberg 8th Floor, New York, NY 10029, USA
pneumothoraces. He developed refractory respiratory failure and was emergently placed on ECMO, on which he remained for 8 days. Despite the clinical picture and high IL-6 values, he tested negative for COVID-19 antibodies. Continuous electroencephalogram (cEEG) found the child to be in nonconvulsive status epilepticus, which was controlled on four anti-seizure medications. Daily screening head ultrasounds were performed per ECMO protocol. On day 1 of ECMO, a head ultrasound demonstrated multifocal echogenicity suspicious for hemorrhage. A follow-up CT revealed bilateral MCA and posterior cerebral artery (PCA) territory infarctions with the hemorrhagic transformation (Fig. 1b). The patient continued to have poor seizure control, requiring several weeks of intermittent EEG placement and anti-epileptic medication titration, including phenobarbital
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