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Table 1 Clinical, para clinical and therapeutic data in 10 patients with Pediatric Inflammatory Multisystem Syndrome (PIMS) Associated with SARS -CoV-2

From: Clinical characteristics of 10 children with a pediatric inflammatory multisystem syndrome associated with COVID-19 in Iran

Number of case, age, sex, date of admission

COVID-19 test

First presentation symptoms and signs

Ongoing presentation

Abdomino pelvic Ultrasonography

Chest imaging

Echocardiography

Laboratory data at admission

Ongoing laboratory data

treatments

Total admission days, PICU stay, Out come

First impression

Case 1: 12 years old boy,

28 march

Covid-19 RT- PCR: positive

fever and chills, rash, diarrhea, fatigue, toxic appearance

Second day: respiratory distress, heart and respiratory failure

 

Chest CT-scan: patchy ground glass opacity and interlobar septal thickening

First day: mild MR, Mild TR, mild diastolic dysfunction, LVEF 50%,

Second day: moderate MR and TR, moderate diastolic dysfunction LVEF 30%

CBC: WBC: 8.7, N: 90, L: 10, Hb: 9.5, Plt: 75, CRP: 1+, ESR: 32, urea: 75, Cr: 2.5, AST: 62, ALT: 30, UA: Pro: 1+, WBC: many, RBC: 10–12

ABG: PH: 7.2, Hco3: 11.8, Pco2: 30, Po2: 32

Cr: 3.2, urea: 126,

D. dimer: 6888, CRP: 50

Vasoactives, Oseltamivir, meropenem, vancomycin, hydroxychloroquine, Kaletra, IVIG 1 g/kg, hydrocortisone 2 mg/kg/dose, packed cell

Total: 3 days

ICU: 3 days

Died

COVID-19 infection

Case 2:

5 years old girl, 8 April

COVID-19 RT-PCR positive

Fever, vomiting, diarrhea and skin rash, cough and otalgia, conjunctivitis, Loss of appetite

3 to 5 days after admission: Tachypnea, drowsiness, generalized edema, headache, myalgia, pharyngeal congestion, purulent conjunctivitis, Abdominal pain

mild to moderate free fluid in abdomen and bilateral mild to moderate plural effusion

Normal CT-scan at admission.

But on day 5, bilateral plural effusion and patchy infiltration, ground glass apearance

mild TR, trivial MR, normal coronary arteries on 2 occasion

CBC: WBC: 8.1, N: 60, Hb: 10,

, Plt: 150,

ESR: 71, CRP:28, Alb: 2.6

CBC: WBC: 6.6, N: 74, L: 20, Hb: 7.4, Plt: 86, ESR: 28, CRP: 23,

Alb: 2.2, total protein: 4

Vitamin D: 15

Hydroxychloroquine, Azithromycin, Ceftriaxone, changed to meropenem,, IVIG 1gr/kg, Albumin, Red Packed cell

Total: 13

PICU: 5

Alive, without sequel

Sepsis

Case 3: 13 months old boy, 13 April

COVID-19 RT-PCR positive

Fever, generalized erythematous patches, papule and some target shape lesion on edematous base

3 days after admission,

Respiratory distress, decrease spo2: 84% in ambient room and generalized edema

mild intra-abdominal fluid

at admission: Normal chest CT-scan.

At day 3: Chest CT-scan:

bilateral plural effusion, basilar patchy infiltration and reverse halo sign

Mild TR, mild MR and normal coronary arties on 2 occasion

CBC: WBC: 8.2, N: 65, Hb: 10.8, PLT: 189, Alb: 3.4

ESR: 54, CRP: 96

day 3: CBC, WBC: 14.5, N: 58, L: 29, Hb: 7.5, Plt: 141

ESR: 60, CRP: 26, Alb: 2.2,

hydroxychloroquine, Ceftriaxone, changed to meropenem, Vancomycin, IVIG 1gr/kg, Albumin, Red Packed cell

Total: 8

PICU: 2 days,

Alive, complete improvement without sequel

Acute hemorrhagic edema of infancy

Case 4: 10 years old girl, 27 April

COVID-19 IgG: positive

Fever, itching skin rash, maculopapular and target shape rashes with more accumulation around neck and trunk and axilla cough, abdominal pain, oliguria, bilateral non purulent conjunctivitis, hypotension and toxic appearance

Generalized edema, right leg edema and sever pain,

mild plural effusion

Urinary system ultrasonography was normal, color Doppler ultrasonography of lower limbs veins were normal

CXR and Chest CT-scan before admission: NL

Chest CT-scan at day 4: COVID-19 compatible changes and mild bilateral plural effusion

mild MR, mild TR, Mild PI, EF: 60–64% in 3 occasion

CBC:

WBC: 9, N: 69, L: 10,

Hb: 7.5, Band: 12, Plt: 130, ESR: 30, CRP: 36,

Urea: 78, cr: 2.3,, D Dimer: 6556

Alb: 2

Third day: CBC:

WBC: 13.9, N: 87

L: 6

Hb: 9.6

Plt: 211

meropenem, clindamicine, vancomicine,

vasoactives, IVIG 1 g/kg, red packed cell, albumin, enoxaparine, Vitamin D, zinc

Total: 11

PICU: 8

Alive, complete improvement without sequel

Toxic shock syndrome

Case 5: 14 months old boy, 3 May

COVID-19 RT-PCR negative, IgM: positive

fever, irritability, macoulopapolar erythematous rashes, edema of hands and feet, Cracked and erythematous lips, erythematous tongue and bilateral non purulent conjunctivitis

Irritability, abdominal distension, giant coronary aneurysm

Liver span: 117 mm, spleen: 98 mm, greater than normal, mild intra-abdominal fluid, mild bilateral plural effusion

First day: CXR normal, Chest CT-scan showed non-significant changes

Day 4: chest CT-scan: non-significant changes

First day: normal coronary arteries, minimal right Pleural effusion (5 mm), minimal MR, good EF

CBC: WBC: 22, N: 83, L: 5, 6, Band: 5, Hb: 10.6, plt: 197, ESR: 65, CRP: 38, Na: 129, AST: 200, ALT: 197, Alb: 2.3,

PTT: 50, PT: 18, INR: 2

Day 4:

WBC 21.8, N: 79, L: 15, Hb: 8.7, Plt: 224,

Alb: 3.2, AST: 57, ALT: 55, PT: 14.8, PTT: 42, INR: 1.3,

Day 14: CBC: WBC: 25.7 N: 38, L: 44, Mono: 17, Hb: 11.6, Plt: 1168

CRP: 10.9, ESR: 25

IVIG 2 g/kg/day × 2, Aspirin, hydroxychloroquine, zinc, Vitamin D,

Cefotaxim, changeed to meropenem and vancomicine. Albumin, red packed cell, methyl prednisolone 2 mg/kg/day, vasoactives, heparin, warfarin, infliximab

Total: 24

PICU: 20

Alive, Giant coronary arteries aneurysm

Kawasaki disease

Case 6: 6.5 years old boy,

4 May

COVID-19 RT-PCR negative, COVID-19 IgG positive

fever, anorexia abdominal pain, vomiting, loose defecation, erythematous rash around feet, hands, trunk and perioral, periorbital edema, erythema of oropharynx, right TM erythema

At day 2: dyspnea, repertory distress, spo2 87%, mild abdominal distension, irritability, anasarca edema

spleen: 117 mm, more than normal with normal parenchymal echo, free interloop fluid, sub hepatic and sub splenic, several reactive lymph nodes 15*7 mm in para aorta and peripancreatic

At admission: Chest CT, non-significant changes for COVID-19

At day 4: Chest CT-scan bilateral opacities compatible with COVID-19

Day 2: minimal TR Day 4: mild TR, trivial MR

CBC: WBC: 4.7

N: 77,

L: 14, band: 3, Hb: 10, Plt: 121, ESR: 48, CRP: 45,

UA: blood: trace, WBC: 8–10,

CBC: WBC: 6.93

Hb: 7.8

Plt: 73

L: 14

N: 80

Alb: 2.3

CRP: 39

ESR: 58

Ceftriaxone, Vancomycin, Meropenem, hydroxychloroquine, packed cell, Albumin

Total: 11

PICU: 7

Alive, without sequel

Urosepsis

Case 7: 7.5 year old girl 4 May

COVID-19 RT-PCR negative

fever, irritability, abdominal pain, myalgia, vomiting, diarrhea and generalized erythematous maculopapular and patches

Facial edema, tachypnea and tachycardia developed and the patient got toxic with gallop in heart auscultation

Normal

Admission Chest CT: NL

CXR: at day 3: bilateral mild Ground Glass opacity

Day 3: Mod MR, TR, low EF 50%, Dilated RV, LV: myocarditis

Day 7: moderate MR, mild Pleural effusion, low LVEF, lack of tapering, brightness in RCA and LAD compatible with KD and Myocarditis

CBC: WBC: 9.8, N: 89, L: 10,

Vitamin D: 4 ng/ml

AST:93

ALT: 69

CBC:

WBC: 13.3

Hb: 7.5,

Plt: 213

N: 85

L: 10

Alb: 1.9,

ESR: 73, CRP: 35

Urea: 72 Cr: 1.1

Ceftriaxone, changed to Vancomycin, Meropenem, hydroxychloroquine, Zinc, Vitamin D, magnesium sulfate, packed cell, Albumin,

IVIg: 2 g/kg

Total: 12

PICU: 8

Alive, without sequel

myocarditis

case 8: 20 months old boy, 9 may

COVID-19 RT-PCR negative, COVID-19 IgG, IgM negative

Fever, coryza, vomiting diarrhea, abdominal pain, irritability during urination and loss of appetite, erythematous papule in 2 centimeter diameter in the forehead, erythema of oropharynx

tachypnea with unilateral tongue swelling and drooling, with discrete ulcers under the tongue

Normal

Chest CT: bilateral ground opacity compatible with COVID-19

lack of tapering in RCA and LAD, Mild dilatation of LA, LMCA: 3.7 mm, RCA: 2.2, LAD: 2.2, perivascular brightness around LAD, moderate MR, diastolic dysfunction

WBC: 52.5, N: 80, L: 10, band: 4, Hb: 9.5, Plt: 932, ESR: 100, CRP: 1+

SE: WBC: 4–5, RBC: 2–3

ABG: PH: 7.33, Pco2: 37, HCO3: 19.9, PO2: 71,

Alb: 2.5

Ceftriaxone changed to clindamycin and Meropenem, hydroxychloroquine, Zinc, Vitamin D, IVIG 2 g/ kg, aspirin 80 mg/kg/day

Total: 11

PICU: 9

Alive, without sequel

KD

Case 9: 7 years old boy, 23 may

COVID-19 IgM and IgG and RT.PCR negative

Fever with epigastric pain which shift to Right Lower Quadrant, nausea, vomiting

ill, abdominal distension and recurrent vomiting

Reactive lymph node, max diameter 6 mm, fat stranding in Right Lower Quadrant and free inter loop fluid

Chest CT: sub plural atelectasis, mild bilateral pleural effusion, some nodular like lesions in both inferior lobes of lungs compatible with COVID-19

NL

CBC: WBC: 24,000, L: 6%, N: 90%, band: 4%,

Hb: 11, Plt: 356, ESR: 72, CRP: 2+

Day 2: CBC: WBC: 13.5, N: 77, L: 10, Mono: 11,

Hb: 10.3, Plt: 347, ESR: 90, CRP: 25

Alb: 3.2

Meronidazole, Ceftriaxine changed to meropenem, hydroxychloroquine, Vitamin D, Zinc

Total: 6

Appendicitis

Case 10: 18 months old girl

13 June

RT- PCR COVID-19 positive

Fever and status epilepticus

Second day: ill and lethargic, maculopapolar blench able rash, tachypnea

 

CXR: nl

Chest CT in 2 occasion: bilateral nonspecific opacity in inferior lobes

Normal

CBC: WBC: 8.5, N: 80%, L: 14%, Hb: 11.8, PLT: 160

ESR: 15, CRP: 16

Alb: 2.3

WBC: 1.88, N: 34, L: 59, M: 5, Hb: 10.2, plt: 103

CRP: 3

Alb: 2.5

Meropenem, clindamycine, phenobarbital, hydroxychloroquine, Vitamin D

Albumin, IVIG, 1 g/kg, Zinc

Total: 12

PICU: 9

Prolonged febrile seizure

  1. ABG Arterial blood gas, Alb Albumin, grams per deciliter, Alt Alanine aminotransferase, units per liter, AST Aspartate aminotransferase, units per liter, CBC Complete blood count, Chest CT-scan Chest computed tomography scan, COVID-19 Coronavirus disease 2019, Cr Creatinine, milligrams per deciliter, CRP C reactive protein, milligram per liter, CXR Chest roentgenogramD-dimer ng/mL, increased level > 500, ESR Erythrocyte sedimentation rate, millimeters per hour, Hb Hemoglobin, grams per deciliter, IgM Immunoglobulin MIgG Immunoglobulin G, INR International normalized ration, IVIG Intravenous immunoglobulin, KD Kawasaki disease, L Lymphocyte, %, LAD Left anterior descending artery, LMCA Left main coronary artery, LVEF Left ventricular ejection fraction, Mono Monocyte, %, MR Mitral regurgitation, NA Not assessed, N Neutrophil%, Na Sodium, mill equivalents per liter, NL Normal, Plt Platelet, × 109/Liter, PICU Pediatric intensive care unit, Pro Protein, PT Prothrombin time, seconds, PTT Partial thromboplastin time, seconds, RCA Right coronary artery, RT-PCR Reverse transcription polymerase chain reaction, SARS-CoV-2 Acute respiratory syndrome coronavirus 2, TR Tricuspid regurgitation, Total protein Grams per deciliter, Urea Milligrams per deciliter, Vitamin D, ng/mL, WBC White blood cell, × 109/Liter