Some Severely Ill Children May Mount an Overly Aggressive Response to COVID-19
George Ofori-Amanfo, MD, Chief of the Division of Pediatric Critical Care at The Mount Sinai Hospital and Mount Sinai Kravis Children’s Hospital
Nine pediatric patients admitted to The Mount Sinai Hospital during the past two weeks, who either tested positive for COVID-19 or had antibodies, had severe abdominal pain and low blood pressure, which progressed to shock. Some of the patients also had clinical signs of myocarditis. This inflammation affects the heart muscle and the heart’s electrical system, reducing the heart’s ability to pump and causing abnormal rhythms, or arrhythmias. SARS-CoV-2, which causes COVID-19, is the first coronavirus associated with myocarditis.
Prior to their infections, the patients—six boys and three girls—did not have co-morbidities that would have put them at higher risk for disease, according to George Ofori-Amanfo, MD, Chief of the Division of Pediatric Critical Care at The Mount Sinai Hospital and Mount Sinai Kravis Children’s Hospital.
“These patients presented with very unusual symptoms,” says Dr. Ofori-Amanfo. “Until now, the pediatric patients who came to the Emergency Department with COVID-19 all had respiratory problems like the adults—dry coughs, difficulty breathing, and sometimes decreased oxygen saturation. In this recent series of patients, the children presented with abdominal pain, low-grade fever, vomiting, and in some cases diarrhea.” The pain was so severe that one child was sent to Mount Sinai to determine whether the problem was appendicitis, which was not the case. Another child was sent to the hospital for a CT scan to see whether the cause was inflamed abdominal lymph nodes. This was also ruled out upon closer examination.
Two of the nine pediatric patients also had a rash and conjunctivitis, which put their symptoms in a constellation of conditions that are similar to but not the same as Kawasaki disease, which causes blood vessels to become inflamed and also affects the heart. Both of these patients were among those with the least severe symptoms.
Dr. Ofori-Amanfo says that when the children and young adults progressed into a state of shock with low blood pressure, they did not respond to the traditional methods of resuscitation and large amounts of IV fluids, so the clinicians gave them high doses of blood pressure medication, which helped. Three of the patients required mechanical ventilation for shock and two of these patients also required mechanical cardiac support.
“This is a new phenomenon and it is rare. Perhaps these patients had mild symptoms of COVID-19 or were asymptomatic. We think what we’re seeing is a post-infectious process. It is an aggressive immune response to either the virus or some aspect of the viral infection that we don’t know yet. Because when you look at their lab profiles, the patients have very elevated inflammatory markers and this suggests an acute inflammatory response,” says Dr. Ofori-Amanfo. “The exaggerated immune response affects the heart function, which is mildly to moderately depressed, and their low blood pressure is a result of the hyper state of their immune system.”
At Mount Sinai, a team of specialists in areas that include pediatrics, immunology, hematology, infectious diseases, and basic science is treating this syndrome by targeting and modulating the overwhelming immune response and managing anticoagulation therapies for potential strokes. “This is a real entity, but it is rare, and we are hypervigilant and looking out for our patients,” says Dr. Ofori-Amanfo. “We think we have developed some therapies that are working. We have really smart, dedicated specialists working together. It is a great partnership.”
Other hospitals in the New York metropolitan region, around the country, and in Europe have reported smaller clusters of similar pediatric cases.
“We are studying the children to learn what predisposes them to developing this syndrome,” Dr. Ofori-Amanfo says. “These children had siblings. We don’t know why one child gets this but his brother or sister doesn’t.”
These days, we are all worried about contracting COVID-19. We know people who have symptoms of the virus often go to a hospital’s emergency department—most known to patients as the emergency room—to seek immediate care. For this reason, many people are nervous about going to the hospital for any other reason. But, that is not always the best approach. 
COVID-19 is a serious disease, and doctors and scientists are working hard to learn more about how it affects different patients in order to develop the best treatments and help speed recovery. For many patients who are recovering, a loss of lung function is one of the key hurdles they face.