Молодежный инновационный вестникМолодежный инновационный вестник2415-7805Федеральное государственное бюджетное образовательное учреждение высшего образования "Воронежский государственный медицинский университет имени Н.Н. Бурденко" Министерства здравоохранения Российской Федерации6482CLINICAL CASE OF A NEW CORONAVIRUS INFECTION WITH MULTISYSTEM INFLAMMATORY SYNDROME IN A CHILDBobrovaElenaelena.viktorovna.21@yandex.ruhttps://orcid.org/0000-0002-8080-23581405202110S13373401502202123022021Copyright © 2021, Молодежный инновационный вестник2021<p>The pandemic of the new coronavirus infection COVID-19, declared by the WHO in March 2020, is an emergency for humanity. In most cases, it is not severe in children, but cases of severe multisystem inflammation associated with COVID-19 have been described that require intensive therapy. Risk factors for severe multisystem inflammation in children have not yet been studied. Therapy of such patients includes the appointment of oxygen therapy, anticoagulants, glucorticosteroids (pulse therapy), interleukin inhibitors, high-dose intravenous immunoglobulins, antibiotics in case of suspected bacterial infection. The article describes and analyzes the critical form of COVID-19 infection-a multisystem inflammatory syndrome in a 12-year-old child with a premorbid background-grade 2 obesity of a constitutionally exogenous nature.The critical form of infection manifested more than three weeks after a mild course of COVID-19 and a prolonged replication of the SARS-CoV-2 virus for 21 days. The disease required the use of respiratory support, the appointment of high doses of glucocorticosteroids, anticoagulants and combined antibacterial therapy. The clinical example presented in the article demonstrates the severe course of a new coronavirus infection COVID-19 with the development of a multisystem inflammatory syndrome in a child with a burdened premorbid background grade 2 obesity.</p>COVID-19, children, multisystem inflammatory syndromeCOVID-19, дети, мультисистемный воспалительный синдром<p>The novel coronavirus infection COVID-19 is one of the most serious threats to public health [1,2]. Seasonal coronavirus infection, characterized by epidemic rises in the cold season, was registered mainly in young children and was manifested by a mild lesion of the upper and lower respiratory tract. [3,4,5].<br />The incidence of new coronavirus infection among children is lower than among adults. The infection proceeds more easily, complications develop less often.[6,7]. However, WHO informs about cases of multisystem inflammation in children from Europe and North America, occurring with signs of Kawasaki disease, toxic shock, multiple organ failure, which does not exclude the relationship with a new coronavirus infection [8]. Multisystem inflammation in children and adolescents is characterized by a fever of at least three days and the following symptoms (at least two): rash or non-purulent conjunctivitis, hypotension or shock, heart damage, coagulopathy, gastrointestinal damage, and an increase in inflammatory markers such as ESR, CRP, or PCT. Risk factors for the development of multisystem inflammation in children have not yet been studied.</p>
<p><strong>About the patient</strong><br />Child B. 12 years old was hospitalized in an infectious diseases hospital on October 16, 2020 due to an increase in temperature to 39.70 C and the appearance of a rash.<br />Anamnesis vitae: Early anamnesis of a child without features, vaccinated. He suffered from chickenpox and SARS. I have gained a lot of weight over the past 2.5 years (weight at admission 77 kg, height 1.67 m), which, according to my mother, is due to an unbalanced diet.<br />Anamnesis morbi: In early September, all family members suffered a mild "SARS". On September 16, the child B. registered a temperature of 37.30 C, mild nasal congestion, and on the second day a decrease in the sense of smell. Received azithromycin and ingavirin. A new coronovirus infection was verified by PCR. Clinical symptoms persisted for 6-7 days, but the PCR test was positive three times during the 21 days from the onset of the disease.<br />On October 13 (day 27), the boy had a sharp rise in temperature to 39.70 C, and on the next day, the appearance of a rash of bright pink color on the trunk and limbs, the child became sluggish. Outpatient was appointed josamycin, cetirizin. The condition remained without dynamics for three days and the child was hospitalized in an infectious hospital.</p>
<p>Upon admission, the condition is severe due to pronounced skin manifestations and feverish intoxication syndrome. The boy is capricious, sluggish, emotionally labile. On the face, ears, trunk, more in the armpits and inguinal folds, the inner surface of the forearms, hands, and back of the thighs, there is a profuse spot-papular rash, bright pink in color, prone to fusion; pasty face; puffiness and hyperemia of the phalanges of the fingers, hands, and feet. Identified manifestations of scleractinia: conjunctival hyperemia, injection of the sclera. The mucosa of the lips with a clear rim and bright red color. Pharynx, moderately hyperemic, clean. In the lungs, respiration is vesicular, heart tones are loud and rhythmic, tachycardia is 120 per minute, SpO2 is 98%. Stool and urine output is normal.</p>
<p><strong>Preliminary diagnosis</strong><br />Main: New coronavirus infection. Allergic dermatitis (toxic-allergic reaction). Generalized bacterial infection. Clinical examination. Background: Constitutional-exogenous obesity.<br /><strong>Dynamics and outcomes</strong><br />In the hemogram, there was a slight leukocytosis of 10.6109/l of neutrophil nature with a sharp shift to the left to myelocytes of 1%, ESR accelerated 55 mm / h. In biochemical parameters, hyperfermentemia is 2 norm, an increase in bilirubin to 36 mmol/l due to the free fraction, an increase in lactate twice, a very high CRP - 321 mg/l, a slight decrease in the prothrombin index in the coagulogram, an increase in fibrinogen A and RFMC. According to the CT scan of the lungs, left-sided small hydrothorax was diagnosed, according to ECG data-a violation of myocardial repolarization. The boy received antibacterial therapy (ceftriaxone), antiviral (umifinovir), antihistamines (chloropyramine), sorbents per os, infusion therapy with crystalloid, dexamethasone was added 8 mg parenterally (4 mg/m2).</p>
<p>The patient continued to have a fever, increased intoxication (the child is very negative, with periods of aggression, quickly exhausted and fell asleep), there were visual hallucinations, impaired consciousness (deafening), new elements of the rash appeared with a gravitation to large joints. The rash acquired a two-contour character and a cellular "openwork" pattern, with a hemorrhagic cyanotic component in the center, in the area of the ankle joints there was a small-point hemorrhagic rash. Oxygen saturation on self-respiration was 90%. Leukocytosis reached 41.7109/l, neutrophilosis with a persistent shift to young forms was detected, ESR 56 mm/h, thrombocytopenia 83109/l; small proteinuria 0.16 g/l, leukocyturia 8-10 v/s; urea 8.9 mmol/l, creatinine 119 mmol/L, LDH 554U/L, CRP remained at high numbers 264 mg/L, hypoproteinemia, hyponatremia, high ferritin 526 (norm 8-143), D-dimer 2,4 (norm0,4), which, given the clinical symptoms of the disease, allowed us to think of a multisystem inflammatory syndrome (Kawasaki-like syndrome) associated with COVID-19. PCT reached 10 ng / ml, IL6 31.1 pg / ml (norm 0-5. 9). According to the results of chest CT, left-sided segmental pneumonia, the volume of the CT1 lesion were recorded, according to the results of ultrasound GPDZ - signs of diffuse liver changes, hepatosplenomegaly, bilateral pleurisy, with Echo-KG-aortic insufficiency of the first degree.</p>
<p>Enhanced antibacterial therapy (carbopenems in combination with glycopeptides), oxygen support (moistened oxygen through a face mask), pron-position 12-16 hours a day. The child's condition remained serious for the next two days. After the introduction of standard intravenous immunoglobulin at the rate of 0.5 g / kg, there was a tendency to fade the rash, reduce leukocytosis-28109/l, the platelet level stabilized 137109/l, the level of CRP decreased to 74 mg/l, PCT 2 ng / ml. But the boy continued to have a fever, and the intoxication persisted.</p>
<p>Taking into account the absence of positive dynamics and the preservation of inflammatory markers, on the 8th day of the child's stay in the hospital, methylprednisolone therapy was prescribed intravenously 1.5 mg/kg 3 times a day, heparin 100 U / kg / day parenterally, antiplatelet agents, systemic antimycotics and potassium preparations were added. After three days, the temperature returned to normal, after 5 days, the rash completely disappeared, which allowed us to begin reducing the dose of glucocorticosteroids.White blood cells reached 13.9109/l, the leukocyte formula and ESR normalized. After a day of receiving methylprednisolone, PCT decreased, and on the fourth day CRP. On the 20th day, the child was discharged home with a clinical and laboratory recovery.</p>
<p><strong>Clinical diagnosis</strong><br />Main: Multisystem inflammatory syndrome in a teenager associated with a new COVID-19 coronovirus infection: acute left-sided segmental pneumonia, grade 2 DN, CT-1, hydrothorax, cardiopathy, hydropericardium, Covid-associated vasculitis, Kawasaki-like syndrome, nephritis, encephalopathy.<br />Background: Constitutional-exogenous obesity (body mass index 95 percentels).</p>
<p><strong>Conclusion.</strong><br />The described clinical example demonstrates a severe multisystem lesion in an obese adolescent from a family focus of a new coronavirus infection associated with COVID-19. The critical form of COVID-19 developed with negative results of a PCR study on SARS-COV2 RNA 3 weeks after a laboratory-confirmed episode of a mild course of a new coronavirus infection. A special feature of the described clinical case was the long-term (3 weeks) preservation of SARS-COV2 replication with a mild course of infection at the onset. The basis for this diagnosis was the following clinical manifestations and laboratory examination data: high febrile fever for 12 days, rash, skin lesions of the hands, feet, lip mucosa and bilateral non-purulent conjunctivitis, pericarditis, myocardial dysfunction coagulopathy (D-dimer 6N), as well as an increase in the level of inflammatory markers (ESR, CRP, PCT) in the absence of data for bacterial infection and response to antibacterial therapy.In addition, the child had signs of hypoxic encephalopathy with impaired consciousness before sopor and the development of psychopathic reactions. The administration of glucocorticosteroids and the introduction of standard intravenous immunoglobulins allowed to achieve a rapid clinical effect and normalization of laboratory tests.</p>
<p></p>[1. World Health Organization (WHO) Coronavirus disease (COVID-19) pandemic. [Электронный ресурс]. URL: https://www.who.int/emergencies/diseases/novelcoronavirus-2019 (дата доступа 31.03.2020).][2. Мелехина Е.В., Музыка А.Д., Горелов А.В., К вопросу о противовирусной терапии острых респираторных инфекций у детей в сезон новой коронавирусной инфекции: обзор исследований и опыта применения в клинической практике // Вопросы практической педиатрии, -2020, -Т.15. - №2. -с. 7–20. [Melehina E.V., Muzika A.D., Gorelov A.V., K voprosu o protivovirusnoy ostrih respiratornih inekciy u detey v sezon novoy koronavirusnoy infekcii: obzor isslidovaniy I opit primeneniya v klinicheskoy preltike // Voprosi prakticheskoy pediatrii. -2020, -Т.15. - №2. -S. 7–20].][3. Кокорева С.П., Трушкина А.В., Разуваев О.А., и др., Этиологическая структура острых респираторных заболеваний в 2009-2013гг. у детей г. Воронежа. // Детские инфекции.- 2015. - Т.14. - № 4 - С.53-56. [ Kokoreva S.P., Trushkina A.,V., Razuvaev O.A., et.al., The Etiologocal Structure of Acute Respiratoty Diseases in the Yaers 2009-2013 in Children of Voronezh .- 2015. - Т.14. - № 4 - S.53-56].][4. Лернер А.А., Кокорева С.П., Разуваев О.А, Клинические особенности боковирусной, метапневмовирусной, короновирусной инфекции у детей // Молодежный инновационный вестник. -2018. -Т.7. -№51. - С. 147-148. [Larner A.A., Kokoreva S.P., Razuvaev O.A., Klinicheskie osobennosti bokovirosnoy, metapnevmovirusnoy, koronavirusnoy ifekcii u detey // Molodezhnii inovacionnii vestnik. -2018. -Т.7. - №51. -S.147-148.].][5. Кококрева С.П., Разуваев О.А., Атачук Т.А., и др., Сезонная коронавирусная инфекция у детей. // Инфекционные болезни в современном мире: эпидеитология, диагностика, лечение и профилактика. Сборник трудов XII Ежегодного Всероссийского интернет-конгресса по инфекционным болезням -2020. – 278с. – 102-103с. [ Kokoreva S.P., Razuvaev O.A., Atachuk T.A., et. al., Sezonnaya koronavirusnaya infekciya u detey // Infekcionnii bolezni v sovremennom mire: epidemiologia, diagnostika I prophilaktika. Sbornik trudov XII Ezhegodnogo Vserossiyskogo internet-kongressa po infekchionnym boleznyam -2020. – 278s. – 102-103s.].][6. Заплатников А.Л., Османов И.М., Горев В.В., и др., Новая коронавирусная инфекция COVID-19 в практике неонатолога и педиатра // Российский вестник перинатологии и педиатрии. 2020;65(3):11-17. [Zaplatnikov A.L,. Osmanov I.,M., Goreev V.,V., et. al., Novaya koronavirusnaya infekciya COVID-19 v praktike neonatologa i pediatra // Rossiyskiy vestnik perinatologii I pediatrii. 2020;65(3):11-17. DOI:10.21508/1027-4065-2020-65-3-11-17.]][7. Zhang Y.P. The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) in China // Chin J Epidemiol. 2020;41:145–151.][8. Методические рекомендации «Особенности клинических проявлений и лечения заболевания, вызванного новой коронавирусной инфекцией (COVID-19) у детей». Версия 2 (03.07.2020). Министерство здравоохранения Российской Федерации. – С.73 [Metodicheskie rekomendacii «Osobennosti klinicheskih proyavleniy I lecheniya zabolevaniya, vizvannogo novoy koronavirusnoy infekciey (COVID-19) u detey». Versiya 2 (03.07.2020). Ministerstvo zdravoohraneniya Rossiyskoy Federacii. – S.73].]