Elizabeth Timme’s family flew home to Los Angeles from a vacation in the West Indies on New Year’s Day and spent nearly two hours in a tightly packed immigration line at Miami International Airport. Soon after, the whole family became ill with unusually severe colds. Timme didn’t think much of it even after she was prescribed steroids to help her breathe easier — that is, not until her youngest child, Bob, 2, became seriously ill.
“It seemed like a bad cold for the first two weeks, and then it seemed like a bacterial infection that we couldn’t necessarily pin down, and then it seemed like all-out war on his body for about three to four days,” Timme, 38, told Yahoo News in an interview. “It was horrifying.”
When Bob wasn’t recovering after a month, Timme brought him to Children’s Hospital Los Angeles. Doctors there told her he had tested positive for coronavirus, but could not specify whether it was COVID-19. At the time, doctors figured it didn’t matter — the family hadn’t been to China, and children didn’t get severely ill with COVID-19. What mattered, doctors told Timme, was that Bob’s “inflammatory markers were off the charts.”
Bob was diagnosed with a somewhat rare condition called Kawasaki disease, which can affect the heart and the circulatory system. Doctors around the world are just starting to suspect that these cases are tied to COVID-19 infections in children with a genetic susceptibility — but there is currently no way to predict which children carry the gene.
Now, more than three months after Bob was diagnosed with the rare condition, he has been found to have normal heart function on two echocardiograms. He hasn’t had the third and final recommended scan because Timme doesn’t want to risk getting him sick again by bringing him to the hospital. She believes his illness began with a coronavirus infection acquired in that immigration line in Miami. The team at Children’s Hospital Los Angeles wore full protective gear before treating him, which she found strange at the time.
Bob’s cardiologist doesn’t see much point in running an antibody test to confirm that COVID-19 is what caused his illness, because his treatment wouldn’t change. But Timme said Bob’s doctor told her three weeks ago that Bob is the ninth child she is treating for recent-onset Kawasaki disease now, and that five of the other eight had tested positive for COVID-19. (Two of the other three had not been tested.) For Timme it is almost a moot point: Bob is now potentially immunocompromised amid a pandemic, and it is still possible he will have heart complications down the road.
Instead, she is worrying about whether his older sisters can go back to preschool in July when it reopens. She doesn’t want to risk exposing Bob to further complications in the midst of an ongoing pandemic.
“They told us that we had to be very careful with him getting sick,” Timme said. “They told us they suspected he might have lower immunity but that every kid is different. ... What happens to the population whose health is compromised after this? How do they enter the world?”
Meanwhile, a 13-year-old is now fighting for life in the critical care unit at Seattle Children’s Hospital. Dr. Michael Portman, a pediatric cardiologist, is determined to understand why the teen and many other children worldwide have developed dangerous new symptoms after being infected with the coronavirus.
The child entered the hospital Sunday with characteristics of the new syndrome, which doctors believe is related to Kawasaki disease, the same disease that was diagnosed in Timme’s son. The child was sick for a few days last week with nausea, fatigue and vomiting. Doctors at the hospital tested him for the coronavirus and his swab came back negative, but an antibody test was positive, suggesting the severe respiratory and cardiovascular symptoms he’s showing could mean he contracted the coronavirus weeks ago and only now developed the dangerous form of the disease.
While the total number of children now ill with the unusual ailment is small, five top pediatric heart, infectious disease or critical care specialists told Yahoo News they are closely tracking cases of the new syndrome affecting children infected with the coronavirus. And while all five acknowledged it is too soon to understand exactly why some children have become so ill and sustained potentially permanent damage to their hearts after becoming sick with the coronavirus — in some cases, weeks after their initial infections — they all described the new cases as both bewildering and worrisome, particularly since testing for COVID-19 remains challenging and antibody tests do not always accurately capture whether an ill child has been infected with the coronavirus. No children are known to have died as a result of coronavirus-related Kawasaki.
The unusual new syndrome was first reported by the British National Health Service last week and dubbed PIMS (pediatric inflammatory multi-system syndrome). Since then, the New York City Department of Health has reported at least 15 cases through May 1, with additional cases reported in Washington, D.C., Philadelphia, Boston and Seattle. About 80 cases have been seen in Europe, according to Dr. Anthony Rossi, director of the cardiac intensive care unit at Nicklaus Children’s Hospital in Miami.
As it happened, Portman, who is one of the country’s top experts on Kawasaki disease, applied to expand a $3.3 million National Institutes of Health grant that Seattle Children’s Hospital initially won in December 2018 — and did so two weeks ago, before the new pattern emerged and was reported by European doctors. Portman’s team, including his collaborator, Dr. Sadeep Shrestha at the University of Alabama at Birmingham, began researching the grant application in mid-March, well before the first cases emerged in England, Spain and Italy.
“We wrote up a theory that the new coronavirus would stimulate a syndrome like Kawasaki disease, so we submitted that even before all these news reports came out,” Portman told Yahoo News in an interview. “There’s been a lot of discussion among cardiologists and Kawasaki disease experts on the relationship between this new syndrome that we’re seeing with COVID and Kawasaki disease.”
Kawasaki disease was first identified in Japan in the 1960s and has long been believed to have a genetic component. The five doctors interviewed by Yahoo News for this story said they believe it is possible an undetermined number of children, likely with an underlying and undiagnosed mutation, could be vulnerable to the complications now emerging in hospitals around the country.
Prior to the current pandemic, Kawasaki disease was diagnosed in only about 5,000 American children a year, but Portman said experts believe those estimates are low since some cases don’t get reported and others are missed. Of the 5,000 annual cases in the United States, Portman said about 10 percent each year evolve into a more recently identified form of Kawasaki disease known as Kawasaki disease shock syndrome (KDSS), in which patients’ blood pressure drops dangerously low. While treatments for Kawasaki disease exist, a minority of patients are not helped by them. All the pediatric cardiologists and critical care specialists interviewed by Yahoo News stressed that it is vital for children to be treated within five to 10 days of showing symptoms in order to avoid permanent heart damage and aneurysms. They also all agreed that it is too early to know exactly why some children are developing the more serious condition but said they were speaking out to ensure parents know to have their children seen if they develop symptoms.
As recently as last Tuesday, doctors at Children’s National Hospital in Washington, D.C., were “talking about this as a theoretical thing,” according to Dr. Michael Bell, division chief for critical care medicine. That changed quickly.
“We hadn’t seen anybody here in D.C. until Wednesday or Thursday of last week and then saw three kids between then and now, so it does seem like it’s happening,” Bell said. “There’s a concern that the Kawasaki disease related to COVID is also related to more coronary artery problems, as well as possibly more shock states where kids come in with low blood pressure and hemodynamic problems.”
Bell said parents should watch their children closely for a sustained high fever that presents with a rash, red eyes and cracked lips — all signs of Kawasaki disease. Critical care pediatric doctors from around the world have been meeting online and by phone to discuss new patterns as they emerge.
Doctors are still sorting out the picture. “There are some links genetically — probably related to the virus as well as the patient — but it’s unclear the interaction between them, and that’s what everyone is trying to figure out, so people can predict who’s going to get this so we can protect their hearts for later on,” Bell said. He added that he had participated in a call with other critical care specialists from around the world on Saturday, and at that point it appeared the unusual cases were “localized mostly on the eastern U.S. and in Europe, as opposed to Asia and the West Coast, so if Seattle has cases that would be interesting.”
Bell said about 200 Children’s National patients have tested positive for the coronavirus and about 50 have been admitted to the hospital for treatment. Fourteen of them have been transferred to the pediatric intensive care unit, he said. But the new pattern of patients with Kawasaki-type symptoms only just emerged, and it is too soon to know why. He added that in England there have been a few patients who tested negative for COVID-19 but later showed up at hospitals with the new multi-symptom inflammatory disease, so it is possible the testing is not catching all patients.
“It appears there are some kids who get the [multi-symptom inflammatory] disease while they’re sick with COVID while they have some respiratory symptoms, and it appears to me there are some kids who get Kawasaki-like symptoms weeks after they’ve had COVID, so it could be an antibody-related thing,” Bell said.
That would be consistent with a growing belief among doctors that some of the worst symptoms in adult COVID-19, including acute respiratory distress and multiple organ failure, are the result of an overactive immune system response to the infection.
Dr. Michael Neely, chief of infectious diseases at Children’s Hospital Los Angeles, where Timme’s son was treated, told Yahoo News in a statement that the hospital experienced an increase in Kawasaki cases in April compared with previous years. “Preliminary data indicate that three patients treated at CHLA exhibited symptoms consistent with PIMS,” Neely said. “These patients tested positive for antibodies against SARS-Cov-2 virus [which causes COVID-19] but tested negative for the virus by RT-PCR,” meaning they did not have a current infection.
“These results indicate that their inflammation may have been a late response to a recent past infection with SARS-Cov-2,” Neely said.
But Portman, the Seattle Children’s Hospital pediatric cardiologist, said that while it is too early to say anything for certain about the new and more severe pediatric cases, he has heard from doctors he has trained that they’ve seen the new form of the disease show up in many different ways.
“They’ve had patients come in, children come in early in the COVID when they have the full picture of COVID, but they also have dysfunction of their heart. So it looks like the virus might actually cause inflammation in the heart directly, and that’s without the immune response,” Portman said. “They’ve had some patients who come in and they have all those clinical manifestations of Kawasaki disease, and they come in with this shock-like syndrome, and some of these patients when you do the swab for COVID are negative. Occasionally there’s a positive one, but it’s been variable. And there’s some patients who come in with full-blown Kawasaki disease who even show the aneurysms, and they can develop these aneurysms even while they’re in the hospital.”
Portman said that when Kawasaki disease is not treated in the first 10 days after symptoms appear, 1 out of 4 pediatric patients develops aneurysms, which can lead to heart attacks. Doctors are concerned that if children with coronavirus infections and the unusual Kawasaki-type symptoms aren’t evaluated quickly, they could miss the window for getting treatment in time.
Rossi, now chief of the cardiology division at Nicklaus Children’s Hospital in Miami, spent 10 years at New York’s Mount Sinai Hospital, one of the American hospitals to first report the strange new pattern of cases. Rossi said that while Miami has not yet seen any cases fitting the new pattern, the city also has not yet seen a surge in coronavirus cases.
“We’re really not sure what this relationship is, but it is very, very unusual to see a cluster of cases like this,” he said. “What’s really also unusual is that in this entire pandemic, the first few months, nobody saw anything like this at all.”
Rossi said that the pattern was identified only about three weeks ago, leading to speculation that some patients initially recover only to subsequently develop multi-symptom inflammatory disorder symptoms. But he admitted that even the world’s top pediatric cardiologists don’t know what to make of the shift.
“We’re probably a few weeks behind the rest of the country,” Rossi said. “I think we have to brace for what’s likely to come, and that is a bunch of kids showing up with this Kawasaki-like disease which affects the heart. There is a spectrum of disease that we’re seeing in kids today that is very different from the adult disease, and we have no idea why.”
Whatever is going on, the doctors all warned that parents should ensure that their children continue to maintain social distancing as the country begins to reopen. Dr. James Schneider, chief of critical care at Cohen Children’s Medical Center in New Hyde Park, N.Y., along the border with Queens, who appears to be the first American doctor to speak publicly about the new pattern of cases, said his children wear masks anytime they leave their home — which is almost never.
Schneider’s hospital is in the middle of a coronavirus hot spot and draws patients from across New York City and Long Island. He said his hospital has admitted approximately 90 patients with COVID-related illness and that 15 of those children have shown severe symptoms indicating likely Kawasaki complications. He said the caseload is growing quickly, with five new cases admitted to the hospital’s pediatric intensive care unit in 24 hours this week between Monday and Tuesday.
“We expect to see more kids develop this,” Schneider said. “The consequence of Kawasaki disease, which is why this is really important, is that your coronary arteries, the arteries of the heart, can get affected, and those can lead to aneurysms or ballooning of the coronary arteries, and that’s where it can be life-threatening in the future. That’s why we want to get the word out.”
(Thumbnail Photo: Getty Images)
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