Early recognition of paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) – a case series

BackgroundPIMS-TS has emerged as a novel disease entity. A recent systematic review reported on 662 patients diagnosed with PIMS-TS. Most of these previous studies have focused on children’s presentation at the time of admission to tertiary centres and the subsequent investigations and outcomes.ObjectivesThis case series aims to analyse the clinical features of PIMS-TS at initial presentation and admission to explore if there are any early features of disease, which could enable earlier identification of these patients.MethodsRetrospective data was analysed for all children (aged 0–16 years) seen in North Middlesex University Hospital Paediatric Emergency Department (PED) between March and May 2020 with an eventual discharge diagnosis of ‘PIMS-TS’ or who fulfilled the RCPCH case definition criteria for PIMS-TS. 11 patients met the criteria for inclusion. Data was collected based on the RCPCH guideline including patient demographics, presenting symptoms and laboratory findings.ResultsThe mean age at presentation was 7.8 years (Range 18 months -13 years). Six patients were ‘re-presentations’. The mean time interval between first presentation and eventual admission was 2.7 days (Range 0 - 5 days). The most common symptoms at first presentation were: fever (100%), vomiting (67%), headache (50%) and rash (50%). Two patients were ambulated on IV antibiotics whilst the remaining four patients were reassured and discharged from PED with no follow up. All three patients who had bloods tested on first presentation had a raised CRP and lymphopenia. Two patients had hyponatraemia (67%).The most common presenting symptoms at admission were fever (100%), abdominal pain (73%), rash (55%), vomiting (55%) and difficulty in breathing (55%). Four patients (36%) were hypotensive on initial assessment. The pathology results showed that nearly all patients had a raised CRP (91%) and five patients were lymphopenic (45%). The mean CRP was markedly elevated (212 mg/L). ESR was measured in two patients and was raised in both. Eight patients were hyponatraemic (73%). Fibrinogen, D Dimer and fibrinogen results were elevated in all cases where these were measured. Swab results for SARS-COV-2 PCR were negative in all 11 cases. Five patients tested positive for SARS-COV-2 antibody tests. Kawasaki symptoms were underrepresented in this case series with no such symptoms at first presentation and only some such as conjunctivitis (27%) and mucous membrane involvement (9%) appearing in a small number at admission.ConclusionsThe results of this case series suggest that children with early PIMS-TS can present to PED with a non-specific febrile illness a few days before they become unwell with the more severe later features. There is a suggestion that certain abnormal blood test results at this point may indicate early PIMS-TS. Further research is needed to ascertain the significance of these findings. The authors support routine nationalised data collection for all cases of PIMS-TS. In addition to exploring optimal treatment options, a review of early signs, symptoms and investigation results will assist in answering the question of whether current accepted practices for investigation and follow up for patients with fever and nonspecific symptoms are adequate to ensure timely diagnosis of PIMS-TS.

Early recognition of PIMS-TS: a single centre retrospective review.

Introduction: Research into paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) has focused on tertiary level management. This review reports on symptoms and investigations at presentation. Methods: Single centre retrospective case note analysis of patients fulfilling PIMS-TS diagnostic criteria from March to May 2020 in a London district level university hospital. Results: Six patients presented in the week prior to their final diagnosis with fever and non-specific symptoms. Raised C-reactive protein (CRP), lymphopenia and hyponatraemia were noted. Kawasaki-like symptoms were under-represented in all patients. Interpretation: The results suggest that a proportion of children with early PIMS-TS present with a non-specific febrile illness and abnormal blood results. Further research is needed to determine the most appropriate identification and follow-up of these children.

General Practice in the Time of COVID-19: A Mixed-Methods Service Evaluation of a Primary Care COVID-19 Service.

Primary care coronavirus disease 2019 (COVID-19) clinics were rapidly introduced across the UK to review potentially infectious patients. Evaluation of these services is needed to guide future implementation. This mixed-methods study evaluates patient demographics, clinical presentation, co-morbidities, service usage, and outcomes for the Islington COVID-19 service (London, UK) and from April to May 2020 and thematically analyses survey responses from 29 service clinicians and 41 GP referrers on their service experience. Of the 237 patients booked into the service, a significant number of referrals (n = 91; 38.6%) were made after the presumed infectious period of 14 days. Almost half of all adult referrals (49%) were dealt with remotely (via telephone/video consultation +/- remote oxygen saturation monitoring). The service was perceived to provide a safe way to see patients; it developed local expertise, learning, and empowerment; and it was a positive teamworking experience. These findings suggest that the management of many patients with COVID-19 symptoms is possible in routine general practice with minimal risk through the implementation of remote consultation methods and in patients who present after the post-infectious period. Additionally, the use of remote saturation monitoring and local GP COVID-19 "experts" can support practices to manage COVID-19 patients. Future primary care COVID-19 services should act as empowerment tools to assist GPs to safely manage their own patients and provide support for GPs in this process.