Severe cardiac dysfunction in a patient with multisystem inflammatory syndrome in children associated with COVID-19: Retrospective diagnosis of a puzzling presentation. A case report.

We report one of the earliest known U.S. cases of multisystem inflammatory syndrome in children associated with COVID-19 (MIS-C). This adolescent male presented prior to any known association between COVID-19 and immune mediated inflammatory syndrome in children. He presented in stable condition and without significant multisystem involvement. During hospitalization, he developed severe left ventricular dysfunction and mixed hypovolemic, distributive and cardiogenic shock. Clinical features overlapped with Kawasaki disease, acute rheumatic fever, and toxic shock syndrome. After centers in Europe began reporting a multisystem inflammatory condition in children with COVID-19, the patient's clinical course and laboratory findings were revisited. He underwent newly available antibody testing and was diagnosed as one of the first known cases of MIS-C in the United States.

COVID-19 Vaccine Hesitancy and Refusal:: The Same But Different?

Pediatric providers deal with vaccine hesitancy and vaccine refusal for routine childhood vaccinations on a regular basis. However, the COVID-19 pandemic has brought challenges for pediatricians including COVID-19 vaccine hesitancy and refusal. Some of the issues surrounding COVID-19 vaccine hesitancy are similar to those associated with routine vaccines, however some are unique to COVID-19. Much of COVID-19 vaccine hesitancy has been because of both the fear of the known and unknown. Identifying these issues and reasons for hesitancy is important to devising strategies and approaches pediatric providers can use to address patient and parent concerns, and hopefully convince them to vaccinate against COVID-19.

Return to Activity After SARS-CoV-2 Infection: Cardiac Clearance for Children and Adolescents.

CONTEXT: Sedentary behavior and inability to participate in organized physical activity has negatively affected the physical and mental health of children and adolescents; however, cardiac injury and associated risk for sudden cardiac death with return to activity remains a major concern. Guidelines have been proposed for return to activities; however, these fail to address the needs of younger children and those participating in more casual activities. Guidance is needed for primary care providers to facilitate safe return to everyday activity and sports and to help direct appropriate laboratory, electrocardiographic, and anatomical assessment. EVIDENCE ACQUISITION: Review of computerized databases of available literature on SARS-CoV-2 infection in children and postinfection sequelae, risk factors for sudden cardiac death, and previous return to play recommendations. STUDY DESIGN: Clinical guidelines based on available evidence and expert consensus. LEVEL OF EVIDENCE: Level 4. RESULTS: In this report, we review the literature on return to activity after SARS-CoV-2 infection and propose recommendations for cardiac clearance for children and adolescents. Though severe disease and cardiac injury is less common in children than in adults, it can occur. Several diagnostic modalities such as electrocardiography, echocardiography, cardiac magnetic resonance imaging, and serologic testing may be useful in the cardiac evaluation of children after SARS-CoV-2 infection. CONCLUSION: Gradual return to activity is possible in most children and adolescents after SARS-CoV-2 infection and many of these patients can be cleared by their primary care providers. Providing education on surveillance for cardiopulmonary symptoms with return to sports can avoid unnecessary testing and delays in clearance.

A Complicated Case of Vaccine Refusal.

Parents in the United States have a legal right to refuse vaccination for their children. There are, however, special circumstances under which the state may compel vaccination against parental wishes. In this Ethics Rounds article, we present the case of a young boy with sickle cell disease who was partially vaccinated against encapsulated bacteria and the ethics of whether to compel complete vaccination before splenectomy.

Application of a modified microbiologic criterion for identifying pediatric ventilator-associated pneumonia.

BACKGROUND: Prevention of ventilator-associated pneumonia (VAP) is a major patient safety goal, but accurate identification of VAP in pediatric patients remains challenging. METHODS: We performed a retrospective cohort study to demonstrate feasibility of endotracheal culture and Gram's stain to support VAP diagnosis. Pediatric intensive care unit and cardiac intensive care unit patients with ≥ 1 endotracheal specimen having growth of ≥ 1 organism in conjunction with moderate/many polymorphonuclear leukocytes (ie, the modified microbiologic criterion) were included. Medical records were reviewed for presence/absence of clinical and radiographic Centers for Disease Control and Prevention (CDC) criteria for VAP. Antimicrobial use data were collected before and after culture results were known. RESULTS: Of 102 patients meeting inclusion criteria, 28% (n = 28) also met both clinical and radiographic CDC criteria for VAP (ie, diagnosis of PNU2). An additional 63% (n = 64) met clinical (36%; n = 37) or radiographic (27%; n = 27) criteria, but not both. Ten patients (9%) had neither clinical nor radiographic criteria for VAP. The majority (63%; n = 64) were receiving antibiotics at time of endotracheal specimen collection. Culture identification resulted in altered antimicrobial therapy in 66% of patients (n = 67). CONCLUSIONS: Our study demonstrates the feasibility of endotracheal Gram's stain and culture for diagnosis of pediatric VAP that could potentially standardize accurate surveillance and management of pediatric VAP.

Neurologic manifestations of pediatric novel h1n1 influenza infection.

Reported neurologic manifestations of novel H1N1 influenza have included seizure, meningoencephalitis, and acute necrotizing encephalopathy. We describe the first series of pediatric patients presenting during the second wave of the US novel H1N1 pandemic, with protracted seizures, severe encephalopathy/encephalitis, and acute disseminated encephalomyelitis. In addition to prominent radiographic abnormalities, we provide the first observation and description of associated cerebrospinal fluid abnormalities.

Linezolid-associated peripheral and optic neuropathy in children.

OBJECTIVE: Peripheral neuropathy (PN) and optic neuropathy (ON) associated with linezolid use are described in the adult literature; however limited information is available in pediatrics. The purpose of this communication is to summarize pediatric cases of linezolid-associated neuropathy and to increase awareness of these neurologic side effects so that clinicians can most appropriately balance the benefits and risks of linezolid in the pediatric population. METHODS: A search of the FDA Adverse Events Reporting System was performed for all pediatric cases of neuropathy from April 2000-2009. AERS includes both inpatient and outpatient data. Inpatient utilization patterns for linezolid were also assessed from January 2000 to December 2008. RESULTS: Eight pediatric cases of linezolid-associated neuropathy were identified. Treatment duration ranged from 4 weeks to 1 year. Five patients had PN alone, one had only ON and two had both. Symptoms of PN included pain, numbness, weakness, and paresthesias. Symptoms of ON included decreased visual acuity and color vision. Three children had other adverse events associated with linezolid including acidosis, anemia, and leukopenia. Outcomes were reported in 5 cases. Resolution of symptoms occurred between 2 weeks and 6 months after discontinuation of linezolid. Utilization data showed that during the study period, overall inpatient utilization of linezolid had increased. CONCLUSIONS: While linezolid may be used to treat serious infections often needing extended courses of therapy, potential safety concerns should be kept in mind. In the circumstance of prolonged use of linezolid in children, it is likely that more cases of neuropathy may occur.