Kawasaki Disease like Multisystem Inflammatory Syndrome in a Toddler during SARS-CoV-2 Pandemic in Nepal.

Multisystem inflammatory syndrome in children is a new childhood inflammatory disorder associated with respiratory syndrome coronavirus 2 (SARS-CoV-2). This illness of elevated inflammatory markers and multiple organ involvement similar to Kawasaki disease is not commonly reported from Asia. A 17-month-old boy presented with acute onset fever, rash, non-exudative conjunctivitis and swellings of hands and legs. In x-ray chest there was infiltration on the right lower lobe and echocardiography showed evidence of coronary arteritis. The diagnosis of multisystem inflammatory syndrome in children was confirmed on the basis of characteristic clinical features and laboratory parameters fulfilling standard case definition for multisystem inflammatory syndrome in children. The child responded to treatment with intravenous immunoglobulin and high dose aspirin. Hence, amidst SARS-CoV-2 pandemic, multisystem inflammatory syndrome in children should be suspected and effectively treated even in a country like Nepal. Keywords: Kawasaki disease; multiple inflammatory syndrome in children; Nepal; respiratory syndrome coronavirus 2.

A preliminary randomized double blind placebo-controlled trial of intravenous immunoglobulin for Japanese encephalitis in Nepal.

BACKGROUND: Japanese encephalitis (JE) virus (JEV) is a mosquito-borne flavivirus found across Asia that is closely related to West Nile virus. There is no known antiviral treatment for any flavivirus. Results from in vitro studies and animal models suggest intravenous immunoglobulin (IVIG) containing virus-specific neutralizing antibody may be effective in improving outcome in viral encephalitis. IVIG's anti-inflammatory properties may also be beneficial. METHODOLOGY/PRINCIPAL FINDINGS: We performed a pilot feasibility randomized double-blind placebo-controlled trial of IVIG containing anti-JEV neutralizing antibody (ImmunoRel, 400mg/kg/day for 5 days) in children with suspected JE at two sites in Nepal; we also examined the effect on serum neutralizing antibody titre and cytokine profiles. 22 children were recruited, 13 of whom had confirmed JE; 11 received IVIG and 11 placebo, with no protocol violations. One child (IVIG group) died during treatment and two (placebo) subsequently following hospital discharge. Overall, there was no difference in outcome between treatment groups at discharge or follow up. Passive transfer of anti-JEV antibody was seen in JEV negative children. JEV positive children treated with IVIG had JEV-specific neutralizing antibody titres approximately 16 times higher than those treated with placebo (p=0.2), which was more than could be explained by passive transfer alone. IL-4 and IL-6 were higher in the IVIG group. CONCLUSIONS/SIGNIFICANCE: A trial of IVIG for JE in Nepal is feasible. IVIG may augment the development of neutralizing antibodies in JEV positive patients. IVIG appears an appealing option for JE treatment that warrants further study. TRIAL REGISTRATION: ClinicalTrials.gov NCT01856205.