Case Series: Cardiac Dysfunction and Shock in Children With COVID-19

Cardiac injury and shock can occur in pediatric patients with coronavirus disease 2019 (COVID-19), according to a case series published in JACC: Case Reports.

Most pediatric cases of COVID-19 are mild. Investigators described evidence for cardiac dysfunction and injury in 3 previously healthy children admitted to the pediatric intensive care unit (PICU) for COVID-19-related shock.

Patient 1

A 13 year-old boy with obesity presented with 5 days of fever, headache, and abdominal pain, as well as 2 days of diarrhea and 1 day of shortness of breath. The patient was afebrile, tachycardic (119 beats/min), hypotensive (76/35 mm Hg), and tachypneic (56 breaths/min). His oxygen saturation was 94%.

Laboratory analysis revealed leukocytosis with neutrophil predominance and significant elevation of inflammatory markers, including C-reactive protein, procalcitonin, lactate dehydrogenase, triglycerides, ferritin, D-dimer, and fibrinogen. High-sensitivity troponin T (hsTnT) levels were also elevated (389 ng/L). An initial chest X-ray showed a left basal opacity with no cardiomegaly. His heart rhythm was regular with a gallop.

Lactate levels increased during hospitalization (peak, 11 mmol/L), so the patient was intubated, placed on a ventilator, sedated, and chemically paralyzed, and epinephrine and milrinone infusions were started.

The patient was treated with tocilizumab, intravenous immunoglobulin, remdesivir, and intravenous methylprednisone. The patient experienced brief episodes of atrial tachycardia.

After 4 days in PICU, inotropic infusions were halted and the patient was extubated. On day 5, he was weaned to room air and inflammatory markers and troponin levels declined. Fractional shortening (FS; 45%) and left ventricular ejection fraction (LVEF; 65%) both improved. The patient was discharged after 11 days.

Patient 2

A 6-year-old boy with mild persistent asthma presented with 6 days of fever, pharyngitis, myalgia, and abdominal pain, as well as 1 day of diarrhea and shortness of breath. Upon examination, the patient was afebrile, tachycardic (130 beats/min), hypotensive (71/34 mm Hg), and tachypneic (40 breaths/min). His oxygen saturation was 97%. Laboratory tests revealed leukocytosis with neutrophil predominance and significant elevation of inflammatory markers. His lactate levels were normal but hsTnT levels were elevated (116 ng/L). A grade 3/4 systolic murmur was detected at the left upper sternal border.

Upon admission to PICU, the patient had low to normal LVEF (56%), a FS of 29%, mild mitral regurgitation, and holodiastolic reversal of flow in the descending aorta.

The patient was treated with hydroxychloroquine and intravenous tocilizumab, as well as an epinephrine infusion for hypotension.

All inotropic support was weaned by 36 hours. By PICU day 3, inflammatory markers were trending downward. He was discharged with an LVEF of 57% and a FS of 35%.

Patient 3

The third patient was a 13-year-old girl with a known small midmuscular ventricular septal defect. She presented with intermittent fever, headache, cough, abdominal pain, and diarrhea, which had been ongoing for ≥5 days. She was febrile, tachycardic (119 beats/min), normotensive, and mildly tachypneic (18 breaths/min). Her oxygen saturation was 100% and her heart sounds were normal. Her white blood cell count, inflammatory markers, and hsTnT (43 ng/L) were elevated. 

The girl received fluid boluses for worsening tachycardia (134 beats/min) and hypotension (85/45 mm Hg). Her LVEF was 40% and she had an FS of 21% with mild mitral regurgitation, holodiastolic flow reversal in the descending aorta, and a small pericardial effusion.

Upon admission to PICU, she received a milrinone infusion and continued on hydroxychloroquine treatment. Her inflammation and hsTnT levels improved by PICU day 2, and by day 3, her LVEF (54%) and FS (28%) had improved, and milrinone was discontinued. She was discharged on PICU day 4.

“These cases demonstrate that COVID-19 infection can cause severe illness in previously healthy children. Shock and cardiac dysfunction can be a significant component of illness independent of lung disease,” the study authors noted. “Long-term follow-up is important to understand the pathophysiology and long-term prognosis of children with cardiac injury resulting from COVID-19.”

Reference

Joshi K, Kaplan D, Bakar A, et al. Cardiac dysfunction and shock in pediatric patients with COVID-19. JACC: Case Reports. 2020;2(9):1267-1270. doi:10.1016/j.jaccas.2020.05.082