Children who developed pediatric multisystem inflammatory syndrome (P-SIM) due to Covid-19 continue to have changes in the blood vessels that nourish the heart muscle six months after hospital discharge. But they do not have symptoms, such as tiredness, which can let the condition go unnoticed by the family and doctors.
The alert comes from a new study by the ICr (Instituto da Criança e do Adolescente) at Hospital das Clínicas de São Paulo and reinforces the need for long-term follow-up of children who had the syndrome after Covid. These changes, if they persist, lead to an increased risk of heart attack and heart failure in later life.
The syndrome is a rare condition. It affects one in every 3,000 children and young people under the age of 21 who contract Covid. It occurs due to an intense reaction of the immune system to try to fight the coronavirus and can affect several vital organs, such as the heart. The mortality rate in Brazil is 6%, four times lower than in the United States.
The ICr study is the first to point out the persistence of these changes six months, on average, after the child’s discharge. Other research published last month in the Journal of the American Heart Association suggested that the hearts of children affected by SIM-P recover within a week to three months.
The Instituto da Criança has been following the impact of Covid on children since the first wave of the disease, in 2020. In the study, already accepted in the scientific journal dedicated to the cardiology area Microcirculation, a group of six children (three girls and three boys) with average age of nine years, admitted to the institute between July 2020 and February 2021.
“These are children who were discharged, went home and have a normal routine electrocardiogram. That is, if they go to any service and are evaluated with an echo [cardiograma] base, the result will be normal. But when subjected to a special electrocardiogram, the changes are visible”, explains pediatric cardiologist Gabriela Leal, coordinator of the echocardiogram service at ICr.
The doctor says that the group decided to publish the study even with a small number of children as a form of alert, so that other specialists start to follow the children who had SIM-P more rigorously and with more adequate exams.
“Could this be resolved with the child’s growth? Great. If it is resolved, the problem is over. But this can continue, and we will only have this answer by following it. The message is: we have a problem and a problem that is still present six months, on average, after the child was discharged.”
The alert is also directed at parents to vaccinate their children and maintain preventive measures, such as the use of mask and gel alcohol, against Covid. “As long as we have many infected children, one or the other will develop this exacerbated inflammatory response,” she says.
In the ICr study, a special echocardiogram was used, which has a technique that maps the heart muscle into 17 segments. “I look at the heart in small pieces and study how much the heart muscle can perform, that is, contract, relax.”
The children were also evaluated by a PET-CT with labeled ammonia. Through the injection of this radioactive substance, it is possible to observe the flow that reaches the microvessels of the heart muscle.
Both exams found the changes in the same segments. The good news is that the special electrocardiogram, much more accessible and less invasive than PET-CT, could be used as a marker of future cardiovascular risk, according to the doctor.
Still in the first wave of Covid, in 2020, the ICr group realized that children hospitalized with SIM-P who had ventricular dysfunction, that is, loss of heart pump function, were also those who had a marker (dedimer) higher inflation and thrombosis.
“For the heart to function properly, the heart muscle needs to be well irrigated. The fact of having the dedimer increased alerts to the possibility of microthrombosis also occurring in the coronary territory”, explains the doctor.
Another work by the institute, in conjunction with the pathology department at USP, analyzed heart samples from eight children who died of SIM-P. The Sars-Cov-2 virus was found inside the heart muscle, causing inflammation (myocarditis). Inflammation of the vessels that nourish the heart muscle (coronary microcirculation) and small clots within them were also observed.
“If these children don’t improve, they may be at greater risk of a heart attack or failure in later life, especially if they are subject to other risk factors, such as hypertension, diabetes, obesity, smoking.”
The country had an explosion of new cases of child hospitalizations for Covid in January and SIM-P registrations are expected in the coming weeks, as the manifestation is late.
“Ten, 15 days after an increase in cases of acute Covid, cases of SIM-P begin to appear. We saw this last year and we are preparing for possible new records in the coming days”, says pediatrician Mario Palumbo Neto, director health technician at Hospital Infantil Cândido Fontoura.
In 2021, the hospital, the largest public pediatric institution in the state of São Paulo, recorded 36 SIM-P visits.
According to the director, most of the time, the child had to be admitted to the ICU. “It is a serious disease, which often affects the coronary artery, the artery that supplies the heart. The child needs a specific medication, hemoglobulin, which needs monitoring in intensive care.”
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