Early diagnosis of post-Covid syndrome is crucial to prevent child deaths

“How beautiful!” It was the first expression that the boy Alisson Fontes, 12, said to the doctor when he was extubated, after ten days in the ICU of Hospital Pequeno Príncipe, in Curitiba (PR), the largest pediatric institution in the SUS, to treat complications from Covid-19. 19. The entire intensive care team applauded him.

The boy’s mother, Maria Camila Calisto Fontes, 35, says that on January 17, 2021, he began to have fever and vomiting, in addition to having spots on the skin, below the ribs.

At the nearest UBS where he lives, in the rural area of ​​São José dos Pinhais (PR), the boy was treated for his symptoms and released. The spots were mistaken for insect bites.

On the morning of the 22nd, Alisson vomited blood. In the UPA, the diagnosis was gastritis caused by coughing.
At night, on the same day, the parents decided to take the child to the hospital, even without prior referral from the UBS or UPA – a necessary condition according to SUS regulations.

Upon arrival at Pequeno Príncipe, several changes were observed in the child’s exams. “The pressure was altered, the oxygen saturation was getting worse, worse”, remembers the mother.

Then the boy started vomiting blood again. “When they told me: ‘mother, let’s send him to the ICU to investigate further. We’re just going to put a little hose in his mouth’. Wow, that was a blow to me. That’s when I understood that he was going to be intubated”, he recalls, thrilled.

Laboratory tests showed that Alisson had likely had Covid in December 2020, but was asymptomatic and at that time had SIM-P (Multisystem Inflammatory Syndrome), a serious and rare condition that affects teenage children weeks and even months after infection. by Covid.

In the ICU, the boy was also diagnosed with myocarditis as a consequence of post-Covid. Of the 14 days spent in the hospital, he remembers little, but the return home is vivid in his memory.

“First I gave Grandma and Grandpa a hug. Then I ran to hug Liza,” he says, referring to his five-year-old pet mare, his inseparable companion.

Vaccinated with the first dose, the boy continues to be accompanied at Pequeno Príncipe. He no longer has any sequelae of the disease. Last January, he and the rest of his family got Covid again, but he only had mild symptoms. “Just scratched his throat,” he says.

Since the beginning of the pandemic, the country has recorded more than 1,550 cases of SIMP-P and at least 96 deaths. The fatality rate is high, at 6%, four times higher than in the United States and Europe. The disease adds to the serious cases of Covid in children, which skyrocketed in January with the advancement of the omicron variant.

In Pequeno Príncipe, there were 23 cases of the syndrome and three deaths. Since then, there have been many lessons learned not only in how to diagnose it early but how to treat it correctly.

“Inflammatory syndrome has a high mortality rate when the diagnosis is late. Although it is a challenge, pediatricians have become more attentive to early diagnosis. Gastrointestinal manifestations are very common in SIM-P”, explains Victor Horácio da Costa Souza Júnior , pediatrician and infectologist at Pequeno Príncipe.

The effectiveness of treatment is also related to early diagnosis, he said. “Both the use of corticosteroids and immunoglobulin [proteínas de importância vital que circulam no sangue] will be more effective in early diagnosis.”

Infectologist Francisco Ivanildo Ribeiro, quality manager at Sabará Hospital Infantil, says that the available studies on the outcomes of SIMP-P are still very restricted to the first waves of the pandemic, but there is a lot of accumulated knowledge.

For example, that the combination of immunoglobulin and corticosteroid is better than using immunoglobulin alone. “There is already accumulated knowledge that allows scaling up. For example, I’m not going to use an immunobiological for everyone. For some I’m going to use cytokine blockers [outro tipo de tratamento]”, he explains.

For pediatrician and infectious disease specialist Renato Kfouri, director of SBIm (Brazilian Society of Immunizations), in the same way as in severe cases of Covid in adults, doctors also learned to better manage the effects of the disease on children.

“We saw that the use of corticosteroids and anticoagulation in critically ill hospitalized patients makes a difference. We took a long time to intubate, resisted early ventilation and that was overcome”, he says.

In relation to SIM-P, the Brazilian challenge, according to him, lies in reducing the high mortality rate. An international systematic review showed a case fatality rate of 1.9%. “In Brazil, as in so many other areas, there is still a lot of room for improvement in diagnosis and care.”

A new study published this month in the print edition of the Journal of Allergy and Clinical Immunology suggests how the syndrome evolves from an immunological and inflammatory point of view and opens the way for the creation of tests with the potential to more quickly detect its signs.

Although other studies have analyzed these responses, most investigated patients after starting treatment and made comparisons with healthy control groups.

“For us, these comparisons with healthy groups do not differentiate the underlying inflammatory response from the unique features of SIM-P,” says Mark Gorelik, an assistant professor of pediatrics at Columbia University, one of the study’s authors.

In the study, eight patients with SIM-P were compared with 14 patients who had other febrile infections and observed the variety of immune cells and responses already in the first blood samples collected in the hospital emergency.

“Only a few cells were activated [na SIM-P]which suggests that these cells are misdirecting the immune system to attack blood vessels in the body that have been damaged by the virus,” says Robert Winchester, professor of medicine, pathology and cell biology at Columbia.

“These cells are attracted to blood vessels because of the presence of the virus, but they seem to misidentify the culprit when they alert the rest of the immune system.”

Both in the case of SIM-P and in severe cases of Covid, Brazilian pediatricians draw attention to the crucial importance of preventing the disease through childhood vaccination and also ask for more attention to the problems that arise in the post-Covid period.

“Attention is necessary both during the disease and after Covid. The clinical manifestation can go far beyond the initial respiratory and gastrointestinal symptoms. Many have hair loss, headache, insomnia, depression, peripheral neuropathy. [formigamento da mão] and heart complications”, says Victor Souza Júnior, from Pequeno Príncipe.