Clinical Characteristics of 58 Children With a Pediatric Inflammatory Multisystem Syndrome Temporally Associated With SARS-CoV-2 | Adolescent Medicine | JAMA | JAMA Network
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    2 Comments for this article
    “Pre-existing” Endothelial Dysfunction and PIMS-TS
    Giovanni Ghirga, Pediatrician, Italy | Civitavecchia, Italy
    Pre-existing endothelial dysfunction has been suggested as a unifying hypothesis for the burden of severe SARS-CoV-2 (1). Endothelial dysfunction is silently present in children and young adults exposed to conventional risk factors including hypercholesterolemia or family history of hypertension. Indeed, conventional risk factors cluster in certain individuals, and clear relations emerge between the risk factor burden and degree of endothelial dysfunction. This has particular relevance for the rapidly expanding population of overweight and obese children with mild hypertension, dyslipidemia, insulin resistance, and low-grade inflammation (2). We postulate that pre-existing endothelial dysfunction might play a role in Pediatric Inflammatory Multisystem Syndrome temporally associated with SARS-CoV-2.


    1.Ghirga G. R.R. Pre-existing endothelial  dysfunction: a unifying hypothesis for the burden of severe SARS-CoV-2. BMJ  2020;368:m627.

    2.Childhood origins of endothelial dysfunction. Heart. 2005 Oct; 91(10): 1272–1274.
    Coronary study
    Michael Zarate, Fellow | Hospital Nacional Edgardo Rebagliati Martins
    Thanks for the information provided, the study shows many interesting things. In Peru we also have patients with this clinical condition and more and more appear and some of them with coronary dilatations, although we have not yet been able to appreciate giant coronary aneurysms, at least in the institution where I work. I would like to know what method was used in the analysis of the coronary Z score? We know that it depends on the method, it can come out in a normal or extended range and that is why my doubt, I would like to know which one is used by you in your institution. I hope you can answer my question, thank you very much.
    Original Investigation
    June 8, 2020

    Clinical Characteristics of 58 Children With a Pediatric Inflammatory Multisystem Syndrome Temporally Associated With SARS-CoV-2

    Author Affiliations
    • 1Department of Paediatrics, Imperial College Healthcare NHS Trust, London, United Kingdom
    • 2Section of Paediatric Infectious Disease, Department of Infectious Disease, Imperial College London, London, United Kingdom
    • 3Department of Paediatric Infectious Diseases, Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
    • 4Infection, Immunity, and Inflammation Department, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
    • 5Department of Paediatric Infectious Diseases, Evelina London Children’s Hospital, London, United Kingdom
    • 6Department of Women and Children’s Health, School of Life Course Sciences, Kings College London, London, United Kingdom
    • 7Faculty of Medicine and Institute for Life Sciences, University of Southampton and NIHR Southampton Clinical Research Facility and NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
    • 8Children’s Acute Transport Service, Great Ormond Street Hospital for Children, London, United Kingdom
    • 9Paediatric Cardiology Services, Royal Brompton Hospital, London, United Kingdom
    • 10Department of Congenital Heart Disease, Evelina London Children’s Hospital, London, United Kingdom
    • 11Institute in Child Health, King’s College Hospital, London, United Kingdom
    • 12Paediatric Critical Care Unit, Nottingham Children’s Hospital, Nottingham, United Kingdom
    • 13Cardiology, Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
    • 14Paediatric Intensive Care, Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
    • 15Paediatric Intensive Care, Evelina London Children’s Hospital, London, United Kingdom
    • 16Kawasaki Disease Research Center, Department of Pediatrics, University of California San Diego
    JAMA. 2020;324(3):259-269. doi:10.1001/jama.2020.10369
    Key Points

    Question  What are the clinical and laboratory characteristics of critically ill children who developed an inflammatory multisystem syndrome during the coronavirus disease 2019 pandemic?

    Findings  This case series included 58 hospitalized children, a subset of whom required intensive care, and met definitional criteria for pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus 2 (PIMS-TS), including fever, inflammation, and organ dysfunction. Of these children, all had fever and nonspecific symptoms, such as abdominal pain (31 [53%]), rash (30 [52%]), and conjunctival injection (26 [45%]); 29 (50%) developed shock and required inotropic support or fluid resuscitation; 13 (22%) met diagnostic criteria for Kawasaki disease; and 8 (14%) had coronary artery dilatation or aneurysms. Some clinical and laboratory characteristics had important differences compared with Kawasaki disease, Kawasaki disease shock syndrome, and toxic shock syndrome.

    Meaning  These findings help characterize the clinical features of hospitalized, seriously ill children with PIMS-TS and provide insights into this apparently novel syndrome.


    Importance  In communities with high rates of coronavirus disease 2019, reports have emerged of children with an unusual syndrome of fever and inflammation.

    Objectives  To describe the clinical and laboratory characteristics of hospitalized children who met criteria for the pediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (PIMS-TS) and compare these characteristics with other pediatric inflammatory disorders.

    Design, Setting, and Participants  Case series of 58 children from 8 hospitals in England admitted between March 23 and May 16, 2020, with persistent fever and laboratory evidence of inflammation meeting published definitions for PIMS-TS. The final date of follow-up was May 22, 2020. Clinical and laboratory characteristics were abstracted by medical record review, and were compared with clinical characteristics of patients with Kawasaki disease (KD) (n = 1132), KD shock syndrome (n = 45), and toxic shock syndrome (n = 37) who had been admitted to hospitals in Europe and the US from 2002 to 2019.

    Exposures  Signs and symptoms and laboratory and imaging findings of children who met definitional criteria for PIMS-TS from the UK, the US, and World Health Organization.

    Main Outcomes and Measures  Clinical, laboratory, and imaging characteristics of children meeting definitional criteria for PIMS-TS, and comparison with the characteristics of other pediatric inflammatory disorders.

    Results  Fifty-eight children (median age, 9 years [interquartile range {IQR}, 5.7-14]; 20 girls [34%]) were identified who met the criteria for PIMS-TS. Results from SARS-CoV-2 polymerase chain reaction tests were positive in 15 of 58 patients (26%) and SARS-CoV-2 IgG test results were positive in 40 of 46 (87%). In total, 45 of 58 patients (78%) had evidence of current or prior SARS-CoV-2 infection. All children presented with fever and nonspecific symptoms, including vomiting (26/58 [45%]), abdominal pain (31/58 [53%]), and diarrhea (30/58 [52%]). Rash was present in 30 of 58 (52%), and conjunctival injection in 26 of 58 (45%) cases. Laboratory evaluation was consistent with marked inflammation, for example, C-reactive protein (229 mg/L [IQR, 156-338], assessed in 58 of 58) and ferritin (610 μg/L [IQR, 359-1280], assessed in 53 of 58). Of the 58 children, 29 developed shock (with biochemical evidence of myocardial dysfunction) and required inotropic support and fluid resuscitation (including 23/29 [79%] who received mechanical ventilation); 13 met the American Heart Association definition of KD, and 23 had fever and inflammation without features of shock or KD. Eight patients (14%) developed coronary artery dilatation or aneurysm. Comparison of PIMS-TS with KD and with KD shock syndrome showed differences in clinical and laboratory features, including older age (median age, 9 years [IQR, 5.7-14] vs 2.7 years [IQR, 1.4-4.7] and 3.8 years [IQR, 0.2-18], respectively), and greater elevation of inflammatory markers such as C-reactive protein (median, 229 mg/L [IQR 156-338] vs 67 mg/L [IQR, 40-150 mg/L] and 193 mg/L [IQR, 83-237], respectively).

    Conclusions and Relevance  In this case series of hospitalized children who met criteria for PIMS-TS, there was a wide spectrum of presenting signs and symptoms and disease severity, ranging from fever and inflammation to myocardial injury, shock, and development of coronary artery aneurysms. The comparison with patients with KD and KD shock syndrome provides insights into this syndrome, and suggests this disorder differs from other pediatric inflammatory entities.