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COVID Crisis Post 44: Kids and a Kawasaki-Like Illness.

Pandemics require an expert-directed, science-based, coordinated response. Our government officials politicizing the virus has made this almost impossible to achieve.

The following should be REQUIRED reading for the nation. Thank you Lynda for bringing this to my attention:

This article is both simultaneously fascinating and infuriating, and I hope you feel the same way too once you read it.

It may only speak about Seattle and New York City, but its points can be applied across the country, and specifically, to the failure of our leaders throughout, including the top of the Federal government.

The parallels between the responses of St. Louis and Philadelphia during the 1918 flu pandemic and Seattle and New York City during the COVID-19 pandemic, respectively, are eerie. Especially how a coordinated response at the government level can make a huge difference during a pandemic.

The fact the same mistakes are being repeated is simply mind-boggling.

Moving on.

Disclaimer: Severe complications of COVID-19 are still VERY rare in children. The following is NOT meant to raise an alarm, but to keep everyone updated on the latest possible associations of the virus. Also, I think it is fun to teach a bit of medicine here and there because, well, it is pretty damn cool and I take care of children so this topic is of particular interest to me.

There has been a noticeable increase in the number of cases in Italy, Spain, the UK, and now the US, of children presenting with a multiple system inflammatory state that mimics features of toxic shock syndrome (TSS) and atypical Kawasaki Disease (KD) - atypical meaning the disease demonstrates incomplete presentation of KD and may have other atypical features.

Many of these children are testing positive for COVID-19, though some are not. It is unclear if these are false negatives or if there is a different pathogen responsible for this presentation. A definitive link between COVID-19 and this presentation has NOT been established, but the increase in cases have been enough to get the attention of health officials in both the UK and US.

TSS is an acute, toxin-mediated illness characterized by fever, rash, low blood pressure, multiple organ involvement, and skin peeling. It can present in both children and adults. It is associated with bacterial infection with Staphylococcus aureus or Streptococcus pyogenes. Treatment mostly involves support of blood pressure, fluid resuscitation, and systemic antibiotics, with prognosis varying depending on the degree of organ involvement.

KD is also known as acute febrile mucocutaneous lymph node syndrome, or simply, it presents with a sudden onset of fever, mucous membrane and skin rashes, and enlarged lymph nodes. It typically is found in children less than 5 years old and though its cause is unknown, links have been made to viral or bacterial infection. It is relatively rare in the US, with a higher geographic incidence in East Asia.

KD presents with an acute systemic inflammatory vasculitis, meaning the blood vessels of the body become inflamed. Untreated, 15-25% of these patients can develop lifelong coronary artery lesions, such as dilation of the coronary arteries, aneurysms, and in rare cases, death, due to clotting and subsequent heart attack. This is why early diagnosis and treatment is essential and usually successful, with treatment involving IVIG and high-dose aspirin and follow-up echocardiogram once resolved.

A severe manifestation of KD, called Kawasaki Disease Shock Syndrome (KDSS), is uncommon, but can present very similarly to TSS. However, since their treatments are very different, it is important to distinguish between the two.

And now, some of my own observations based on my reading:

The systemic inflammatory response, or cytokine storm, associated with COVID-19 involves the IL-1/IL-6 cytokine pathway. In addition, interferons, including interferon gamma, have been shown to play a crucial role in the defense against coronavirus diseases, with evidence the virus may impede the interferon response in humans. Both IL-1/IL-6 inhibitors as well as interferons are thus being used or targeted as possible treatments for COVID-19.

This is where it gets really interesting, at least for me. Earlier induction of interferons in children and their less developed immune system could be the reason behind their zero or near-zero fatality rate, and the variation in interferon response across all age groups may give insight into the differences in mortality found in COVID-19. In addition, elevated IL-6 as well as elevated interferon gamma levels have been associated with an increased risk of developing KDSS, perhaps signaling more serious disease.

The IL-6 and interferon gamma connections between COVID-19 and possible increased incidence of KDSS are ones I made on my own, not because I read it anywhere. Coincidence? Maybe. Just a thought of mine I found interesting enough to share.

One final point: I am trying to be clear as possible in my posts and not over-simplify the topics as I do not want to eliminate details I think are essential to fully understand the topics at hand. HOWEVER, if there are things in my post that are difficult to understand, PLEASE reach out and ask for clarification.

No one knows everything. I most definitely do NOT. And as a result, I read and constantly ask questions to those more informed about a topic OR to those who may offer insight into a topic I am well-versed in but may not have considered.

So maybe I am one of the smart ones, at least according to Malcolm Forbes. And I'm hoping the same applies to you because:

"The smart ones ask when they don’t know. And, sometimes, when they do." - Malcolm Forbes

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