• COVID-19
• virology

While most children experience only mild symptoms after contracting SARS-CoV-2 infection,1 a small number suffer from severe disease characterised by an exaggerated inflammatory response leading to multiorgan dysfunction termed paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS).2 Most previous studies have focused on children’s presentation and subsequent investigations at admission to tertiary centres. This review of 11 cases of PIMS-TS at a District University Hospital analyses clinical features at admission as well as previous presentations to explore if there are any early features of the disease.

Retrospective data were analysed for all children (aged 0–16 years) seen in North Middlesex University Hospital paediatric emergency department (PED) between March and May 2020 who fulfilled the Royal College of Paediatrics and Child Health (RCPCH) case definition criteria for PIMS-TS.2 Data were collected based on the RCPCH guideline including patient demographics, presenting symptoms and relevant laboratory findings.2

Eleven patients met the criteria for inclusion. Five were female and six were male. The mean age at presentation was 7.8 years (range 18 months−13 years). Six children had been seen and discharged in the week prior to their subsequent diagnosis. Their initial diagnoses were COVID-19 infection, scarlet fever, migraine, viral upper respiratory tract infection, suspected bacterial sepsis and bacterial tonsillitis. The mean time between first presentation and admission was 2.7 days (range 0–5 days). The most common symptoms at first presentation for these six patients were fever (six patients), vomiting (four patients), headache (three patients) and rash (three patients) (table 1). Two patients were ambulated on intravenous antibiotics while the remaining were discharged with no follow-up. All three patients who had blood tested on first presentation had a raised C-reactive protein (CRP) (range 58–137 mg/L) and lymphopenia (range 0.63–0.83×10⁹/L), two had hyponatraemia (results 132 and 134 mmol/L).

At admission, the most common symptoms were fever (11 patients), abdominal pain (8 patients), rash (6 patients), vomiting (6 patients) and difficulty in breathing (6 patients) (table 1). Ten patients had a raised CRP (range 7.5–328 mg/L, mean 212 mg/L), five were lymphopenic (range 0.45–3.3×10⁹/L) and eight were hyponatraemic (range 125–137 mmol/L). Fibrinogen, D-dimer, ferritin, pro b-type natriuretic peptide (pro-BNP) and erythrocyte sedimentation rate (ESR) were raised in all patients in which they were tested. Seven patients had positive SARS-CoV-2 antibody tests.

The results of this review present interesting comparisons with the current literature. A recent systematic review showed that fever (100%), abdominal pain (73.7%) and vomiting (68.3%) were the most frequent symptoms at presentation. These symptoms were also common in this cohort. Additionally, consistent with previous reviews, most patients had a raised CRP, lymphopenia and hyponatraemia at presentation.3

In contrast with early descriptions of PIMS-TS which highlighted similarities to Kawasaki disease,4 these symptoms were under-represented in this review. One large case series reported shock (87%) as the second most common presenting feature in PIMS-TS5; however, only four patients in this review were hypotensive on admission, suggesting presentation earlier in the disease course.

The results of this review suggest that children with early PIMS-TS can present to PED with a non-specific febrile illness a few days before they become unwell with the more severe later features. Certain abnormal blood test results at this point may indicate early PIMS-TS; however this review is limited by the small case numbers making generalisation difficult. Further research is needed to ascertain the significance of these findings to determine whether current accepted practices for investigation and follow-up for patients with fever and non-specific symptoms are adequate to ensure timely diagnosis of PIMS-TS.