au:Eisencraft, Adriana Pasmanik
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1. Multisystem inflammatory syndrome associated with COVID-19 from the pediatric emergency physician's point of view
Simon Junior, Hany ; Sakano, Tania Miyuki Shimoda ; Rodrigues, Regina Maria ; Eisencraft, Adriana Pasmanik ; Carvalho, Vitor Emanoel Lemos de ; Schvartsman, Claudio ; Reis, Amelia Gorete Afonso da Costa .
Jornal de Pediatria apr 2021, Volume 97 N. 2 Pages 140 - 159
ABSTRACT Objective: Multisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease (COVID-19) is a rare and challenging diagnosis requiring early treatment. The diagnostic criteria involve clinical, laboratory, and complementary tests. This review aims to draw pediatrician attention to this diagnosis, suggesting early treatment strategies, and proposing a pediatric emergency care flowchart. Sources: The PubMed/MEDLINE/WHO COVID-19 databases were reviewed for original and review articles, systematic reviews, meta-analyses, case series, and recommendations from medical societies and health organizations published through July 3, 2020. The reference lists of the selected articles were manually searched to identify any additional articles. Summary of the findings: COVID-19 infection is less severe in children than in adults, but can present as MIS-C, even in patients without comorbidities. There is evidence of an exacerbated inflammatory response with potential systemic injury, and it may present with aspects similar to those of Kawasaki disease, toxic shock syndrome, and macrophage activation syndrome. MIS-C can develop weeks after COVID-19 infection, suggesting an immunomediated cause. The most frequent clinical manifestations include fever, gastrointestinal symptoms, rash, mucous membrane changes, and cardiac dysfunction. Elevated inflammatory markers, lymphopenia, and coagulopathy are common laboratory findings. Supportive treatment and early immunomodulation can control the intense inflammatory response and reduce complications and mortality. Conclusions: MIS-C associated with COVID-19 is serious, rare, and potentially fatal. The emergency department pediatrician must recognize and treat it early using immunomodulatory strategies to reduce systemic injury. Further studies are needed to identify the disease pathogenesis and establish the most appropriate treatment.
2. Differences in children and adolescents with SARS-CoV-2 infection: a cohort study in a Brazilian tertiary referral hospital
Marques, Heloisa Helena de Sousa ; Pereira, Maria Fernanda Badue ; Santos, Angélica Carreira dos ; Fink, Thais Toledo ; Paula, Camila Sanson Yoshino de ; Litvinov, Nadia ; Schvartsman, Claudio ; Delgado, Artur Figueiredo ; Gibelli, Maria Augusta Bento Cicaroni ; Carvalho, Werther Brunow de ; Odone Filho, Vicente ; Tannuri, Uenis ; Carneiro-Sampaio, Magda ; Grisi, Sandra ; Duarte, Alberto José da Silva ; Antonangelo, Leila ; Francisco, Rossana Pucineli Vieira ; Okay, Thelma Suely ; Batisttella, Linamara Rizzo ; Carvalho, Carlos Roberto Ribeiro de ; Brentani, Alexandra Valéria Maria ; Silva, Clovis Artur ; Eisencraft, Adriana Pasmanik ; Rossi Junior, Alfio ; Fante, Alice Lima ; Cora, Aline Pivetta ; Reis, Amelia Gorete A. de Costa ; Ferrer, Ana Paula Scoleze ; Andrade, Anarella Penha Meirelles de ; Watanabe, Andreia ; Gonçalves, Angelina Maria Freire ; Waetge, Aurora Rosaria Pagliara ; Silva, Camila Altenfelder ; Ceneviva, Carina ; Lazari, Carolina dos Santos ; Abellan, Deipara Monteiro ; Santos, Emilly Henrique dos ; Sabino, Ester Cerdeira ; Bianchini, Fabíola Roberta Marim ; Alcantara, Flávio Ferraz de Paes ; Ramos, Gabriel Frizzo ; Leal, Gabriela Nunes ; Rodriguez, Isadora Souza ; Pinho, João Renato Rebello ; Carneiro, Jorge David Avaizoglou ; Paz, Jose Albino ; Ferreira, Juliana Carvalho ; Ferranti, Juliana Ferreira ; Ferreira, Juliana de Oliveira Achili ; Framil, Juliana Valéria de Souza ; Silva, Katia Regina da ; Kanunfre, Kelly Aparecida ; Bastos, Karina Lucio de Medeiros ; Galleti, Karine Vusberg ; Cristofani, Lilian Maria ; Suzuki, Lisa ; Campos, Lucia Maria Arruda ; Perondi, Maria Beatriz de Moliterno ; Diniz, Maria de Fatima Rodrigues ; Fonseca, Maria Fernanda Mota ; Cordon, Mariana Nutti de Almeida ; Pissolato, Mariana ; Peres, Marina Silva ; Garanito, Marlene Pereira ; Imamura, Marta ; Dorna, Mayra de Barros ; Luglio, Michele ; Rocha, Mussya Cisotto ; Aikawa, Nadia Emi ; Degaspare, Natalia Viu ; Sakita, Neusa Keico ; Udsen, Nicole Lee ; Scudeller, Paula Gobi ; Gaiolla, Paula Vieira de Vincenzi ; Severini, Rafael da Silva Giannasi ; Rodrigues, Regina Maria ; Toma, Ricardo Katsuya ; Paula, Ricardo Iunis Citrangulo de ; Palmeira, Patricia ; Forsait, Silvana ; Farhat, Sylvia Costa Lima ; Sakano, Tânia Miyuki Shimoda ; Koch, Vera Hermina Kalika ; Cobello Junior, Vilson .
OBJECTIVES: To compare demographic/clinical/laboratory/treatments and outcomes among children and adolescents with laboratory-confirmed coronavirus disease 2019 (COVID-19). METHODS: This was a cross-sectional study that included patients diagnosed with pediatric COVID-19 (aged <18 years) between April 11, 2020 and April 22, 2021. During this period, 102/5,951 (1.7%) of all admissions occurred in neonates, children, and adolescents. Furthermore, 3,962 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) detection samples were processed in patients aged <18 years, and laboratory-confirmed COVID-19 occurred in 155 (4%) inpatients and outpatients. Six/155 pediatric patients were excluded from the study. Therefore, the final group included 149 children and adolescents (n=97 inpatients and 52 outpatients) with positive SARS-CoV-2 results. RESULTS: The frequencies of sore throat, anosmia, dysgeusia, headache, myalgia, nausea, lymphopenia, pre-existing chronic conditions, immunosuppressive conditions, and autoimmune diseases were significantly reduced in children and adolescents (p<0.05). Likewise, the frequencies of enoxaparin use (p=0.037), current immunosuppressant use (p=0.008), vasoactive agents (p=0.045), arterial hypotension (p<0.001), and shock (p=0.024) were significantly lower in children than in adolescents. Logistic regression analysis showed that adolescents with laboratory-confirmed COVID-19 had increased odds ratios (ORs) for sore throat (OR 13.054; 95% confidence interval [CI] 2.750-61.977; p=0.001), nausea (OR 8.875; 95% CI 1.660-47.446; p=0.011), and lymphopenia (OR 3.575; 95% CI 1.355-9.430; p=0.010), but also had less hospitalizations (OR 0.355; 95% CI 0.138-0.916; p=0.032). The additional logistic regression analysis on patients with preexisting chronic conditions (n=108) showed that death as an outcome was significantly associated with pediatric severe acute respiratory syndrome (SARS) (OR 22.300; 95% CI 2.341-212.421; p=0.007) and multisystem inflammatory syndrome in children (MIS-C) (OR 11.261; 95% CI 1.189-106. 581; p=0.035). CONCLUSIONS: Half of the laboratory-confirmed COVID-19 cases occurred in adolescents. Individuals belonging to this age group had an acute systemic involvement of SARS-CoV-2 infection. Pediatric SARS and MIS-C were the most important factors associated with the mortality rate in pediatric chronic conditions with COVID-19.
3. Severe clinical spectrum with high mortality in pediatric patients with COVID-19 and multisystem inflammatory syndrome
Pereira, Maria Fernanda Badue ; Litvinov, Nadia ; Farhat, Sylvia Costa Lima ; Eisencraft, Adriana Pasmanik ; Gibelli, Maria Augusta Bento Cicaroni ; Carvalho, Werther Brunow de ; Fernandes, Vinicius Rodrigues ; Fink, Thais de Toledo ; Framil, Juliana Valéria de Souza ; Galleti, Karine Vusberg ; Fante, Alice Lima ; Fonseca, Maria Fernanda Mota ; Watanabe, Andreia ; Paula, Camila Sanson Yoshino de ; Palandri, Giovanna Gavros ; Leal, Gabriela Nunes ; Diniz, Maria de Fatima Rodrigues ; Pinho, João Renato Rebello ; Silva, Clovis Artur ; Marques, Heloisa Helena de Sousa ; Rossi Junior, Alfio ; Delgado, Artur Figueiredo ; Andrade, Anarella Penha Meirelles de ; Schvartsman, Claudio ; Sabino, Ester Cerdeira ; Rocha, Mussya Cisotto ; Kanunfre, Kelly Aparecida ; Okay, Thelma Suely ; Carneiro-Sampaio, Magda Maria Sales ; Jorge, Patricia Palmeira Daenekas .
OBJECTIVES: To assess the outcomes of pediatric patients with laboratory-confirmed coronavirus disease (COVID-19) with or without multisystem inflammatory syndrome in children (MIS-C). METHODS: This cross-sectional study included 471 samples collected from 371 patients (age<18 years) suspected of having severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The study group comprised 66/371 (18%) laboratory-confirmed pediatric COVID-19 patients: 61 (92.5%) patients tested positive on real-time reverse transcription-polymerase chain reaction tests for SARS-CoV-2, and 5 (7.5%) patients tested positive on serological tests. MIS-C was diagnosed according to the criteria of the Center for Disease Control. RESULTS: MIS-C was diagnosed in 6/66 (9%) patients. The frequencies of diarrhea, vomiting, and/or abdominal pain (67% vs. 22%, p=0.034); pediatric SARS (67% vs. 13%, p=0.008); hypoxemia (83% vs. 23%, p=0.006); and arterial hypotension (50% vs. 3%, p=0.004) were significantly higher in patients with MIS-C than in those without MIS-C. The frequencies of C-reactive protein levels >50 mg/L (83% vs. 25%, p=0.008) and D-dimer levels >1000 ng/mL (100% vs. 40%, p=0.007) and the median D-dimer, troponin T, and ferritin levels (p<0.05) were significantly higher in patients with MIS-C. The frequencies of pediatric intensive care unit admission (100% vs. 60%, p=0.003), mechanical ventilation (83% vs. 7%, p<0.001), vasoactive agent use (83% vs. 3%, p<0.001), shock (83% vs. 5%, p<0.001), cardiac abnormalities (100% vs. 2%, p<0.001), and death (67% vs. 3%, p<0.001) were also significantly higher in patients with MIS-C. Similarly, the frequencies of oxygen therapy (100% vs. 33%, p=0.003), intravenous immunoglobulin therapy (67% vs. 2%, p<0.001), aspirin therapy (50% vs. 0%, p<0.001), and current acute renal replacement therapy (50% vs. 2%, p=0.002) were also significantly higher in patients with MIS-C. Logistic regression analysis showed that the presence of MIS-C was significantly associated with gastrointestinal manifestations [odds ratio (OR)=10.98; 95%CI (95% confidence interval)=1.20-100.86; p=0.034] and hypoxemia [OR=16.85; 95%CI=1.34-211.80; p=0.029]. Further univariate analysis showed a positive association between MIS-C and death [OR=58.00; 95%CI=6.39-526.79; p<0.0001]. CONCLUSIONS: Pediatric patients with laboratory-confirmed COVID-19 with MIS-C had a severe clinical spectrum with a high mortality rate. Our study emphasizes the importance of investigating MIS-C in pediatric patients with COVID-19 presenting with gastrointestinal involvement and hypoxemia.
4. Influence of growth hormone replacement on neurological and psychomotor development. Case report
Einstein (São Paulo) 2018, Volume 16 N. 2 elocation eRC3961
ABSTRACT The height response to the use of growth hormone in short height cases has already been confirmed in the literature. The influence of the insulin-like growth factor 1 (GH-IGF1) axis components on development, function, regeneration, neuroprotection, cognition, and motor functions has been evaluated in experimental studies and in adults with central nervous system lesions. However, there is still little research on the clinical impact of hormone replacement on neurological and psychomotor development. This report presents the case of a patient with excellent weight-height recovery and, even more surprisingly, neurological and psychomotor development in response to use of growth hormone. The result strengthens the correlation between experimental and clinical findings related to cerebral plasticity response to growth hormone in children. A preterm male patient with multiple health problems during the neonatal and young infancy period, who for six years presented with a relevant deficit in growth, bone maturation, and neurological and psychomotor development. At six years of age, he had low stature (z-score −6.89), low growth rate, and low weight (z-score −7.91). He was incapable of sustaining his axial weight, had not developed fine motor skills or sphincter control, and presented with dysfunctional swallowing and language. Supplementary tests showed low IGF-11 levels, with no changes on the image of the hypothalamus-pituitary region, and bone age consistent with three-year-old children — for a chronological age of six years and one month. Growth hormone replacement therapy had a strong impact on the weight-height recovery as well as on the neurological and psychomotor development of this child.
RESUMO A resposta estatural ao uso de hormônio do crescimento na baixa estatura já está comprovada na literatura. A influência dos componentes do eixo fator de crescimento semelhante à insulina tipo 1 (GH-IGF1) sobre desenvolvimento, função, regeneração, neuroproteção, cognição e funções motoras tem sido avaliada em estudos experimentais e em adultos com lesão de sistema nervoso central. No entanto, ainda são poucas as pesquisas sobre o impacto clínico da reposição hormonal no desenvolvimento neuropsicomotor. Este relato apresenta o caso de um paciente com excelente recuperação pôndero-estatural e, de forma ainda mais surpreendente, de desenvolvimento neuropsicomotor, em resposta ao uso de hormônio do crescimento. O resultado observado fortalece a correlação entre achados experimentais e clínicos, no que diz respeito à resposta da plasticidade cerebral ao hormônio do crescimento em crianças. Paciente do sexo masculino nasceu pré-termo com múltiplos agravos no período neonatal e de lactente jovem, e que, por 6 anos, apresentou deficit relevante do crescimento, na maturação óssea e do desenvolvimento neuropsicomotor. Aos 6 anos de idade, apresentava baixa estatura (escore Z de −6,89), baixa velocidade de crescimento e baixo peso (escore Z de −7,91). Era incapaz de sustentar o peso axial, não tinha desenvolvido habilidade motora fina e nem controle esfincteriano, e apresentava também disfunção na deglutição e na linguagem. Exames complementares mostraram IGF1 baixo, sem alterações na imagem da região hipotálamo-hipofisária e idade óssea compatível com 3 anos — para a idade cronológica de 6 anos e 1 mês. A terapia de reposição com hormônio do crescimento promoveu forte impacto na recuperação pôndero-estatural e também do desenvolvimento neuropsicomotor desta criança.
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