Australian paediatric doctors will change their approach to children with a little understood illness that causes blood vessels to become inflamed and in some cases leads to heart disease, following overseas reports that Covid-19 may be associated with the rare condition.
The UK’s National Health Service alerted doctors that more than a dozen children had been left in intensive care after developing toxic shock syndrome and in many, but not all of the cases, a disease of the blood vessels known as Kawasaki disease. Despite Kawasaki disease first being identified about 50 years ago, doctors still don’t know what causes it but speculate it may be triggered by childhood infections. It is the most common cause of acquired heart disease in children in developed countries, and most cases occur in children under five years.
NHS officials wrote to general practitioners urging them to refer children with symptoms of Kawasaki and toxic shock syndrome to hospital following a rise in children needing intensive care treatment.
Prof David Burgner, a paediatric and infectious diseases doctor with the Murdoch Children’s Research Institute in Melbourne, said before Covid-19 there would be about one case of Kawasaki disease reported in a child in Australia per day. Since the pandemic, emergency room presentations and general practitioner visits have dropped significantly as people stay inside and are less likely to catch many infections, but Kawasaki rates have remained unchanged, Burgner said.
Burgner stressed it was too early to suggest that Australian cases of the disease were increasing or related to Covid-19, but he said it would be essential to monitor cases more closely in light of data from overseas.
“Absolutely we will be looking at cases clinically very carefully and testing all children we see with Kawasaki for Covid-19 now,” Burgner said. He had heard of one case of the disease in a child with Covid-19 from the US, and reports of some cases from northern Italy. But Burgner said why data was only emerging now, and mostly from London, was intriguing. Kawasaki is more common in Asian children, but Burgner said he was not aware of any cases from China despite high rates of Covid-19 there.
“It’s increasingly recognised that Covid-19 hasn’t read the textbook about what it should be doing as a respiratory virus,” he said. “The adults who have been getting very unwell and dying in the second week around day seven have pathology results that show a lot is happening in the blood vessels in the lungs, rather than the air sacs themselves. Toxic shock syndrome and Kawasaki affects the blood vessels. So these severe symptoms in some children is in keeping with the idea this virus is unusual and causes lots of problems in blood vessels.”
But he urged parents not to panic, saying toxic shock syndrome and Kawasaki are extremely rare. Children with Kawasaki disease and toxic shock syndrome often have fever with a skin rash that does not change when it is pressed, and breathing difficulties. Children with those symptoms should immediately see a doctor, Burgner said.
“What’s different about these kids in the UK is they are also getting shock and that is a rare manifestation of Kawasaki,” Burgner said. “It looks like some of them have an unusual form of Kawasaki and that is why it is probably a manifestation of Covid-19. We will slightly change our approach to Kawasaki patients as a result.”
He stressed Kawasaki was treatable. Children are given intravenous immunoglobulin from donated blood, which reduces their chance of developing heart issues from one-in-four, to one-in-20. Children who do experience changes to their heart often see the issue resolve as they get older.
“We rarely have deaths from it, thankfully,” Burgner said.
Associate Prof Luregn Schlapbach, paediatric intensive care specialist at Queensland children’s hospital in Brisbane, stressed if a child developed toxic shock it was still much more likely to be the result of a common bacteria such as staph or strep. He added that Australia had good databases to monitor Covid-19 cases so when information came from elsewhere, cases could be examined more closely.
“We still need more data about what’s happening,” Schlapbach said. “But we know in rare cases Covid-19 has the effect of triggering a hyper-inflammatory response where the immune system almost goes berserk. Could these cases in the UK be a paediatric presentation of that? We don’t yet know.”
An intensive care specialist at Nepean hospital, Dr Ian Seppelt, said it was important parents knew that there were no reported in Australia.
“I honestly don’t know what to make of the report from the UK – it is reasonably vague, and is in the context of a high community prevalence,” he said. “I don’t think Australian parents need have any concerns about these reports at present … the British are not sure if this is Covid related or not.”
Paediatric infectious diseases specialist with Perth children’s hospital, Dr Asha Bowen agreed. Given Australia had so few virus cases, hospitals were also better prepared to care for children, she said.
“I am not aware of any children in Australia with Covid-19 being admitted to an ICU for management,” she said. “The majority of the children have been cared for by their families at home and have not needed hospital level care. Doctors sharing their observations like this is important so that we can be observant, prepared and provide reassurance as appropriate.”