New pediatric syndrome may be linked to coronavirus

  • COVID toes can be a sign of COVID-19.

    COVID toes can be a sign of COVID-19. Courtesy of Northwestern Medical Group

 
By Dr. Eve Glazier and Dr. Elizabeth Ko
Posted6/7/2020 6:00 AM

Q: What can you tell me about Kawasaki disease? I read that children who had COVID-19 are getting it. But I thought children were supposedly safe from the virus. Why has that changed?

A: You've broached two important topics, and we'll take them in reverse order. As we've mentioned here before, every bit of information about the novel coronavirus, which we all first heard about in the final days of 2019, has been learned in real time. No one had ever seen this specific virus before, so everything about it was a mystery. This included its genetic and physical makeup, how it's transmitted, who it affects, how it enters the body and how the body responds once an infection is launched.

                                                                                                                                                                                                                       
 

Our understanding of the virus and COVID-19, which is the disease that it causes, continues to evolve on a daily, and sometimes hourly, basis.

You're correct that at the start of the pandemic, COVID-19 was known primarily as a viral pneumonia. It's also true that doctors saw significantly fewer cases in children than among adults. People 18 and younger have accounted for only 2% of confirmed cases of COVID-19, and they often experience mild symptoms.

However, as doctors continue to treat patients, the knowledge base about the disease and its many symptoms expands. Now, emerging data points to the novel coronavirus as the cause of a potentially dangerous inflammatory condition in children. Referred to in the U.S. as multisystem inflammatory syndrome in children, or MIS-C, it involves inflammation in the heart, blood vessels, eyes and skin.

Although it's similar to Kawasaki disease, a rare inflammatory illness often seen in infants and young children, it's not the same thing. Kawasaki disease is a condition in which high levels of inflammation affect the blood vessels that serve the heart. Untreated, it can result in damage that is life-threatening.

Symptoms of MIS-C include fever, swollen lymph nodes in the neck, a skin rash, pink eye, redness of the lips and tongue, intestinal distress, inflammation leading to poor organ function that can include the kidneys or heart, inflammation of the blood vessels and joint pain. The two most common symptoms of COVID-19 in adults, which are shortness of breath and a dry, hacking cough, often don't show up in children.

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Doctors in 19 states have reported cases of the new syndrome, including hard-hit New York, New Jersey and California. The condition is also being seen in Europe and the United Kingdom.

Researchers don't yet know what triggers the inflammatory syndrome, which is not caused directly by the novel coronavirus. However, many of the affected children are testing positive for COVID-19 antibodies. This suggests a link between MIS-C and the novel coronavirus. Some researchers suspect the syndrome is a delayed response by the immune system.

So far, the syndrome is rare, and most children are not seriously affected. However, new cases continue to emerge. This has prompted the Centers for Disease Control and Prevention to prepare a national alert with detailed information on symptoms, so that the syndrome can be quickly identified and treated.

Q: My husband started having a lot of stomach pain and was also feeling queasy. Needless to say, I feared the worst -- cancer -- but, instead, his doctor says it's gastroparesis. Is it dangerous? What's the best treatment?

                                                                                                                                                                                                                       
 

A: Gastroparesis is the name of a condition in which the stomach is slow to empty its contents into the small intestine. This isn't due to any type of blockage. Instead, as the name of the condition suggests ("gastro" refers to the stomach, and "paresis" indicates nerve-related muscle weakness), the cause is a malfunction in the nerves that serve the region. This includes the vagus nerve, which animates the stomach muscles and helps send food to the small intestine.

Symptoms include the pain and nausea your husband experienced, as well as poor appetite, feeling full after only small amounts of food or drink, heartburn and unintended weight loss.

When functioning properly, the stomach takes about four hours to saturate its contents with gastric juices, break everything up into smaller particles and pass the majority of it along to the small intestine. For people living with gastroparesis, the process takes significantly longer. The result is delayed digestion, which can lead to a range of problems.

Food that remains in the stomach for too long is susceptible to fermentation, which can encourage the growth of bacteria. The condition can interfere with appetite and sometimes leads to malnutrition. When the contents of the stomach are stalled, they can coagulate into a mass known as a bezoar, which can cause a blockage. And for people living with diabetes, the delayed movement of food from the stomach to the small intestine can interfere with glucose control.

Gastroparesis is often seen in people living with diabetes, which can cause nerve damage. It may also arise as the result of viral stomach infections, hypothyroidism, certain autoimmune or neurological disorders, or surgical injury. It's a known (albeit rare) side effect of medications such as opioids, antihistamines, tricyclic antidepressants and calcium-channel blockers, which can impede digestion.

Diet is important in the management of gastroparesis, with an emphasis on nutrient density and ease of digestion. Patients are asked to eat small meals of soft, well-cooked food, and to avoid high-fat foods, which delay the emptying of the stomach. Foods high in fiber are difficult to digest and are also limited, or in some cases eliminated.

Fruits and vegetables, which contain nondigestible fiber, should be served cooked, and in some cases pureed. For instance, instead of an apple, a patient will have a small serving of applesauce. They are also encouraged drink liquids that contain glucose and electrolytes, including clear soups, low-fat broths, low-fiber fruit and vegetable juices, or sports drinks.

Because glucose control and malnutrition are both a challenge, many people with gastroparesis work with a registered dietitian.

When the condition can't be managed with diet, medications that cause the stomach to contract and emerging therapies such as electrical gastric stimulation may be an option. In severe cases, surgery may be necessary.

We recommend your husband seek out a gastroenterologist to fully assess his case and plan his treatment.

• Dr. Eve Glazier is an internist and associate professor of medicine at UCLA Health. Dr. Elizabeth Ko is an internist and assistant professor of medicine at UCLA Health. Send your questions to askthedoctors@mednet.ucla.edu.

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