Pilot Study Analyzing Combination of Point-of-Care Echocardiography and Clinical Correlation in Unveiling Cryptic Multi-Inflammatory Syndrome in Neonates during Coronavirus Disease 2019 Pandemic

Abstract

Introduction: Coronavirus disease 2019 (COVID-19), an extremely contagious pandemic, caused by the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), originated from Wuhan, Hubei province, in China in December 2019. From April 2020, pediatric epicenters in Europe and the USA reported a new clinical spectrum called “pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2” or “multisystem inflammatory syndrome in children,” respectively. The unique feature was immune-mediated multiorgan dysfunction in response to previous COVID exposure. This case series aims to prospectively analyze the incidence, severity, and patterns of cardiac involvement in sick neonates exposed to perinatal SARS-CoV-2 in India. Methods: Twelve neonates presenting with very early-onset multi-inflammatory syndrome in neonates (MIS-N) at two tertiary care centers in India were included. Their clinical profiles, echocardiography findings, and treatment details were recorded. Results: Clinical presentations varied from loss of fetal movement, perinatal depression, prematurity, unusual respiratory distress syndrome, cardiogenic shock, arrhythmias, and multi-organ dysfunction. Echocardiographic markers were severe pulmonary hypertension, significant valvular regurgitation, cardiomegaly, biventricular dysfunction, neonatal coronary artery aneurysms, intracardiac thrombus, pericardial effusion, and arrhythmias. All babies, except one, had positive COVID IgG antibody and high inflammatory markers. Two mothers had antenatal primary contact with COVID patients 4–6 weeks prior to delivery, while 3 (25%) had documented mild COVID infection. All neonates were started on immunosuppressive therapy. Clinical stabilization and declining inflammatory markers were observed within 48–96 h of targeted therapy. All neonates (except one) recovered and were discharged in a stable condition. Follow-up available up to 9 months demonstrated persistent clinical, laboratory, and echocardiographic recovery in all survivors. Conclusion: Infection of pregnant mothers during community transmission during the two COVID-19 waves in India appears to have caused significant immune dysregulation and cardiac damage in neonates. Echocardiography detected significant damage to coronary arteries, pulmonary arterial hypertension, intracardiac thrombus, ventricular dysfunction, and incompetence of valve apparatus in MIS-N. Aggressive immunomodulators with antiplatelet drugs proved lifesaving. Echocardiography is an inexpensive, readily available imaging modality. It should be utilized to save this fragile, extremely special cohort.