Most children who developed the rare pediatric inflammatory multisystem syndrome temporally associated with SARS-COV-2 (PIMS-TS) had regained practically normal health 6 months after the initial onset, in a retrospective observational cohort study reported in Lancet Child & Adolescent Health (2021; https://doi.org/10.1016/S2352-4642(21)00138-3). But many patients faced persisting emotional dysfunction and mild loss of physical performance.
"When these children came in to us, they had a number of different issues and we didn't know what the long-term consequences of them were," said study author Karyn Moshal, MBChB, MRCP(UK), MRCPCH, DTM+H, consultant in Paediatric Infectious Diseases at Great Ormond Street Hospital, London.
Children entering the study had been weak, had cardiac and ENT abnormalities, had speech and language deficits, and also kidney and neurological abnormalities as well as gastrointestinal symptoms, she told Oncology Times. To document the natural history and long-term consequences of PIMS-TS, a multidisciplinary team followed 46 patients for 6 months.
First Data
As the condition had only emerged in 2020 during the COVID-19 pandemic, the study had provided early data to guide clinicians and families about the longer-term effects of PIMS-TS. The researchers had expected to find a long-term impact on cardiac function, but this was not seen.
"What we did see was profound weakness, which continued to take a period of time to resolve," noted Moshal. "We also found that these children had neurological difficulties, which are quite subtle and were picked up because we have very specialist neurologists."
The researchers found in the long term that the neurological issues continued to some extent, including a condition she described as cognitive fatigue.
"They get tired very quickly and their brains get tired-which is important for them in schooling," she said. "Some of them had nystagmus, some had continued weakness and neuropathy. But, on the whole, these have got better over the 6-month period."
Study Details
A total of 46 children under 18 years who met the PIMS-TS diagnostic criteria and had been admitted to Great Ormond Street Hospital in London (between April and September 2020) were followed up at 6 weeks and 6 months after admission. Biochemical and functional outcomes were analyzed. The median age was 10.2 years; 30 patients were male, 16 were female; and eight patients had pre-existing comorbidities. All patients had elevated markers of systemic inflammation at baseline. None of the patients died.
By 6 months, systemic inflammation had resolved in all but one patient. Ninety percent of patients who had positive SARS-CoV-2 IgG antibodies within 6 weeks of admission continued to be seropositive at 6 months. Echocardiograms were normal in most patients by 6 months, and gastrointestinal symptoms reported in nearly all of the patients at onset were present in only six of them after 6 months.
Renal, hematological, and otolaryngological findings had also largely resolved by 6 months. Minor neurological abnormalities had been detected in half of the patients at 6 weeks and in 39 percent of them at 6 months. But the researchers found only minimal functional impairment at 6 months. All but one of the patients were back at school after this time period.
"These children are-to all intents and purposes-almost back to normal. I'm very optimistic-but cautiously, because obviously you don't know if there are going to be consequences down the line," said Moshal. The gastrointestinal symptoms and signs that had been present among these children on admission were not seen after 6 months, though she noted that vigilance was still needed because they had been "very immunosuppressed."
"We have also seen some quite profound psychological effects," she said, which had not been surprising. "What I found surprising was that there seemed to be a huge amount of stigma and shame being felt by these children and these families in addition to depression and anxiety and feelings of isolation."
Moshal regarded counseling and peer support groups as key to tackling the emotional difficulties faced by these children, especially in the face of the isolation experienced because of coronavirus restrictions.
Many patients had less tolerance to exercise that had persisted to some extent, said Moshal, but had slowly been improving. She could not establish the extent to which pandemic mitigation restrictions had contributed to the lack of physical stamina.
"What we have seen-anecdotally-is that children who were very fit prior to becoming unwell have recovered more quickly than those children who weren't," she said.
In common with the distribution of coronavirus infection itself, four-fifths of the study children with SARS-CoV-2 PIMS-TS came from minority ethnic communities. But Moshal was unable to distinguish whether the disease pattern had been influenced by socioeconomic, ethnic, or other factors.
She gave a reassuring overall message about the prospects of most children who initially encountered the syndrome, but she stressed the need to involve a broad range of health professionals to help these children recover speedily.
Co-author of the study, Justin Penner MD, also from Great Ormond Street Hospital, noted, "As PIMS-TS is a very rare complication of COVID-19 in children, our study included a small number of children from one hospital. Nevertheless, these findings can hopefully signal cautious optimism that many of the most severe effects of PIMS appear to resolve within 6 months. However, the persisting fatigue, difficulty exercising, and mental health effects we saw in some children, which can interfere with daily lives, must be closely monitored, and patients should continue to be supported by medical teams with a range of specialisms."
Peter M. Goodwin is a contributing writer.