TRACKING
COMPLICATIONS OF COVID-19
Experts are assessing the rare effects and treatment of the coronavirus on young children
Doctors in B.C. are on the lookout for signs of unusual medical problems associated with COVID-19, but so far they are mercifully rare.
Nonetheless, headlines about emerging effects of the disease pop up daily, conveying warnings of lingering impacts on the brain, cardiac muscle damage, and an inflammatory response that attacks school-aged children, unhelpfully described in the New York media as “straight up fire” in the veins.
Children have mostly been spared the effects of the novel coronavirus SARS-CoV-2 here in B.C., with just one per cent of B.C. cases happening among children under 10 years old and about two per cent in those between 10 and 19, according to Dr. Kevin Harris, a pediatric cardiologist at the B.C. Children’s Hospital.
More than 2,500 cases of COVID-19 have been confirmed by testing in B.C.
Whether that means children are less susceptible to the disease or have similar infection rates but most don’t get symptoms isn’t quite clear, according to a recent study published in the medical journal The Lancet.
But the authors comment on the emergence of a pediatric complication associated with the disease characterized by acute multi-system inflammation similar to a rare illness called Kawasaki disease. Scientific American also detailed a lengthy list of organs that may be vulnerable to damage by the virus.
A handful of suspected cases of inflammatory response to COVID-19 in children are under investigation in B.C., said Harris.
Teams of specialists are continuously assessing new information on rare effects of the disease, collating that information and distributing it to health care providers across the province so that doctors can identify these complications when they arise.
“We’re actively working across departments, because these children can have different types of signs and symptoms, and we want to ensure that any child with signs of inflammation that may be related to COVID-19 is thoroughly investigated, treated and receives close follow up,” he said.
MULTISYSTEM INFLAMMATORY SYNDROME
Doctors noted a 30-fold increase in Kawasaki-like illness in the city of Bergamo at the peak of the pandemic in Italy. The symptoms — persistent fever, rash, swelling in the lymph nodes and extremities — were often accompanied by shock requiring hospitalization. Only two of 10 children also had severe respiratory symptoms usually associated with COVID-19, but eight of 10 tested positive for antibodies indicating that they had been infected by the virus.
Cases have been identified in the U.S., the United Kingdom, France and Switzerland, all countries with significant outbreaks of COVID-19.
Harris stressed that the illness — now called multisystem inflammatory syndrome — is very rare. That means parents should be vigilant, but not too anxious. The signs of this illness and the cardiac distress that comes with it present the sort of symptoms that would cause a parent to seek medical attention for a child.
Be on the lookout for vomiting, especially with blood,
We want to ensure that any child with signs of inflammation that may be related to COVID-19 is thoroughly investigated.”
Dr. Kevin Harris
diarrhea, abdominal pain, coughing and shortness of breath, blue lips, failure to produce tears or urine, and a fever that doesn’t respond to Tylenol or Advil, said Harris. Symptoms usually occur three to five weeks after the COVID-19 infection.
Only two studies on the syndrome have been published, so our understanding of the illness is still evolving. The good news is that heart function returned to normal in 25 of 35 patients by the time they were released from intensive care, according to the most recent study from Europe.
“So it’s encouraging that in most children, at least, it’s a very reversible condition,” he said.
COVID TOES
Itchy red rashes and purple-blue chilblain-like lesions on the feet and sometimes the fingers are suspected to be a symptom of inflammation associated with the novel coronavirus. The B.C. government’s 811 HealthLink service has recently been fielding more calls from parents concerned about “COVID toes.”
“These particular skin lesions seem to be a specific rash, and they’re usually seen in children or young adults and not associated with severe disease,” said Harris. “The skin lesions occur later in the evolution of the illness and include pain or itching about 30 per cent of the time.”
The lesions may be treated with a topical steroid and usually disappear in a week to 10 days.
DOES COVID-19 ATTACK YOUR HEART?
As early as February, doctors in China were reporting acute cardiac injury in severe cases of COVID-19, raising fears that the virus was directly attacking the heart.
This description of clinical features of the disease published by The Lancet was based on just 41 patients, six of whom had died, who were treated with a variety of drugs and strategies, none of which were particularly effective.
“We started off thinking this was like a bad form of the flu with fever and breathing problems,” said Dr. Andrew Krahn, head of UBC cardiology and president of the
Canadian Cardiovascular Society. “As the scale of things grew, we started to notice these (cardiac) problems around the edges of it.”
COVID-19-related cardiac cases have since coalesced into two groups.
Some otherwise healthy patients who just have COVID-19 do develop an inflammation of the heart called myocarditis, but it turns out to be quite rare.
More commonly, patients with chronic cardiovascular disease can find themselves in all kinds of trouble if COVID-19 impairs the functioning of their lungs.
“As you can imagine, a patient who already has a problem with their heart is very vulnerable and low oxygen levels are very bad for hearts,” said Krahn.
“Our biggest concern is the huge denominator of heart patients who get COVID and that tips them into crisis, more so than the small number of COVID patients who get some kind of unusual heart complications.”
As people begin to chafe under COVID-19 precautions and start to resume their lives, precautions for the most vulnerable people must remain robust, Krahn argues. That includes people with asthma, chronic obstructive pulmonary disease, kidney failure or heart failure.
“There’s no vaccine and no evidence that any of the medications being tested have any kind of preventative value,” he said. “People with an inherent vulnerability, when they get sick, they get sicker than young healthy people.”
Krahn stressed the importance of getting emergency care for symptoms of cardiac distress. Trips to hospital emergency rooms dropped by half when special measures were imposed to control the spread of the virus, and those numbers have only partly recovered.
“If you have chest pain, or symptoms of a stroke, you need to know that hospitals are safe places, with strict measures to prevent people from being exposed to COVID-19,” he said. “We can only assume that if fewer people are coming in, that will mean more people dying at home.”
BRAIN INJURY
A report in the New England Journal of Medicine detailing five cases of stroke in COVID-19 patients younger than 50 sparked a flurry of headlines earlier this month, including speculation that the virus is attacking the brains of otherwise healthy, young people.
Dr. Cheryl Wellington, a leading researcher at the Djavad Mowafaghian Centre for Brain Health, is anxious to pump the brakes on that narrative.
“The biggest message here is that it’s really premature to provide the hard and fast facts on the prevalence of brain disorders,” she said. “We just don’t have the data.”
Wellington and her colleagues are looking hard at the possibilities in a collaboration with physicians at Vancouver General Hospital, Royal Columbian and Surrey Memorial that involves nearly every seriously ill COVID-19 patient in the province.
“We’ve been tremendously successful in barely missing any patients at all,” she said.
Using cutting edge techniques honed by research on brain injuries caused by cardiac arrest, multiple sclerosis and concussion, Wellington’s group is studying daily blood samples from patients in intensive care for signs of damage to neurons and the blood-brain barrier.
“These include protein such as neurofilament light, which is a marker of axonal damage,” she explained. “It’s very sensitive and it tells you there’s definitely damage to neurons, though it doesn’t tell us why.”
Reports that some patients can lose their sense of smell and taste suggests the virus may be having an effect on the brain. The olfactory nerves go directly into the brain and could provide the virus with a point of entry to the central nervous system, she said.
“A related virus — SARS — does seem able to access the brain through the olfactory system in mice, but we don’t know if SARS-CoV-2 does the same thing,” said Wellington. “We do know that the brain has many receptors for the virus so that once it gets in there, by whatever route, it could take hold and cause some damage.”
Doctors have observed that some COVID-19 patients develop blood clots and that alone could have a serious impact on the brain, by triggering a stroke.
The researchers will be looking for other factors that may influence how the virus affects the nervous system, including genetic variations, age and the severity of their initial illness.
A network of neurologists, psychologists, psychiatrists and epidemiologists is collaborating on a plan to follow their patients for two to three years after they recover from COVID-19.
“We already have grants in place that allow us to follow them for 12 months, but cognitive changes to the brain can develop quite slowly,” she said.
PREGNANCY IN THE TIME OF PANDEMIC
Doctors across Canada are monitoring the health of women who have had COVID-19 and are pregnant or have recently given birth, along with the health of their babies.
It’s not because babies are known to be at risk of ill effects from the virus, but out of an abundance of caution.
Kawasaki-like symptoms, seen in school-aged children, have not been reported in newborns.
As part of the CANCOVID-Preg national surveillance program, 22 women in B.C. are being given monthly ultrasounds to ensure that their babies are progressing normally.
Within one to two hours of birth, the babies are tested for SARS-CoV-2 and then again after 24 hours. The health of the mothers and babies will be monitored for six weeks after birth.
The study is being led by Dr. Deborah Money, a UBC professor and faculty of medicine executive vice-dean.
Evidence that mothers can pass the virus to their unborn child — called vertical transmission — is “elusive,” said study collaborator Dr. Julie van Schalkwyk, head of obstetrics and gynecology at B.C. Women’s Hospital and Health Centre.
“There have been approximately 18 reports — in quotations — of positive babies born, but the validity of the testing is questionable,” she said. “The virus does not appear to impact pregnant women any more than any non-pregnant women of the same age, and there does not appear to be a significant increase in preterm birth or in intrauterine growth restriction.”
As the scale of things grew, we started to notice these (cardiac) problems.”
Dr. Andrew Krahn