South Bay baby first with virus, rare condition
Dr. Veena Jones was on her morning commute from her home in Menlo Park to her office at Lucile Packard Children’s Hospital in Palo Alto when she learned of lab test results that nearly jolted her to a stop right in the middle of El Camino Real.
The 6monthold patient she was on her way to release after treatment for a rare inflammatory condition called Kawasaki disease had tested positive for the coronavirus. It was March 16, just before the statewide shelterinplace order and long before there was any reason to consider a link between COVID19 and the feverish and inflammatory symptoms of Kawasaki disease.
Dr. Jones quickly conferred with her colleague, Dr. Roshni Mathew, a pediatric infectious disease specialist at Packard, to see if there was any precedent for this in the medical jour
nals. They found none because Jones had hit on the first recorded diagnosis of a child with both COVID19 and Kawasaki disease.
“That very day, I had a discussion with Dr. Mathew that we should share this with the rest of the world,” Jones told The Chronicle. Their paper, “COVID19 & Kawasaki Disease: Novel Virus & Novel Case” will be published in the Journal of Hospital Pediatrics in June. But it has been rushed into prepublication online and gained urgency in the past week when it was revealed that 73 children in New York had been hospitalized, with three fatalities, for a mysterious disease being described as “pediatric multisystem inflammatory syndrome.”
The New York children had tested positive for the coronavirus or its antibodies, but neither they nor Jones’ patient, a South Bay girl identified only as Zara, showed respiratory symptoms. She has since gone home and passed a 14day quarantine, and nobody knows yet whether her condition was the same as that of the children in New York, with additional cases having been reported in Chicago, Los Angeles, the United Kingdom and Spain.
“We don’t know exactly what these patients are presenting. All we know is that they look like Kawasaki disease because they have cardiac involvement,” said Dr. Mathew.
A disease that mainly affects children ages 1 to 4, Kawasaki is a hyperinflammatory condition whose cause has so far eluded doctors. It can also be found in children younger than 1, as was the case in Palo Alto.
Symptoms include rash, swelling or redness of the lips or throat, swollen lymph nodes, particularly in the neck, swelling of hands and feet, and pink eye. About 25% have “some changes” in their coronary arteries that can lead to an aneurysm, said Dr. Rachel Wattier, a UCSF specialist who cares for children with infectious disease.
Concerns mounted Monday after new reports surfaced out of New York that coronavirus inflammatory syndrome in children was causing heart and kidney failure. Medical experts in the Bay Area said that because of early intervention in the spread of the coronavirus, a cluster of children experiencing similar inflammatory syndromes as those seen in New York is unlikely in Northern California.
“COVID has been around now for a few months, and what we know is that children are not affected as much,” said Dr. Mathew. “Now, there is this information that we are getting that there is a subset of pediatric patients that are having this multisystem inflammatory condition. I don’t think anyone knows for sure if there is a clear link (to the coronavirus), but there is a suspicion of it.”
Nor is there a clear link between Kawasaki and the coronavirus.
Dr. Lyn Dos Santos, the pediatric clinical medical codirector at John Muir Health/ Stanford Children’s Health Joint Venture, said she normally sees 15 to 20 Kawasaki cases a year. Since January, she has seen about five cases. Two of those cases were children diagnosed in midMarch and April, but neither were coronavirus-positive, she said.
Kawasaki is a disease that is well known but not well understood, Wattier said.
“It’s a hyperinflammatory condition and it doesn’t have a specific known cause, though it’s thought to be associated as a postinfectious syndrome in a variety of different infections,” she said.
The baby’s doctors are careful to differentiate their patient from the clusters of cases in New York and elsewhere because she had classic Kawasaki disease, and none of the other children have received that diagnosis. But the symptoms are similar enough that there might be a connection somewhere. Mathew speculates that it could have been the coronavirus that triggered both the case of Kawasaki disease in Zara, and the cases of pediatric multisystem inflammatory syndrome elsewhere.
“The body has already seen the infection, but then the immune response goes into override,” she said. “We can say it is a suspicion,” added Jones, “but not definitively.”
There was no suspicion of either COVID19 or Kawasaki when Zara’s mother, identified as Mahera, brought her to the Mountain View clinic operated by the Sutter Health Palo Alto Medical Foundation on March 10. She was given medication for the fever and sent home, with instructions to watch for worsening symptoms. Three nights later, the baby was back with a body rash, redness of the eyes, and swollen hands and feet — all common symptoms of Kawasaki.
There is no definitive test for the disease, but a blood test revealed enough of the markers that she was transferred to Packard, which has a reputation for treating kids with rare afflictions. Kawasaki qualifies. Although more common in Japan, it afflicts between 4,000 and 5,000 children in America per year.
It was early in the pandemic and the patient would not then have been suspected of suffering from COVID19, but Packard had an early supply of tests and Zara received one as a precaution because she had a fever. She was then given a normal course of medication for Kawasaki, and her symptoms improved dramatically.
Two days after the test, the results came back positive for the coronavirus. It was the first positive test for the coronavirus at Packard and may have been the first in the nation or the world for both Kawasaki and COVID19.
“There was an element of surprise, and we had to put our heads together with a safe plan to send her home,” said Jones, who is affiliated with the Palo Alto Medical Foundation but works at Packard. “We had not been expecting this.”
Zara exhibited no upper respiratory symptoms, so after Jones carefully interviewed her mother, she was sent home with both mother and daughter instructed to maintain in quarantine for 14 days, which they did. Also requiring quarantine was Dr. Evie Huang, who’d spent more than half an hour treating Zara at the Mountain View clinic before Zara was tested. A contact history of the family was taken, and none had traveled or believed they had been in contact with anyone who had tested positive.
“Typically people get it from household contacts,” Mathew said. “At this point we just don’t know how she was exposed to it. It’s a mystery.”
Zara, meanwhile, is being monitored and has passed two echocardiograms in the past two months, and ultrasounds have been normal.
“She seems to be OK,” Jones said. “She has no symptoms of COVID.”