Further cases of PIMS-TS likely in Australia

Evelyn Lewin

8/09/2020 2:25:22 PM

Though rare, it is possible more children may have developed the inflammatory syndrome.

Young boy with a face mask
PIMS-TS tends to occur in primary-school-aged children or early adolescence, and is more common in boys, obese children, and those from ethnicities other than Anglo-European.

On 3 September, Safer Care Victoria issued an alert that cases of Paediatric Inflammatory Multisystem Syndrome Temporally associated with SARS-CoV-2 (PIMS-TS) have been reported in Victoria.
Professor David Burgner is a paediatric infectious diseases clinician scientist at the Murdoch Children’s Research Institute (MCRI) who has been working with Safer Care Victoria on this issue.
He told newsGP there have been ‘a couple’ of confirmed cases of PIMS-TS in Australia, as well as ‘a handful’ of cases that are still under investigation.
‘Mostly, as you would expect, they’re in Victoria because we’ve had the highest level of transmission and infection,’ he said.
‘So that’s why we were asked to work with Safer Care Victoria to put out the alert, so that doctors would be aware of the possibility, and just to highlight some of the salient clinical features.’
Professor Burgner says PIMS-TS, which is also referred to as multisystem inflammatory syndrome in children (MIS–C) in the US, causes a condition similar to, but distinct from, Kawasaki disease.
He says clinicians should consider PIMS-TS in a child with fever, abdominal pain, rash, red eyes and tachycardia (the full case definition is outlined below).
PIMS-TS has been reported in cases ranging in age from infancy through to ‘a few isolated reports’ in adults, according to Professor Burgner, who says it tends to occur in primary-school-aged children or early adolescence, with a median age of nine years.
The condition is also more common in boys, obese children, and those from ethnicities other than Anglo-European.
Professor Burgner is not surprised there have been documented cases of PIMS-TS in Australia.
‘When this first was reported overseas in April–May, we said it was likely that if transmission went up in Australia, we would see a handful of cases,’ he said.
‘And, as predicted, that’s what’s happened.’
Professor Burgner explains that PIMS-TS is a post-infectious phenomenon that tends to occur roughly four weeks after initial exposure to SARS-CoV-2.
‘So about now is when we’re expecting to see a few cases,’ he said.
Even in settings where there are several more cases of COVID-19, there have only been ‘relatively small’ numbers of cases of PIMS-TS, Professor Burgner said
‘It’s thought that there’s possibly a thousand or so cases in total worldwide of PIMS-TS,’ he said.
Despite its rarity, Professor Burgner believes it is important the condition is on the Australia’s healthcare radar, particularly in areas with high transmission of SARS-CoV-2.
‘The important message is for people to be – to use an old cliché – aware but not alarmed,’ he said.
‘It’s a very unlikely diagnosis, but it’s important that doctors on the frontline seeing children just bear it in mind and are aware of the clinical features.’

Professor David Burgner wants healthcare professionals to be ‘aware but not alarmed’ about PIMS-TS in Australia.

Professor Burgner believes the chances of an individual GP coming across a case of PIMS-TS is ‘very low’. However, children with the condition can deteriorate rapidly due to ‘quite marked’ myocardial dysfunction that can lead to shock.
‘So it’s important these children are picked up [early] and managed,’ he said.
If a child has suspected features of PIMS-TS and is tachycardic, that may be a sign of compensated shock.
‘If [a clinician is] worried about some of those features, they should refer urgently to a paediatric emergency department and raise the possibility,’ Professor Burgner said.
Children with asymptomatic COVID-19, or those who only experience mild symptoms, can still develop PIMS-TS.
‘A number of these cases worldwide weren’t even aware that they’d had exposure to the virus,’ Professor Burgner said.
‘It’s only when they presented with PIMS-TS that they realised, and it was diagnosed on serology rather than on PCR.’
He does not believe severity of illness of COVID-19, or the presence or absence of symptoms, affects a person’s chances of developing PIMS-TS.
‘If it was a clear relationship between having severe COVID acutely and then being more likely to have PIMS–TS, then I guess you’d expect most of the cases to have a history of symptomatic COVID,’ Professor Burgner said.
‘But we’re not seeing that, so I don’t think it’s following those lines.’
Professor Burgner says the long-term effects of PIMS-TS are unknown, and for now children with the condition ‘seem to recover well, at least acutely’.
‘A proportion have dilation of the coronary arteries as we see in Kawasaki disease [KD], but they seem to be less dramatic than we see in KD and seem to resolve more quickly,’ he said.
‘Whether there’s ongoing long-term cardiovascular implications or other implications – that’s a really important question for COVID overall, and for this small group of children – so there’s a lot of research going on.’
In terms of mortality, Professor Burgner says there have been a ‘small’ number of deaths related to PIMS-TS overseas.
‘I think there’ve been around 10 deaths reported overseas, mainly in the US and the UK,’ he said.
‘There haven’t been any reported recently as far as I’m aware, which may reflect more familiarity [with the condition] and earlier diagnosis, that’s speculative.
‘Over half [of the children with PIMS-TS] need intensive care, so these children are quite unwell, but globally we’re getting more familiar with the condition and how to treat it.
‘Hopefully, we wont see any further deaths.’
Case definition of PIMS-TS
The case definition is children and adolescents aged 0–19 with fever for more than three days who have two of the following: 

  • Rash or bilateral non-purulent conjunctivitis or muco-cutaneous inflammation signs (oral, hands or feet)
  • Hypotension or shock
  • Features of myocardial dysfunction, pericarditis, valvulitis, or coronary abnormalities (including ECHO findings or elevated Troponin/NT-proBNP)
  • Evidence of coagulopathy (by PT, PTT, elevated d-Dimers)
  • Acute gastrointestinal problems (diarrhoea, vomiting, or abdominal pain)
  • Elevated markers of inflammation such as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), or procalcitonin 
  • No other obvious microbial cause of inflammation, including bacterial sepsis, staphylococcal or streptococcal shock syndromes 
  • Evidence of COVID-19 (RT-PCR, antigen test or serology positive), or likely contact with patients with COVID-19 
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