An outbreak of severe Kawasaki-like disease at the Italian epicentre of the SARS-CoV-2 epidemic: an observational cohort study.
This paper reviewed all of the patients who were diagnosed with a Kawasaki-like disease in a single centre in the past 5 years. The patients were divided according to symptomatic presentation to either before (group 1 comprised of 19 patients diagnosed over 5 years), or after (group 2 comprising ten patients diagnosed over 1 month, 5 classic, 5 incomplete) the beginning of the SARS-CoV-2 epidemic. The change in number of presentations represented a 30-fold increased incidence of Kawasaki-like disease at this institution. To rule out the possible effect of number of referrals to the emergency department in different periods, the authors compared the number of ED presentations prior (mean of 1642 (SD 280) /month) to the month after (283 patients in the study period) the start of CoVid-19 epidemic. They also checked the addresses of all patients to make sure that the observed changes were not the result of alterations in the geographic catchment during the CoVid-19 outbreak. Similar findings have also been reported in France (Toubiana et al.) and the UK (Riphagen et al.).
This is a very comprehensive and well written paper with a very good discussion. One major issue with this paper is that Kawasaki disease does not have a diagnostic test, but rather the diagnosis is based on clinical and laboratory criteria. Furthermore, the pathophysiology of Kawasaki disease has not been fully elucidated. This means that these case reports may represent Kawasaki disease or they may represent a multisystem inflammatory disease that has a large overlap with Kawasaki disease. Indeed, there are marked differences between the two groups with the second (CoVId-19) being older, having more markers for severity (abnormal echocardiograms etc.) and higher rates of sepsis. However, this sematic point does not detract from the importance of this paper in alerting the world to this serious, though rare (1:1000 exposed) complication of SARS-CoVid-19 in children.
Riphagen S, Gomez X, Gonzalez-Martinez C, Wilkinson N, Theocharis P. Hyperinflammatory shock in children during COVID-19 pandemic. Lancet. 2020;395(10237):1607-1608.
Toubiana J, Poirault C, Corsia A, et al. Kawasaki-like multisystem inflammatory syndrome in children during the covid-19 pandemic in Paris, France: prospective observational study. BMJ. 2020;369:m2094.
Reviewed by Dr. Donald Hannah