26-05-2021

WedneSday, May 26, 2021
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Children may overcome serious symptoms after catching Covid
PaM BeLLUCk
Children who get sick from the rare but
serious Covid-related inflammatory
syndrome may surmount their most
significant symptoms within six months,
but they may still have muscle weakness
and emotional difficulties at that time, a
new small study suggests.
Published in the journal Lancet Child
and Adolescent Health on Monday, the
study appears to be the first detailed look at
the health status of children six months
after they were hospitalized with the
condition, called Multisystem
Inflammatory Syndrome in Children. The
syndrome typically emerges two weeks to
six weeks after a Covid-19 infection that is
often quite mild, and it can result in
hospitalizations for children with severe
symptoms involving the heart and several
other organs.
A major question has been whether
children who survive MIS-C will end up
with lasting organ damage or other health
problems. The new study, of 46 children
under 18 who were admitted to a London
hospital for MIS-C (it has a different name
and abbreviation, PIMS-TS, in Britain),
suggests that many of the most serious
problems can resolve with time.
"To be honest, I think we all didn't know
what to expect," said Dr. Justin Penner, a
pediatric infectious disease physician at the
hospital involved in the study, Great
Ormond Street Hospital, known as GOSH.
"We didn't know which body systems
would require assistance or become a
problem one month, three months, six
months down the line."
The children in the study were
hospitalized between April 4 and Sept. 1,
2020, part of the first wave of the
inflammatory syndrome. Many were quite
Most children with MIS-C did not have debilitating health issues.
sick. They all had systemic inflammation,
and most had symptoms involving
multiple organ systems, such as the heart,
kidneys or circulatory system. Forty-five
children had gastrointestinal symptoms,
and 24 had neurological symptoms such as
confusion, memory problems,
hallucinations, headaches or problems
with balance or muscle control.
Sixteen of the children were placed on
ventilators, 22 needed medication to help
their hearts pump more effectively and 40
were treated with immunotherapies like
intravenous immunoglobulin. All survived.
Six months after they were discharged
from the hospital, only one child still had
systemic inflammation, just two children
had heart abnormalities and six children
had gastrointestinal symptoms. All but one
child were able to resume school, either
virtually or in person.
Still, 18 of the children were experiencing
Photo: Getty Images
muscle weakness and fatigue, scoring in
the bottom 3 percent for their age and sex
on the six-minute walking test, a standard
test of endurance and aerobic capacity.
And 15 children were experiencing
emotional difficulties like anxiety or severe
mood changes, according to
questionnaires answered by either the
parents or the children.
In the United States, 3,742 young people
age 20 and under have developed the
syndrome, and 35 have died, according to
the most recent data from the Centers for
Disease Control and Prevention. A major
study of long-term outcomes has already
recruited 600 children and will follow
them for five years, according to a leader of
that effort, Dr. Jane Newburger, associate
chief for academic affairs in the cardiology
department at Boston Children's Hospital.
Dr. Newburger, who was not involved in
the British report, called it a "small but
important study" that "contributes new
information to the knowledge gap about
long-term effects of MIS-C."
She and the authors themselves noted
that there were limitations to the findings
because the children in the study were not
compared with a control group of children
without MIS-C or those with other
illnesses. It is unclear, for example, if their
emotional problems and muscle weakness
were the result of the syndrome, the
process of being hospitalized for an illness
or other stressors during this time. "Mental
health and physical conditioning have
taken a hit in children and adolescents in
general during the pandemic," Dr.
Newburger said.
Dr. Srinivas Murthy, an associate
professor of pediatrics at the University of
British Columbia, who was not involved in
the new study, said it might be difficult to
tease out which residual problems were
directly attributable to the syndrome and
which might have resulted from any
critical illness. He said the fact that some of
the children still had trouble with muscle
weakness and endurance could yield
important lessons, because such issues can
require a different kind of a care including
"post-hospitalization rehabilitation
opportunities."
In fact, Dr. Penner said, the team at
Great Ormond Street Hospital has made
changes in the treatment of children
hospitalized with the syndrome since the
fall, because it has recognized "how
affected their muscles are at the onset and
how profoundly fatigued and weakened
these kids are."
In the hospital, for example, "often just
transferring from the bed to the toilet is
exceptionally difficult for these children,"
he said.
The hospital now has a more concerted
focus on providing the children in-hospital
physical therapy and work with
musculoskeletal therapists, he said, and it
sends them home with an individualized
rehabilitation plan that is linked to an app.
"We've also involved our occupational
therapists, and we've developed a fatigue
program that's run once a month where
the parents dial in for a group session," Dr.
Penner said. "I think the main message
that we give them is to avoid this boomand-bust
cycle, where the kids try to do the
things they used to do at full speed and
then they kind of crash afterwards - as
opposed to a gradual increase of activity
back to their normal state."
The hospital's team is continuing to
follow the children's health. One potential
concern is whether kidney or
gastrointestinal problems might emerge
later, which can occur after other critical
illnesses, the study's authors wrote. The
team also hopes to conduct neurocognitive
evaluations and other neurological testing,
Dr. Penner said.
"We don't know what the longer-term
outcomes will be," Dr. Penner said. But for
now, he added, "being able to relay at least
what we've seen so far to parents has really
enabled us to alleviate some of their
anxieties about this black box of unknowns
with regard to this new condition."
The latest coronavirus
comes from dogs
eMILy antheS
Scientists have discovered a new canine
coronavirus in a child who was
hospitalized with pneumonia in Malaysia
in 2018. If the virus is confirmed to be a
human pathogen, it would be the eighth
coronavirus, and the first canine
coronavirus, known to cause disease in
humans.
It is not yet clear whether this specific
virus poses a serious threat to humans,
the researchers stress. The study does not
prove that the pneumonia was caused by
the virus, which may not be capable of
spreading between people. But the
finding, which was published on
Thursday in the journal Clinical
Infectious Diseases, highlights the need
to more proactively search for viruses
that could jump from animals into
humans, the scientists said.
"I think the key message here is that
these things are probably happening all
over the world, where people come in
contact with animals, especially intense
contact, and we're not picking them up,"
said Dr. Gregory Gray, an infectious
disease epidemiologist at Duke
University who is one of the study's
authors. "We should be looking for these
things. If we can catch them early and
find out that these viruses are successful
in the human host, then we can mitigate
them before they become a pandemic
virus." Seven coronaviruses are currently
known to infect humans. In addition to
SARS-CoV-2, which is the virus that
causes Covid-19, there are coronaviruses
that cause SARS, MERS and the common
cold. Many of these viruses are believed
to have originated in bats, but can jump
from bats to humans, either directly or
after a stopover in another animal host.
Scientists have known for decades that
coronaviruses can cause disease in dogs,
but until now there has been no evidence
that canine coronaviruses can infect
people.
Scientists still cannot be certain
whether it was a dog that transmitted the
new virus to the patient; it likely was a
dog, Dr. Gray said, but another,
intermediate animal host, including a cat,
may have been responsible.
(There is also no evidence that dogs
transmit SARS-CoV-2 to humans,
although both cats and dogs can catch it.)
The new research began last spring,
after the pandemic hit, when Dr. Gray
asked Leshan Xiu, a doctoral student, to
develop a screening tool that could help
them detect all kinds of coronaviruses,
not just the ones that scientists already
knew about.
Then they used the technique, a
variation on the gold-standard P.C.R. test
that is commonly used to diagnose Covid,
to analyze some old patient specimens.
The samples were nasopharyngeal swabs
taken from 301 people who had been
hospitalized with pneumonia in Sarawak,
Malaysia, in 2017 and 2018.
In eight of the specimens, they detected
what seemed like a novel coronavirus,
similar to those known to infect dogs.
These specimens were primarily from
children who lived in settings or areas in
which contact with domestic and wild
animals was common.
At first, Dr. Gray said, he and his
colleagues thought that they had made a
mistake. "If we examine 300 patients and
eight of them show a canine coronavirus
that had never been seen before, you go,
'This must be a contaminant, this must be
- this can't be true,'" he said.
So they sent the samples to Dr.
Anastasia Vlasova, a veterinarian and
virologist at Ohio State University, for
further investigation. Using a slightly less
sensitive screening technique, she
confirmed that two of the eight samples
did appear to contain a novel canine
coronavirus. Moreover, one of those
samples proved capable of causing
damage to canine cells, she found.
Then she assembled the complete
genome of the virus from this sample. Its
genome closely matched that of other
known canine coronaviruses. "It is highly
similar to a number of previously
characterized canine coronaviruses, but
it's a novel strain," Dr. Vlasova said.
The virus seemed to be a combination
of two previously identified canine
coronaviruses, and also contained
fragments of both a cat coronavirus and a
pig coronavirus. (These recombinant
coronaviruses are common in dogs, Dr.
Vlasova said.)
It also had an unusual genetic
mutation, a deletion in what is commonly
known as the N gene, which codes for an
important structural protein. This
deletion has not been documented in
other canine coronaviruses, Dr. Vlasova
said, but similar mutations have
appeared in the viruses that cause Covid
and SARS. "So what does this mean?" Dr.
Gray asks. "Well, you know, we don't
know exactly."
Although much more research is
needed, one possibility is that the
mutation may help animal coronaviruses
to adapt to human hosts, the researchers
said.
It is too soon to say whether this virus
poses a risk to humans. Researchers have
not yet proved that this virus is the cause
of the pneumonia that sent patients to the
hospital. And they have not yet studied
whether people who may contract the
virus from animals can spread it to other
people.
Scientists detected a new canine coronavirus in a pneumonia patient hospitalized in Malaysia in
2018. Photo: ohio State University
I've failed to practice what I preached about limiting sun exposure, but a new report has prompted
me to reform.
Photo: Gracia Lam
Paying the price for sun damage
Jane e. Brody
Pick your favorite cliché: Do as I say, not
as I do; an ounce of prevention is worth
a pound of cure; better safe than sorry;
forewarned is forearmed. Mea culpa. All
the above relate to my failure to follow
the well-established health advice about
sun exposure that I've offered
repeatedly to my readers: Routinely
protect your skin from the cancercausing
and aging effects of the sun's
ultraviolet rays.
For decades I've failed to practice
what I preached (OK to wince) and am
now paying for my negligence with
unsightly splotches, bumps and bruises
and at least one cancerous lesion on my
sun-damaged skin. My litany of excuses
has included: hats mess up my hair,
long sleeves and pants are too hot in
summer and exercising while coated
with sunscreen is suffocating.
Annually vowing to do better, every
summer I dutifully purchase the latest
dermatology-recommended sunscreen
that, alas, spends the summer
unopened on a bathroom shelf. I hereby
pledge to do better this year, albeit late
in the game.
A new report from a dermatology
team at Kaiser Permanente health care
centers in California has prompted me
to reform. The team, headed by the
epidemiologist Lisa Herrinton in
Oakland, followed nearly half a million
patients seen at the centers for up to 10
years. Half had already developed one
or more actinic keratosis, a
precancerous rough, scaly skin lesion
caused by years of unprotected sun
exposure.
As you might expect, these lesions
most often form on the face, ears, back
of the hands, forearms, scalp and neck
and are - or should be - routinely
removed when found by dermatologists
to prevent progression to cancer. The
lesions are markers of sun damage and
can serve as an early warning system for
people at risk of developing cancer
somewhere on sun-exposed skin.
While the hazard is greatest for people
with light skin, blue eyes, freckles or red
hair, having a dark complexion is not a
free pass. Tanning, not just burning, is a
form of sun damage.
Among patients in the Kaiser
Permanente study who were younger
than 50, those with a diagnosis of actinic
keratosis were nearly seven times more
likely to develop a skin cancer called
squamous cell carcinoma during the
decade-long follow-up. The cancer risk
was eight times higher among patients
older than 50 who had one or more
actinic keratosis removed, and the more
such lesions these patients had, the
more likely they were to develop skin
cancer during the follow-up.
Furthermore, the older the patient,
the sooner cancer was diagnosed after
actinic keratosis was found and
presumably treated. It took seven to
eight years for 10 percent of patients in
their 50s with an actinic keratosis to
receive a diagnosis of skin cancer, but it
took only three to four years for patients
in their 70s and one to two years for
those in their 80s.
Alas, those of us in the upper decades
of life knew little in our younger years
about the risks of sun damage beyond
the need to avoid a bad sunburn. Many
youngsters like me swam, hiked, biked
and played sports minimally clothed
while the sun tanned or burned our
skin. We sunbathed coated in baby oil in
a misguided effort to acquire a rich tan.
And many of us, myself included, failed
to reach adulthood with sun-protective
habits that could have prevented the
skin damage now woefully apparent.
Given that the risk of ultraviolet light
to healthy skin has since been widely
publicized, I'm astonished at how many
people today visit tanning salons or use
tanning beds at home, damaging the
wholesome cutaneous barrier nature
gave us.
Happily, the new study suggests that
more people now have a greater
understanding and respect for the sun's
effects on skin and can look forward to a
healthier future, said Dr. Sangeeta
Marwaha, a dermatologist in
Sacramento and co-author of the study.
Among people who entered the study in
2018, the risk of developing skin cancer
was two-thirds that of study entrants in
2008 who were followed for an equal
number of years.
"There's been an increase in sunprotective
habits and a resulting
decrease in the development of skin
cancer," Dr. Marwaha said in an
interview. "Parents today are more
likely to protect their children from
undue sun exposure, and the use of
sunscreen is now more mainstream."
But there's still a long way to go.
Fostering a healthy respect for sun
protection in young children is
especially important because experts
estimate that 80 percent of a person's
lifetime sun exposure is acquired before
age 18. Repeated exposure to the sun's
ultraviolet radiation causes most of the
skin changes - wrinkles, age spots and
tiny broken blood vessels - generally
considered a normal result of aging. Yes,
aging plays a role, but these effects occur
much earlier in life on sun-exposed skin.
UV light damages the elastin fibers in
skin, causing it to stretch, sag and
wrinkle.