When Juliet Daly, a 12-year-old girl living in Louisiana, fell ill, her mother suspected the flu or appendicitis—but at the hospital Juliet deteriorated quickly, and she tested positive for the new coronavirus, Ariana Eunjung Cha and Chelsea Janes report for the Washington Post.

The next 'surge' to prepare for? Cardiovascular care

A new inflammatory syndrome threatens young Covid-19 patients around the world

Doctors in recent weeks have reported a rising number of cases of the deadly inflammatory syndrome, which currently is known as Pediatric Multi-System Inflammatory Syndrome Potentially Associated with Covid-19. The condition typically afflicts children who develop it within days or weeks after they become infected with the new coronavirus.

Doctors have reported cases of the syndrome among children who have tested positive for the new coronavirus and displayed respiratory symptoms commonly linked with Covid-19, the disease caused by the virus. The condition also has been detected in children who have tested positive for the new coronavirus or have antibodies for the virus, suggesting they had been infected at some point, but who did not exhibit those respiratory symptoms. However, not every child with the syndrome has tested positive for Covid-19.

Doctors said the syndrome causes inflammation of the blood vessels, impairs organ function, and can potentially cause damage to the heart. Other symptoms include fever, skin rashes, gland swelling, abdominal pain, vomiting, and diarrhea.

So far, the cause of the condition is unknown, but some physicians believe it stems from a patient's immune system overacting to an infection. Doctors have said the volume of cases of the syndrome in Covid-19 patients implies the conditions are likely linked. Juliet's case offers a unique look at just how severe the condition can become.

Juliet's heart stopped—twice

Juliet had been feeling sick for two days. She had a 101.5-degree fever and abdominal pains, and she was vomiting. However, since she didn't have a cough and wasn't experiencing any shortness of breath, her parents didn't consider she may have Covid-19.

Juliet's mother Jennifer Daly, who is a radiologist, suspected Juliet had appendicitis, the flu, or a stomach bug, and she took Juliet to a hospital ED on April 6. Doctors there discovered that Juliet's heart rate was sitting around 40 beats per minute—much lower than the 70 to 120 beats per minute that is typical among children Juliet's age. Doctors also found that, when they squeezed Juliet's nails, they turned white and stayed that way instead of turning back to pink, as they typically should. According to Eunjung Cha and Janes, "Juliet was in a kind of toxic shock, and her heart had become so inflamed it was barely beating."

While at the hospital, Juliet went into cardiac arrest. Doctors performed almost two minutes of CPR on Juliet and were able to revive her, Eunjung Cha and Janes write. The doctors then decided to place Juliet on a ventilator and transfer her via helicopter to Ochsner Medical Center once she was stabilized—but Juliet again went into cardiac arrest. Doctors were able to revive her a second time and place her on a ventilator, and Juliet eventually was transferred to Ochsner.

When Juliet arrived at Ochsner, doctors her organs had begun to fail; her liver and kidneys were in shock, her pancreas was inflamed, and she had blood in her lungs.

"They were not sure she was going to make it the first night," Juliet's mother said. "It was a total nightmare."

Doctors began giving Juliet medications to treat her conditions and administered diagnostic tests for the new coronavirus. According to Eunjung Cha and Janes, although April 6 was "was still relatively early in" America's coronavirus epidemic and hospitals at this point hadn't seen many children in Juliet's condition, "doctors knew enough about the pathogen's effects on adults that they immediately suspected the coronavirus."

Juliet's diagnostic tests came back positive for the new coronavirus, and doctors then began treating her with an immunoglobulin product that had been successfully used on patients in Japan with an illness known as Kawasaki disease. The disease causes blood vessels to become inflamed and fever, Eunjung Cha and Janes write.

Within 24 hours of receiving the treatment, Juliet's condition started to stabilize and doctors eventually removed her from the ventilator. On April 15, doctors discharged Juliet from the hospital and said she should make a full physical recovery.

Jake Kleinmahon, a pediatric cardiologist who treated Juliet, said her most recent echocardiogram was normal. "I do not expect her to have any long-term complications or limitations, even though she came in so severely ill," he said. "She is quite a fighter and such a brave young girl."

Warnings of multisystem inflammatory syndrome in children

Eunjung Cha and Janes write that Juliet "is among the first known children in the United States to develop" the multisystem inflammatory syndrome, or MIS-C, which doctors believe is tied to the new coronavirus. According to Eunjung Cha and Janes, providers now believe there are more than 100 children in New York who also developed the syndrome—including three who died. In addition, "medical centers in 14 other states have reported similar cases," Eunjung Cha and Janes write.

According to Eunjung Cha and Janes, researchers still say most children who contract the new coronavirus experience mild or asymptomatic of cases Covid-19, but they're concerned about the severity of MIS-C in the relatively few children who develop it—and that the condition "seem[s] to be appearing in children weeks after a wave of infections in their communities."

Jennifer Owensby, a pediatric intensivist at Robert Wood Johnson University Hospital, said the first children with Covid-19 who she treated had the respiratory symptoms typically associated with the disease, like shortness of breath. But now, "[t]he vast majority are coming in with symptoms of cardiac failure, which is extremely rare in pediatrics, especially in normal, healthy kids—which is why this is so alarming," she said.

Roberta DeBiasi, an infectious disease specialist at Children's National Hospital, said, "[T]his presentation [of Covid-19] is clearly different. It's not that we just didn't notice this before. It's a new presentation. And the fact that it's happening two months after the initial circulation of the virus gives weight to the idea that it's an immune-mediated phenomena" (Eunjung Cha/Janes, Washington Post, 5/17).