Acute bilateral anterior uveitis in paediatric inflammatory multisystem syndrome temporally associated with COVlD-19

We report the case of a young child who presented with bilateral acute anterior uveitis in the context of suspected paediatric inflammatory multisystem syndrome temporally associated with COVID-19 (PIMS-TS).

The study was conducted in accordance with the principles of the Declaration of Helsinki. Written consent obtained from father as the patient is a minor.

PIMS-TS is a novel condition that has emerged during COVID-19 pandemic, first reported in the United Kingdom in April 2020. Conjunctivitis is the most common ocular manifestation.

中國汽車維修行業(yè)協(xié)會原會長康文仲，交通運輸部科學院原黨委書記、中國汽車保修設備行業(yè)協(xié)會原副會長王曉曼，中國汽車維修行業(yè)協(xié)會原會長孫守仁，中國汽車保修設備行業(yè)協(xié)會原副會長羅大柱 ，中國汽車保修設備行業(yè)協(xié)會原副會長張熙倫，中國汽車保修設備行業(yè)協(xié)會原副會長兼秘書長田國華，中國汽車維修行業(yè)協(xié)會常務副秘書長王逢鈴， 中國汽車保修設備行業(yè)協(xié)會原常務副秘書長劉蘊，中國汽車保修設備行業(yè)協(xié)會秘書長劉建農，中國汽車維修行業(yè)協(xié)會連鎖工委秘書長嚴雪月，廣東省道協(xié)機動車維修檢測分會會長羅少澤，北京汽車維修行業(yè)協(xié)會副秘書長侯金鳳及數(shù)十位國內知名汽保企業(yè)負責人作為嘉賓出席此次茶話。

In addition, an exaggerated cytokine storm may lead to increased vascular hypermeability, multiorgan failure and eventually death if the elevated cytokine concentrations remain over time

.

劉東泉是安徽三泰“糧食銀行”一萬多存糧農戶中的一員，這些農戶存糧后都領了“糧食銀行存折”。多位農戶出示了“糧食銀行存折”，這些“存折”與存錢存折樣式一樣，上面印著“像存錢一樣存糧食，存糧有息、通存通兌、降低糧耗、利國利民”。打開“存折”，里面有“賬號”“戶名”“地址”“開戶網(wǎng)點”等信息，空白頁上有“日期”“業(yè)務”“品名”“單價與規(guī)格”“數(shù)量”“折合原糧”“結存數(shù)量”等。

She was extubated 4d later and was stepped down from Paediatric Intensive Care Unit (PICU). At that moment, her eyes were noted to be red, and she complained of blurry vision and sore eyes, so she was referred to Ophthalmology. Best corrected visual acuity was 0.0 logMAR in both eyes. Examination revealed bilateral conjunctival hyperaemia, fine keratic precipitates (KPs) in both eyes and 1+ cells on the right eye with 0.5+ cells on the left eye based on Standardization of Uveitis Nomenclature (SUN) classification

(Figure 1).Crystalline lens and vitreous were clear in both eyes. No abnormalities were found in the retina and intraocular pressure was within normal limits in both eyes. She was started on topical steroids 4 times a day and reviewed one week later. The inflammation was successfully resolving with only a residual faint flare bilaterally. Her visual function was normal, therefore topical steroids were tapered. She was seen one month later when the ocular inflammation had completely resolved.

2013年，水電局在部黨組的正確領導下，認真貫徹落實黨的十八大和十八屆三中全會精神，按照中央加快水利改革發(fā)展決定提出的“大力發(fā)展農村水電”，“在保護生態(tài)和農民利益前提下，加快水能資源開發(fā)利用”的要求，積極轉變發(fā)展方式，全力推進民生水電、平安水電、綠色水電、和諧水電建設，中央投資30.8億元，比2012年增加了108%，協(xié)調國家農發(fā)行出臺了農村水電信貸支持政策，全年完成投資240億元，新增裝機200多萬kW，總裝機超過6 800萬kW，年發(fā)電量2 000多億kWh，很好地完成了各項工作任務。

Our patient met these 3 criteria, so diagnosis was made,and prompt management was started. Due to the severity of her symptoms, and although her eyes were noted to be red in PICU, ophthalmology referral was only placed once patient was extubated. She then complained of blurry vision and sore eyes.

To our knowledge, this is the first reported case of bilateral anterior acute uveitis in a PIMS-TS child in the UK.

Furthermore, a case series of 5 children diagnosed with multisystem inflammatory syndrome secondary to COVID-19 and bilateral anterior acute uveitis has been reported in Turkey

. Three of these patients also had severe corneal punctate epitheliopathy. All of them were successfully treated with topical steroids.

A 9-year-old girl presented to the local Accident and Emergency Department with a 5-day history of fever and cervical lymphadenopathy, accompanied by abdominal pain,diarrhoea and reduced oral intake. She required intubation and was transferred to our hospital. In Intensive Care Unit (ICU),she required triple inotropes (noradrenaline, adrenaline, and milrinone). Severe acute respiratory syndrome coronavirus-2(SARS-CoV-2) polymerase chain reaction (PCR) and immunoglobulin G (IgG) were negative on admission.Chest radiography (XR) showed moderate bilateral perihilar bronchial wall thickening, but no effusion and no lymph node enlargement seen. C-reactive protein (CRP) was elevated (307 mg/L). D dimer, fibrinogen, ferritin, troponin 1, triglyceride and pro-B- type natriuretic peptide were also elevated.Interleukin 6 (IL-6) and tumor necrosis factor alpha (TNF-α)were not evaluated. Echocardiogram showed moderate global systolic dysfunction and diastolic dysfunction with mild mitral regurgitation, small pericardial effusion, and normal coronaries.Inferior vena cava was distended. Other microbial cause,including bacterial sepsis, staphylococcal or streptococcal shock syndromes and infections associated with myocarditis such as enterovirus were excluded. As laboratory results supported PIMS-TS, protocol was activated and she was started on intravenous methylprednisolone, dalteparin, vitamin D, milrinone and adrenaline. Noradrenaline was weaned.

A cluster of children with hyperinflammatory shock and features similar to Kawasaki disease was first reported in the UK in April 2020

. Subsequently, many countries reported similar presentations.

Xia

reported a case where the patient was diagnosed with COVID-19 and conjunctivitis and had a positive reverse transcriptase-polymerase chain reaction (RT-PCR) test from conjunctival swab. Our patient did not have follicular conjunctivitis, so we did not perform tear conjunctival swab.A case of ophthalmia neonatorum as the presenting sign of COVID-19 has also been reported in the literature

.Mucopurulent discharge was noted on day 3 of life after an uncomplicated pregnancy and preventive erythromycin ointment applied at birth. Both parents had negative COVID-19 testing on admission, but mother did become positive after the event. Patient had positive nasopharyngeal and conjunctival SARS-CoV-2 PCR. Conjunctivitis resolved within 8d after a course of intravenous ceftriaxone, oral azithromycin, and topical erythromycin. Patient did not develop systemic disease.In the Netherlands, a very similar case report has recently been published in the literature

. A 12-year-old boy with suspected PIMS-TS reported blurry vision with conjunctival hyperaemia.He was found to have mild anterior chamber reaction (1+ cells)and was successfully treated with topical steroids.

Ocular findings on COVID-19 patients have been reported,suggesting the ocular surface could serve as an entry point and a reservoir for viral transmission

. Acute conjunctivitis is the most common ocular manifestation. Keratoconjunctivitis has also been described in a young female after travelling to a high-riskarea

. She presented with a 1-day history of unilateral conjunctivitis, photophobia, and watery discharge along with rhinorrhoea and nasal congestion. Eye and nasopharyngeal swab were positive for SARS-CoV-1 virus and negative for chlamydia, gonorrhoea with negative bacterial cultures. She had 20/20 vision both eyes (OU), conjunctival injection,follicles, 1 small pseudodendrite and subepithelial infiltrates with overlying epithelial defect, but no signs of intraocular inflammation.

Preliminary definitions of this syndrome were published by the UK Royal College of Paediatrics and Child Health (RCPCH)and included 3 main criteria

. First, a persistent fever with inflammation (neutrophilia, elevated CRP and lymphopenia)and evidence of single or multi-organ dysfunction (shock,cardiac, respiratory, renal, gastrointestinal or neurological disorder) should be confirmed. Second, any other microbial cause should be excluded. And, last, SARS-CoV-2 PCR testing may be positive or negative.

甜瓜喜好強光，但由于冬季和早春太陽光線弱，光照時間短，冬春季甜瓜苗床普遍光照不足，致使幼苗莖細葉小，葉片發(fā)黃，容易徒長，也容易感病，定植后緩苗慢，影響產(chǎn)量。應選擇新薄膜并注意清除薄膜表面的碎草、泥土、灰塵等，草簾、紙被等保溫覆蓋物，在不受寒害的前提下，應早揭晚蓋，即使在陰天，只要棚室溫度能達到10℃以上，仍要堅持揭開草簾等，使幼苗接受散射光。注意久陰乍晴時，草簾等覆蓋物應揭“花簾”（即隔一個揭一個）；連陰天后的第一個晴天，要避免馬上大揭大放，要有一個適應階段；如果過早揭放，因床土溫度不夠，根系吸收能力差，蒸發(fā)量增大，易發(fā)生萎蔫現(xiàn)象?？上仍谟酌缟蠂娝?，再逐漸揭開草簾。

List

examined the aqueous and vitreous samples of 16 patients who died from respiratory failure due to SARS-CoV-2 infection. All individuals included in this study were positive for the SARS-CoV-2 in nasopharyngeal swab test, but it was not found in the post-mortem aqueous and vitreous samples.Our patient’s SARS-CoV-2 PCR and IgG were negative, so we did not perform aqueous or vitreous samples. Goel

reiterate in their study the rate of aqueous humour turnover is estimated to be 1.0% to 1.5% of the anterior chamber volume per minute, so all aqueous is re-secreted within a few hours.

This first reported case of bilateral anterior acute uveitis in association with PIMS-TS in the UK, along with the reported case from the Netherlands found in the literature, confirm uveitis is an ocular manifestation in children diagnosed with paediatric inflammatory multisystem syndrome temporally associated with COVID-19.

三組比較，年齡、性別、受教育年限、糖尿病病程、BMI、空腹血糖、C肽、血脂差異均無統(tǒng)計學意義（P＞0.05）。與Non-DPN組相比，Painful DPN組有更低的HbA1C（P＜0.05）。三組患者MoCA評分差異均無統(tǒng)計學意義（P＞0.05）。與Non-DPN組相比，Painful DPN及Painless DPN組SDS、SAS、SRSS得分均顯著增高（P＜0.05，表1）。

We encourage a multidisciplinary approach of these patients and a referral to ophthalmology for any child with conjunctival hyperaemia to rule out intraocular inflammation and to prevent possible ocular complications resulting from this.

ACKNOWLEDGEMENTS

None.

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