KOCHI: Sharath* was a three-year-old boy who had just started playschool in June. A few days later, he developed a cough and fever. The family consulted a local paediatrician to treat his illness. But a few days later, he became tired and irritable, and the temperature started spiking again. His appetite was poor, and he was mostly sleeping. Also, his urine became concentrated with a cola-like colour.
His parents took him back to the clinic. After tests, the doctor found he had severe anaemia (drop in Hemoglobin levels) with mild jaundice, and his kidney function was affected. When he visited a higher centre, doctors found he had developed a problem called hemolysis (breakdown of his red blood cells) due to antibodies in his blood against them.
This hemolysis was also responsible for jaundice and poor kidney function due to the increased deposition of heme pigment. Another student, Manu*, a 16-year-old boy, had just received his class 10 results when he picked up a high fever, cold and cough from his family members.
On the fourth day, he started developing breathing difficulty and coughing up bloody sputum. He was rushed to the Pediatric ICU at a higher centre. Soon he needed ventilator support.
X-rays and a CT Scan showed that he was bleeding into the air sacs in his lungs due to severe inflammation. The findings suggested a condition called Diffuse Alveolar Haemorrhage which can have serious consequences.
Both these children developed secondary complications from the infections they caught. Sharath* had an infection due to Mycoplasma pneumonia (a tiny organism that spans the threshold of bacterium and virus). It is notorious for causing immune-mediated complications outside the lung.
Manu had an Influenza virus infection, but his immune system got considerably activated, leading to a profound state of inflammation in his lungs. It is called cytokine storm syndrome, which led to Diffuse Alveolar Haemorrhage.
The recent Covid pandemic exposed doctors and laypeople to various aspects of infection. We found that organisms use many ways to attack the host. The immune system that comes to the aid of the individual can also play a villain if it gets triggered adequately.
Some mechanisms of the immune system can turn against various targets in the host. During Covid, we heard about the immune-mediated complication in children called Multisystem Inflammatory syndrome or MISC.
Both Sharath* and Manu* were admitted to the Pediatric ICU for such immune-mediated complications that are now common. Using antibiotics to kill the bug was not the priority at this stage.
But it was important to control the immune process from continuing assault on the body and provide supportive care.
Sharath required immunomodulation with steroids, intravenous immunoglobulin and supportive care, including temporary dialysis till his kidneys recovered. Manu* began to improve with supportive care, especially ventilation. Both have since been discharged and are doing well with an excellent long-term prognosis. Now, children have returned to school during the monsoon season. And infections such as Influenza, parainfluenza, dengue enterovirus, etc. are rising.
While infections are common in children, if the fever continues for several days with emerging symptoms, the recovery is not going as planned. It could be due to the initial bug and then the immune-mediated complication.
Generally, these complications are not common. But when there’s a large outbreak of infections, proportionately the numbers of these problems too increase. In these cases, children will need adequate support and immunomodulatory therapy.
The author is a paediatric rheumatologist and HOD of the department of rheumatology & clinical immunology at Amrita Institute of Medical Sciences
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