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.

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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

.

刘东泉是安徽三泰“粮食银行”一万多存粮农户中的一员，这些农户存粮后都领了“粮食银行存折”。多位农户出示了“粮食银行存折”，这些“存折”与存钱存折样式一样，上面印着“像存钱一样存粮食，存粮有息、通存通兑、降低粮耗、利国利民”。打开“存折”，里面有“账号”“户名”“地址”“开户网点”等信息，空白页上有“日期”“业务”“品名”“单价与规格”“数量”“折合原粮”“结存数量”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，水电局在部党组的正确领导下，认真贯彻落实党的十八大和十八届三中全会精神，按照中央加快水利改革发展决定提出的“大力发展农村水电”，“在保护生态和农民利益前提下，加快水能资源开发利用”的要求，积极转变发展方式，全力推进民生水电、平安水电、绿色水电、和谐水电建设，中央投资30.8亿元，比2012年增加了108%，协调国家农发行出台了农村水电信贷支持政策，全年完成投资240亿元，新增装机200多万kW，总装机超过6 800万kW，年发电量2 000多亿kWh，很好地完成了各项工作任务。

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.

甜瓜喜好强光，但由于冬季和早春太阳光线弱，光照时间短，冬春季甜瓜苗床普遍光照不足，致使幼苗茎细叶小，叶片发黄，容易徒长，也容易感病，定植后缓苗慢，影响产量。应选择新薄膜并注意清除薄膜表面的碎草、泥土、灰尘等，草帘、纸被等保温覆盖物，在不受寒害的前提下，应早揭晚盖，即使在阴天，只要棚室温度能达到10℃以上，仍要坚持揭开草帘等，使幼苗接受散射光。注意久阴乍晴时，草帘等覆盖物应揭“花帘”（即隔一个揭一个）；连阴天后的第一个晴天，要避免马上大揭大放，要有一个适应阶段；如果过早揭放，因床土温度不够，根系吸收能力差，蒸发量增大，易发生萎蔫现象。可先在幼苗上喷水，再逐渐揭开草帘。

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.

三组比较，年龄、性别、受教育年限、糖尿病病程、BMI、空腹血糖、C肽、血脂差异均无统计学意义（P＞0.05）。与Non-DPN组相比，Painful DPN组有更低的HbA1C（P＜0.05）。三组患者MoCA评分差异均无统计学意义（P＞0.05）。与Non-DPN组相比，Painful DPN及Painless DPN组SDS、SAS、SRSS得分均显著增高（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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