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Neonatal infection with SARS-CoV-2 is considered to have no major complications. A neonate with lower limb gangrene owing to spontaneous aortic thrombosis in the setting of a fetal inflammatory response syndrome (FIRS) post-intrauterine COVID-19 infection is presented. A healthy full-term newborn discharged from hospital on Day 3 developed irritability and progressive blackish discoloration of the toes of the right lower limb on Day 6 of life. Doppler imaging revealed acute thrombosis of the abdominal aorta with a critically ischaemic right lower limb. On Day 11 of life, SARS-CoV-2 RT-PCR was negative but total antibodies (IgG and IgM) were positive in both mother and neonate. The neonate showed raised inflammatory markers including CRP, ESR, interleukin-6, procalcitonin, ferritin and LDH along with elevated N-terminal pro-brain natriuretic peptide and D-dimer. In the absence of clinical signs of sepsis, FIRS was diagnosed. The neonate was treated with corticosteroids, heparin infusion and recombinant tissue plasminogen activator, and required surgical embolectomy followed by right limb amputation. By Day 31 of life, inflammatory markers showed serial return to normal and the neonate was discharged on oral steroids and aspirin. Intrauterine SARS-CoV-2 infection may trigger a systemic inflammatory response in some fetuses which is similar to post-COVID-19 multisystem inflammatory syndrome in children (MIS-C). Development of lower limb gangrene is a unique COVID-19-related neonatal complication and is attributed to thrombo-inflammation.ABBREVIATIONSCRP: C-reactive protein; FIRS: fetal inflammatory response syndrome; MIS-C: multisystem inflammatory syndrome in children; NT-proBNP: N-terminal pro-brain natriuretic peptide; RT-PCR: real-time polymerase chain reaction.

Although presentation of multisystem inflammatory syndrome (MIS-C) in children is typically with fever and symptoms like diarrhea, vomiting, rash, conjunctival injection, or shock, the spectrum of associated multisystem involvement is wide. Here, we present an account of patients with MIS-C that presented at a tertiary hospital in Navi Mumbai, India in the latter half of the pandemic from October 2020 to January 2021. We retrospectively studied the clinical features of 12 patients satisfying World Health Organization criteria for MIS-C. Eleven (91.6%) required PICU admission. Median age was 7 years and two had comorbidity. At the time of presentation, eight (66.6%) had respiratory failure, four (33.3%) had shock, and one (8.3%) had renal failure. The most common system involved was respiratory (75%) followed by mucocutaneous manifestations (66.6%). Seven patients (58.3%) showed involvement of >4 systems. Atypical presentations included a 14-year-old male with COVID-19 like pulmonary involvement on computed tomography, and a 20-month-old male with gross hematuria, nephrotic range proteinuria, and rapidly progressive renal failure. Elevated N-terminal-pro B-type natriuretic peptide was seen in 75% patients and abnormal two-dimensional echo in 50%. All patients were treated with intravenous methylprednisolone at 30 mg/kg/day for 5 days. Death occurred in three (25%), all of whom had hypotensive shock at presentation. In the wake of an ongoing pandemic, any febrile child with nonspecific symptoms suggestive of multisystem involvement warrants suspicion of MIS-C and should be evaluated with the help of markers of systemic inflammation and organ involvement, after ruling out other obvious causes. We report good response to methylprednisolone in patients without hypotensive shock at presentation and its use as firstline drug may be considered in settings with financial constraints.

Our aim was to study the clinical profile, immediate outcome and risk factors associated with poor outcome in critically ill children presenting with seizures requiring PICU admission. As seizures lasting 10 min or more can potentially cause brain damage, we included all children regardless of seizure duration. The records of 157 children aged 1 month to 16 years admitted in the PICU at a tertiary hospital in India with seizures as the presenting symptom during a three-year period were studied retrospectively. Median age of patients was 4 years. 34 (21%) had pre-existing epilepsy and 33 (21%) had previous developmental delay/neuro-deficit. Seizure duration was > 30 min in 75 (47.7%) and 56 (35.6%) required the use of more than 2 antiseizure drugs. 101 (64%) had acute symptomatic seizures, 28 (17%) remote symptomatic and 27 (17.1%) had unknown cause. New onset neurological deficit was seen in 18 (15.6%) and 14 (8.9%) died. Young age, high PEWS score at presentation, prolonged/recurrent seizures, CNS infection, need for multiple antiseizure drugs and ventilation/pressor use were risk factors for poor outcome. Neurological outcome and survival of children in our study were good. Further all-inclusive studies irrespective of seizure duration are needed to obtain a complete picture of critical children presenting with seizures., Highlights • All critical children presenting with seizures were included irrespective of seizure duration • 52.2% patients had seizures lasting for less than 30 min • 28.6% patients had CNS infection as the underlying etiology • Short-term neurological outcome was comparable to previous reports • Mortality associated with status epilepticus was lower than that reported by other Indian studies