• Lael M Yonker, Anne M Neilan, Yannic Bartsch, Ankit B Patel, James Regan, Puneeta Arya, Elizabeth Gootkind, Grace Park, Margot Hardcastle, Anita St John, Lori Appleman, Michelle L Chiu, Allison Fialkowski, Denis De la Flor, Rosiane Lima, Evan A Bordt, Laura J Yockey, Paolo D'Avino, Stephanie Fischinger, Jessica E Shui, Paul H Lerou, Joseph V Bonventre, Xu G Yu, Edward T Ryan, Ingrid V Bassett, Daniel Irimia, Andrea G Edlow, Galit Alter, Jonathan Z Li, and Alessio Fasano.
• Mucosal Immunology and Biology Research Center, Massachusetts General Hospital, Boston, MA; Department of Pediatrics, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA. Electronic address: lyonker@mgh.harvard.edu.
• J. Pediatr. 2020 Dec 1; 227: 45-52.e5.

ObjectivesAs schools plan for re-opening, understanding the potential role children play in the coronavirus infectious disease 2019 (COVID-19) pandemic and the factors that drive severe illness in children is critical.Study DesignChildren ages 0-22 years with suspected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection presenting to urgent care clinics or being hospitalized for confirmed/suspected SARS-CoV-2 infection or multisystem inflammatory syndrome in children (MIS-C) at Massachusetts General Hospital were offered enrollment in the Massachusetts General Hospital Pediatric COVID-19 Biorepository. Enrolled children provided nasopharyngeal, oropharyngeal, and/or blood specimens. SARS-CoV-2 viral load, ACE2 RNA levels, and serology for SARS-CoV-2 were quantified.ResultsA total of 192 children (mean age, 10.2 ± 7.0 years) were enrolled. Forty-nine children (26%) were diagnosed with acute SARS-CoV-2 infection; an additional 18 children (9%) met the criteria for MIS-C. Only 25 children (51%) with acute SARS-CoV-2 infection presented with fever; symptoms of SARS-CoV-2 infection, if present, were nonspecific. Nasopharyngeal viral load was highest in children in the first 2 days of symptoms, significantly higher than hospitalized adults with severe disease (P = .002). Age did not impact viral load, but younger children had lower angiotensin-converting enzyme 2 expression (P = .004). Immunoglobulin M (IgM) and Immunoglobulin G (IgG) to the receptor binding domain of the SARS-CoV-2 spike protein were increased in severe MIS-C (P < .001), with dysregulated humoral responses observed.ConclusionsThis study reveals that children may be a potential source of contagion in the SARS-CoV-2 pandemic despite having milder disease or a lack of symptoms; immune dysregulation is implicated in severe postinfectious MIS-C.Copyright © 2020 Elsevier Inc. All rights reserved.

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