Multisystem inflammatory syndrome in children: a cross-sectional study of cases and factors associated with deaths during the COVID-19 pandemic in Brazil, 2020

Relvas-Brandt, Laís de Almeida; Gava, Caroline; Camelo, Fernanda Sindeaux; Porto, Victor Bertollo Gomes; Alves, Ronaldo Fernandes Santos; Costa, Marcela Santos Correa Da; Carvalho, Sandra Maria Deotti; Carmo, Greice Madeleine Ikeda do; Fantinato, Francieli Fontana Sutile Tardetti; Wada, Marcelo Yoshito; Mendes, Yluska Myrna Meneses Brandão e; Vieira, Martha Gonçalves; Steenhouwer, Roselle Bugarin; Branco, Klebia Magalhães Pereira Castello; Santos, Maria Verônica Câmara dos; Rivera, Ivan Romero; Nicoloso, Luiz Henrique; Safadi, Marco Aurelio Palazzi; Assis, Dalva Maria de

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Brasil

Epidemiologia e Serviços de Saúde

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Original Article • Epidemiol. Serv. Saúde 30 (4) • 2021 • https://doi.org/10.1590/S1679-49742021000400005 copy

Multisystem inflammatory syndrome in children: a cross-sectional study of cases and factors associated with deaths during the COVID-19 pandemic in Brazil, 2020 ^* * This study received financial support from the National Council for Scientific and Technological Development/Ministry of Science, Technology and Innovation, and also from the Ministry of Health, via a health professional training scholarship, as part of the Field Epidemiology Training Program Applied to Brazilian National Health System Services (EpiSUS): File No 161970/2019-2.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

To characterize the clinical-epidemiological profile of multisystem inflammatory syndrome in children temporally associated with COVID-19 (MIS-C), and to identify factors associated with MIS-C deaths in Brazil, 2020.

Methods

This was a cross-sectional study, using national MIS-C monitoring data. Logistical regression was performed to estimate crude and adjusted odds ratios (OR).

Results

Median case (n=652) age was 5 years, 57.1% were male, 52.0% were of brown race/skin color and 6.4% died. Likelihood of death was greater among those who presented O2 saturation <95% (ORa=4.35 – 95%CI 1.69;11.20) and altered urea results (ORa=5.18 – 95%CI 1.91;14.04); likelihood of death was lower when red skin blotches were not present (ORa=0.23 – 95%CI 0.09;0.62), when anticoagulants were used (ORa=0.32 – 95%CI 0.12;0.89) and when immunoglobulins were used (ORa=0.38 – 95%CI 0.15;1.01).

Conclusion

Fatality ratios were higher among cases that presented O2 saturation <95% and altered urea results. Fatality ratios were lower among those with red skin blotches, and those who used immunoglobulins and anticoagulants.

Coronavirus Infections; Pediatrics; Systemic Inflammatory Response Syndrome; Death; Epidemiological Monitoring; Cross-Sectional Studies

Characteristics	N	%
Age group (in years)
<1	70	10.7
1-9	419	64.3
<20	163	25.0
Sex
Male	372	57.1
Female	280	42.9
Race/skin color (N=517)
Brown	269	52.0
White	215	41.6
Black	31	6.0
Indigenous	2	0.4
Presence of prior comorbidity
Yes	131	20.1
Signs and symptoms presented
Gastrointestinal	571	87.6
Dermatocutaneous	472	72.4
Respiratory	430	66.0
Circulatory and hemodynamic	402	61.7
Neurological	366	56.1
Edema	295	45.1
Myalgia	152	22.3
Oliguria	129	19.8
Altered markers of inflammation, coagulopathy or organ dysfunction
C-reactive protein (N=622)	590	94.9
D-dimer (N=526)	493	93.7
ESR^a(N=427)	379	88.8
Ferritin (N=404)	303	75.0
LDH^b(N=424)	258	60.8
Albumin (N=454)	269	59.3
AST^c(N=588)	301	51.2
ALT^d(N=590)	273	46.3
TT^e(N=529)	226	42.7
Troponin (N=454)	190	41.9
aPTT^f(N=523)	203	38.8
Urea (N=588)	151	25.7
Creatinine (N=592)	150	25.3
Sodium (N=559)	142	25.4
Potassium (N=556)	117	21.0
Treatment
Immunoglobulins (N=616)	418	67.9
Corticoids (N=603)	376	62.3
Anticoagulants (N=601)	335	55.7
Antiviral therapy (N=600)	96	16.0
COVID-19 confirmation criterion
Clinical-epidemiological	141	21.6
Laboratory	511	78.4
Serology	399	61.2
Molecular	145	22.2
Complications
Hypotension (need for vasoactive drugs)	181	27.8
Need for invasive ventilation	128	19.6
Pneumonia	126	19.3
Need for non-invasive ventilation	72	11.0
Kidney failure	62	9.5
Convulsions	34	5.2
Hospitalized in ICU^g(N=563)
Yes	290	44.5
Progression
Hospital discharge	525	80.5
Death	42	6.4
Unknown	85	13.1

Characteristics	Deaths (N=42)	Hospital discharge (N=525)	p-value^a
Characteristics	n	n (%)	p-value^a
Age group (in years)
<1	10	44 (8.4)	0.001
1-9	17	352 (67.0)
<20	15	129 (24.6)
Sex
Male	19	307 (58.5)	0.101
Female	23	218 (41.5)	0.101
Presence of prior comorbidity
Yes	16	105 (20.0)	0.007
Signs and symptoms presented
Abdominal pain	19	316 (60.2)	0.056
Nausea or vomiting	22	290 (55.2)	0.697
Diarrhea	18	255 (48.6)	0.467
Conjunctivitis	7	352 (67.0)	<0.001
Red blotches on body^b	10	313 (59.6)	<0.001
Dyspnea	31	178 (33.9)	<0.001
O₂saturation<95%	29	152 (29.0)	<0.001
Cough	14	116 (22.1)	0.105
Runny nose	7	79 (15.0)	0.769
Sore throat	4	76 (14.5)	0.359
Headache	11	132 (25.1)	0.886
Lethargy	14	121 (23.0)	0.140
Irritability	9	106 (20.2)	0.881
Mental confusion	7	41 (7.8)	0.071
Tachycardia	25	184 (35.0)	<0.001
Hypotension/shock	35	173 (33.0)	0.002
Skin color alterations^c	20	154 (29.3)	0.017
Hand or foot edema	6	167 (31.8)	0.010
Lymphadenopathy	2	113 (21.5)	0.003
Myalgia	12	121 (23.0)	0.448
Oliguria	14	93 (17.7)	0.023
Altered markers of inflammation, coagulopathy or organ dysfunction
C-reactive protein	39/40	478/502 (95.2)	0.477
AST^d	31/39	235/477 (49.3)	<0.001
ALT^e	22/38	216/477 (45.3)	0.132
Urea	25/38	107/481 (22.2)	<0.001
Creatinine	21/40	110/480 (22.9)	<0.001
Treatment
Immunoglobulins	15/38	357/501 (71.3)	<0.001
Corticoids	30/39	300/493 (60.9)	0.043
Anticoagulants	14/38	281/487 (57.7)	0.013
Antiviral therapy	11/38	74/487 (15.2)	0.039

Model/variables	OR_c^a(95%CI)^b	OR_a^c(95%CI)^b	p-value^d
Model 1: Sociodemographic and comorbidity variables (AIC: 204)
Age group (reference: 1-9 years)			0.159
<1	2.56 (0.79;8.32)	2.57 (0.79;8.39)
<20	2.01 (0.87;4.75)	1.97 (0.84;4.62)
Presence of any prior comorbidity			0.092
Yes	2.09 (0.93;4.72)	2.07 (0.91;4.71)
Model 2: Signs and symptoms presented (AIC: 182)
Presence of signs and symptoms (reference: No)
Red blotches on body^e	0.19 (0.08;0.48)	0.23 (0.09;0.62)	0.001
Skin color alterations^f	2.29 (1.05;4.95)	1.31 (0.53;3.22)	0.557
O₂saturation<95%	5.10 (2.19;11.92)	4.35 (1.69;11.20)	0.002
Mental confusion	2.07 (0.74;5.78)	1.59 (0.51;4.92)	0.437
Hand or foot edema	0.34 (0.12;1.01)	0.52 (0.16;1.68)	0.254
Lymphadenopathy	0.26 (0.06;1.10)	0.35 (0.08;1.60)	0.127
Oliguria	1.88 (0.82;4.33)	1.41 (0.55;3.57)	0.476
Model 3: Altered test results (AIC: 163)
Presence of signs and symptoms (reference: No)
Red blotches on body^e	0.19 (0.08;0.48)	0.18 (0.07;0.49)	< 0.001
O₂saturation<95%	5.10 (2.19;11.92)	3.6 (1.44;8.98)	0.004
Altered markers of inflammation, coagulopathy or organ dysfunction (reference: No)
AST^g	4.07 (1.61;10.26)	2.11 (0.77;5.82)	0.135
Urea	7.85 (3.42;18.03)	5.18 (1.91;14.04)	< 0.001
Creatinine	3.84 (1.76;8.40)	1.12 (0.43;2.95)	0.817
Model 4: Treatment (AIC: 191)
Presence of signs and symptoms (reference: No)
Red blotches on body^e	0.19 (0.08;0.48)	0.19 (0.07;0.54)	< 0.001
O₂saturation<95%	5.10 (2.19;11.92)	4.64 (1.75;12.28)	0.001
Altered markers of inflammation, coagulopathy or organ dysfunction (reference: No)
Urea	7.85 (3.42;18.03)	4.7 (1.88;11.73)	< 0.001
Treatment (reference: No)
Antiviral therapy	1.67 (0.68;4.11)	2.28 (0.79;6.53)	0.137
Corticoids	2.39 (0.95;6.05)	2.48 (0.83;7.44)	0.091
Immunoglobulin	0.25 (0.11;0.56)	0.38 (0.15;1.01)	0.050
Anticoagulant	0.33 (0.14;0.74)	0.32 (0.12;0.89)	0.025

Secretaria de Vigilância em Saúde e Ambiente - Ministério da Saúde do Brasil SRTVN Quadra 701, Via W5 Norte, Lote D, Edifício P0700, CEP: 70719-040, +55 61 3315-3464, Fax: +55 61 3315-3464 - Brasília - DF - Brazil
E-mail: ress.svs@gmail.com

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[1] Correspondence: Laís de Almeida Relvas-Brandt – Ministério da Saúde, Secretaria de Vigilância em Saúde, SRTVN, Quadra 701, Bloco D, Edifício PO 700, 6º andar, Brasília, DF, Brazil. CEP: 70719-040 E-mail: laisrelvas@gmail.com