Pediatric multisystem inflammatory syndrome associated with COVID-19: urgent attention required

Carlos Alberto Nogueira-de-Almeida Luiz Antonio Del Ciampo Ivan Savioli Ferraz Ieda Regina Lopes Del Ciampo Andrea Aparecida Contini Fábio da Veiga Ued About the authors

SUMMARY

OBJECTIVE:

To identify epidemiological and clinical characteristics of multisystemic inflammatory syndrome associated with coronavirus infection as one of the severe forms of COVID-19 involvement in children and adolescents.

METHODS:

review was based on articles published in 2020 in the PubMed, Medline, Scopus, SciELO and Cochrane databases.

SUMMARY:

Multisystemic inflammatory syndrome is a serious clinical disorder that affects children and adolescents and is associated with the detection of previous exposure to SARS-CoV-2. It is characterized by the installation of a shock picture, with a significant increase in inflammatory markers such as presentations of Kawasaki Disease or shock syndrome related to Kawasaki Disease, or even toxic shock syndrome, with the clinical picture being characterized by fever of difficult control, rash, conjunctivitis, peripheral edema, generalized pain in the extremities and gastrointestinal symptoms.

CONCLUSIONS:

Although the vast majority of children with COVID-19 have mild symptoms, it is necessary to consider that some have a hyperinflammatory response. It is essential that health professionals receive information that can assist in the recognition of this clinical condition, differentiating it from other diagnoses, so that early and appropriate treatment is instituted.

KEYWORDS:
Betacoronavirus; Coronavirus infections; Child; Systemic inflammatory response syndrome; Mucocutaneous lymph node syndrome

INTRODUCTION

The first case of a disease with significant pulmonary impairment caused by a new species of coronavirus (SARS-CoV-2) was reported In China, in December 2019. Due to its high transmissibility, it was quickly declared a pandemic, responsible for more than 19 million confirmed cases and over 728,000 deaths worldwide by August 10th, 202011. Word Health Organization. Coronavirus disease (COVID-19). Situation report – 204. Report N°: 204. 11 August 2020. Geneva: Word Health Organization; 2020. [cited on Aug. 12, 2020]. Available from: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200811-covid-19-sitrep-204.pdf?sfvrsn=1f4383dd_2
https://www.who.int/docs/default-source/...
. Its incidence among children and adolescents can reach 5% of all cases22. Hon KL, Leung KKY, Leung AKC, Sridhar S, Qian S, Lee SL, et al. Overview: the history and pediatric perspectives of severe acute respiratory syndromes: novel or just like SARS. Pediatr Pulmonol. 2020;55(7):1584-91. https://doi.org/10.1002/ppul.24810
https://doi.org/10.1002/ppul.24810...
and mortality is probably low33. Panahi L, Amiri M, Pouy S. Clinical characteristics of COVID-19 infection in newborns and pediatrics: a systematic review. Arch Acad Emerg Med. 2020;8(1):e50. PMID:32440661, but children under one year of age are more likely to have complications of the disease44. Dong Y, Mo X, Hu Y, Qi X, Jiang F, Jiang Z, et al. Epidemiology of COVID-19 among children in China. Pediatrics. 2020;145(6):e20200702. https://doi.org/10.1542/peds.2020-0702
https://doi.org/10.1542/peds.2020-0702...
. Obese children are also at risk for serious manifestations55. Nogueira-de-Almeida CA, Del Ciampo LA, Ferraz IS, Del Ciampo IRL, Contini AA, Ued FDV. COVID-19 and obesity in childhood and adolescence: a clinical review. J Pediatr (Rio J). 2020;96(5):546-58. https://doi.org/10.1016/j.jped.2020.07.001
https://doi.org/10.1016/j.jped.2020.07.0...
, including higher risk of multisystem inflammatory syndrome66. Godfred-Cato S, Bryant B, Leung J, Oster ME, Conklin L, Abrams J, et al. COVID-19-Associated multisystem inflammatory syndrome in children – United States, March-July 2020. MMWR Morb Mortal Wkly Rep. 2020 Aug 14;69(32):1074-1080. https://doi.org/10.15585/mmwr.mm6932e2
https://doi.org/10.15585/mmwr.mm6932e2...
.

On the other hand, adults with comorbidities and older adults represent the main risk groups; the majority of affected children and adolescents are asymptomatic or have mild airway infection or gastrointestinal symptoms, abdominal pain, vomiting, and diarrhea77. Parri N, Lenge M, Buonsenso D. Children with Covid-19 in pediatric emergency departments in Italy. N Engl J Med. 2020;383(2):187-90. https://doi.org/10.1056/NEJMc2007617
https://doi.org/10.1056/NEJMc2007617...
. However, in view of clinical peculiarities manifested during the evolution of some cases, a group of children who had severe forms of a systemic inflammatory disease could be identified, similar to Kawasaki Disease (KD), which was called multisystemic inflammatory syndrome in children (MIS-C) due to coronavirus infection88. Feldstein LR, Rose EB, Horwitz SM, Collins JP, Newhams MM, Son MBF, et al. Multisystem inflammatory syndrome in U.S. children and adolescents. N Engl J Med. 2020;383(4):334-46. https://doi.org/10.1056/NEJMoa2021680
https://doi.org/10.1056/NEJMoa2021680...
. KD is a febrile and acute vasculitis that affects young children, primarily not belonging to any specific risk group99. Modesti AM, Plewa MC. Kawasaki Disease. 2021. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021. PMID: 30725848.. Given this syndrome does not yet have adequately defined etiological factors, it becomes even more challenging to understand its overlapping with MIS-C1010. Diorio C, Henrickson SE, Vella LA, McNerney KO, Chase J, Burudpakdee C, et al. Multisystem inflammatory syndrome in children and COVID-19 are distinct presentations of SARS-CoV-2. J Clin Invest. 2020;130(11):5967-75. https://doi.org/10.1172/JCI140970
https://doi.org/10.1172/JCI140970...
,1111. Ebina-Shibuya R, Namkoong H, Shibuya Y, Horita N. Multisystem inflammatory syndrome in children (MIS-C) with COVID-19: insights from simultaneous familial Kawasaki disease cases. Int J Infect Dis. 2020;97:371-3. https://doi.org/10.1016/j.ijid.2020.06.014
https://doi.org/10.1016/j.ijid.2020.06.0...
,1212. Greene AG, Saleh M, Roseman E, Sinert R. Toxic shock-like syndrome and COVID-19: multisystem inflammatory syndrome in children (MIS-C). Am J Emerg Med. 2020;38(11):2492.e5-6. https://doi.org/10.1016/j.ajem.2020.05.117
https://doi.org/10.1016/j.ajem.2020.05.1...
and its relation with COVID-19, as well as its causes and prognosis, which are still being better studied. Due to its severity, different scientific societies have sought to create criteria for defining cases and treatment, and alert health professionals about the disease1313. Henderson LA, Canna SW, Friedman KG, Gorelik M, Lapidus SK, Bassiri H, et al. American College of Rheumatology clinical guidance for multisystem inflammatory syndrome in children associated with SARS-CoV-2 and hyperinflammation in pediatric COVID-19: Version 2. Arthritis Rheumatol. 2021;73(4):e13-29. https://doi.org/10.1002/art.41616.
https://doi.org/10.1002/art.41616...
,1414. Miller J, Cantor A, Zachariah P, Ahn D, Martinez M, Margolis KG. Gastrointestinal symptoms as a major presentation component of a novel multisystem inflammatory syndrome in children that is related to coronavirus disease 2019: a single center experience of 44 cases. Gastroenterology. 2020;159(4):1571-4.e2. https://doi.org/10.1053/j.gastro.2020.05.079.
https://doi.org/10.1053/j.gastro.2020.05...
,1515. Riollano-Cruz M, Akkoyun E, Briceno-Brito E, Kowalsky S, Reed J, Posada R, et al. Multisystem inflammatory syndrome in children related to COVID-19: a New York City experience. J Med Virol. 2021;93(1):424-33. https://doi.org/10.1002/jmv.26224
https://doi.org/10.1002/jmv.26224...
,1616. Stevens JP, Brownell JN, Freeman AJ, Bashaw H. COVID-19-associated multisystem inflammatory syndrome in children presenting as acute pancreatitis. J Pediatr Gastroenterol Nutr. 2020;71(5):669-71. https://doi.org/10.1097/MPG.0000000000002860.
https://doi.org/10.1097/MPG.000000000000...
.

This article seeks to review current knowledge about MIS-C, with the main objective of providing health professionals with the necessary knowledge so that they can make the diagnosis and implement the treatment of this condition in face of the COVID-19 pandemic.

MULTISYSTEMIC INFLAMMATORY SYNDROME IN CHILDREN ASSOCIATED WITH SARS-COV-2 (MIS-C)

Case series

MIS-C refers to a new and serious clinical disorder, first described in April 2020 by Riphagen et al.1717. Riphagen S, Gomez X, Gonzalez-Martinez C, Wilkinson N, Theocharis P. Hyperinflammatory shock in children during COVID-19 pandemic. Lancet. 2020;395(10237):1607-8. https://doi.org/10.1016/S0140-6736(20)31094-1
https://doi.org/10.1016/S0140-6736(20)31...
, affecting previously healthy children. They studied eight cases in England, and all patients evolved with circulatory shock refractory to volumetric expansion, requiring use of vasoactive drugs for hemodynamic support; pleural, pericardial effusions and ascites were common findings; ventricular dysfunctions were observed in most patients, and an eight-year-old child developed significant coronary dilation. Most children did not have significant respiratory involvement, although ventilatory support was required in seven (87.5%) of the eight patients. An obese 14-year-old patient died, secondary to extensive cerebral infarction. During hospitalization, everyone tested negative for SARS-CoV-2 in bronchoalveolar lavage or nasopharyngeal aspirates. However, four children had previously known family exposure to COVID-191717. Riphagen S, Gomez X, Gonzalez-Martinez C, Wilkinson N, Theocharis P. Hyperinflammatory shock in children during COVID-19 pandemic. Lancet. 2020;395(10237):1607-8. https://doi.org/10.1016/S0140-6736(20)31094-1
https://doi.org/10.1016/S0140-6736(20)31...
.

After this initial report, others were published. In an American series with 186 children and adolescents under 21 years of age (mean 8.3 years) with MIS-C, 70% of the individuals were positive for SARS-CoV-2 (RT-PCR or antibodies); 40% had symptoms that met the criteria for KD, and 15%, coronary aneurysms. A total of 92% had a significant increase in at least four inflammation markers, and four patients died88. Feldstein LR, Rose EB, Horwitz SM, Collins JP, Newhams MM, Son MBF, et al. Multisystem inflammatory syndrome in U.S. children and adolescents. N Engl J Med. 2020;383(4):334-46. https://doi.org/10.1056/NEJMoa2021680
https://doi.org/10.1056/NEJMoa2021680...
. In another series, 90% of 21 patients under 18 years of age (mean 7.9 years) with MIS-C treated at a hospital in Paris, presented evidence of infection by SARS-CoV-2; 57% manifested signs and symptoms of shock syndrome associated with KD, and 76%, myocarditis. No patient died, but 24% had coronary dilation and significant increase in inflammation markers1818. Toubiana J, Poirault C, Corsia A, Bajolle F, Fourgeaud J, Angoulvant F, et al. Kawasaki-like multisystem inflammatory syndrome in children during the covid-19 pandemic in Paris, France: prospective observational study. BMJ. 2020;369:m2094. https://doi.org/10.1136/bmj.m2094
https://doi.org/10.1136/bmj.m2094...
. Among individuals in whom the presence of previous symptoms related to COVID-19 could be identified, the time interval between the onset of those symptoms and the onset of MIS-C was 25 days in American and 45 days in French series.

As to the features of the case series already described, some conclusions can be drawn: the syndrome has been manifested in children and adolescents about four weeks after contact with SARS-CoV-2. It appears to affect patients aged between four and 14 years old and is associated with detection of previous exposure to SARS-CoV-2. Children present with shock and increase in inflammatory markers, as seen in KD1717. Riphagen S, Gomez X, Gonzalez-Martinez C, Wilkinson N, Theocharis P. Hyperinflammatory shock in children during COVID-19 pandemic. Lancet. 2020;395(10237):1607-8. https://doi.org/10.1016/S0140-6736(20)31094-1
https://doi.org/10.1016/S0140-6736(20)31...
, however, the age range in the MIS-C seems to be more advanced (average age of 10 years compared to two years for KD) and respiratory, gastrointestinal and neurological symptoms are more frequent1919. Whittaker E, Bamford A, Kenny J, Kaforou M, Jones CE, Shah P, et al. Clinical characteristics of 58 children with a pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2. JAMA. 2020;324(3):259-69. https://doi.org/10.1001/jama.2020.10369
https://doi.org/10.1001/jama.2020.10369...
. The clinical condition of MIS-C can be characterized by difficulty to control fever, rash, conjunctivitis, peripheral edema, generalized pain in the extremities, and gastrointestinal symptoms1717. Riphagen S, Gomez X, Gonzalez-Martinez C, Wilkinson N, Theocharis P. Hyperinflammatory shock in children during COVID-19 pandemic. Lancet. 2020;395(10237):1607-8. https://doi.org/10.1016/S0140-6736(20)31094-1
https://doi.org/10.1016/S0140-6736(20)31...
. Affected children show marked lymphopenia and thrombocytopenia, coagulopathy, increased cardiac enzymes (troponin and cerebral natriuretic peptide, brain natriuretic peptide), hyponatremia, hypoalbuminemia, and increased serum lactate dehydrogenase and ferritin2020. Singh-Grewal D, Lucas R, McCarthy K, Cheng AC, Wood N, Ostring G, et al. Update on the COVID-19-associated inflammatory syndrome in children and adolescents; paediatric inflammatory multisystem syndrome-temporally associated with SARS-CoV-2. J Paediatr Child Health. 2020;56(8):1173-7. https://doi.org/10.1111/jpc.15049
https://doi.org/10.1111/jpc.15049...
.

Diagnostic criteria and classification

Recently, the American Centers for Disease Control and Prevention (CDC) proposed a criteria for screening MIS-C, which has been adopted in the United States to notify new cases (Figure 1). They also suggested a classification into three classes (Figure 2), aiming to better identify the most common presentations of the disease66. Godfred-Cato S, Bryant B, Leung J, Oster ME, Conklin L, Abrams J, et al. COVID-19-Associated multisystem inflammatory syndrome in children – United States, March-July 2020. MMWR Morb Mortal Wkly Rep. 2020 Aug 14;69(32):1074-1080. https://doi.org/10.15585/mmwr.mm6932e2
https://doi.org/10.15585/mmwr.mm6932e2...
. Both definitions were based on a series of 570 patients diagnosed with MIS-C in 40 states in the U.S., between March 2 and July 18, 2020. These patients had median age of eight years, 55.4% were male, and 40% were Hispanic/Latino. Two thirds were previous healthy, and 25.6% were obese. Regarding organ system, 86% had four or more involved. The majority were admitted at intensive care units (63.9%) and had severe complications: cardiac dysfunction (40.6%), shock (35.4%), myocarditis (22.8%), coronary artery dilatation or aneurysm (18.6%), and acute kidney injury (18.4%)66. Godfred-Cato S, Bryant B, Leung J, Oster ME, Conklin L, Abrams J, et al. COVID-19-Associated multisystem inflammatory syndrome in children – United States, March-July 2020. MMWR Morb Mortal Wkly Rep. 2020 Aug 14;69(32):1074-1080. https://doi.org/10.15585/mmwr.mm6932e2
https://doi.org/10.15585/mmwr.mm6932e2...
. The World Health Organization (WHO)2121. World Health Organization. Multisystem inflammatory syndrome in children and adolescents temporally related to COVID-19. Geneva: World Health Organization; 2020. [cited on Aug. 12, 2020]. Available from: https://www.who.int/news-room/commentaries/detail/multisystem-inflammatory-syndrome-in-children-and-adolescents-with-covid-19
https://www.who.int/news-room/commentari...
also proposed a diagnostic criteria for preliminary case definition of MIS-C (Figure 1).

Figure 1
Case definition for multisystemic inflammatory syndrome in children, according to the centers for disease control and the World Health Organization.

MIS-C: multisystemic inflammatory syndrome in children; CDC: centers for disease control; WHO: World Health Organization.

Figure 2
Classification in accordance with the centers for disease control, of 570 patients affected by multisystemic inflammatory syndrome.

These CDC data also show that 99% (n=565) of confirmed MIS-C cases in the United States tested positive for SARS-CoV-22222. Centers for Disease Control and Prevention. Health department-reported cases of multisystem inflammatory syndrome in children (MIS-C) in the United States. Atlanta: Centers for Disease Control and Prevention; 2020. [cited on Aug. 12, 2020]. Available from: https://www.cdc.gov/mis-c/cases/index.html
https://www.cdc.gov/mis-c/cases/index.ht...
. Although available data suggest that MIS-C is an uncommon complication of SARS-CoV-2 infection in children and adolescents88. Feldstein LR, Rose EB, Horwitz SM, Collins JP, Newhams MM, Son MBF, et al. Multisystem inflammatory syndrome in U.S. children and adolescents. N Engl J Med. 2020;383(4):334-46. https://doi.org/10.1056/NEJMoa2021680
https://doi.org/10.1056/NEJMoa2021680...
, current evidence does not support the conclusion that SARS-CoV-2 infection is the cause of MIS-C, with only a temporal relation being established. It should be noted that some cases may have a different underlying cause, such as toxic shock associated with other viruses2323. MacDonald KL, Osterholm MT, Hedberg CW, Schrock CG, Peterson GF, Jentzen JM, et al. Toxic shock syndrome. A newly recognized complication of influenza and influenzalike illness. JAMA. 1987;257(8):1053-8. https://doi.org/10.1001/jama.257.8.1053
https://doi.org/10.1001/jama.257.8.1053...
,2424. Tofte RW, Williams DN. Toxic shock syndrome. Evidence of a broad clinical spectrum. JAMA. 1981;246(19):2163-7. https://doi.org/10.1001/jama.246.19.2163
https://doi.org/10.1001/jama.246.19.2163...
. In addition, several cases of MIS-C have been identified at hospitals units, so the results are not generalizable beyond the surveillance population. Seen that, in the absence of a comparison group, caution is warranted when interpreting data to infer risk factors for MIS-C.

Treatment

In the screening of patients with clinical and epidemiological symptoms of COVID-19, initial ambulatory evaluation may be considered. A preliminary laboratory workup is necessary, including complete blood count with differential, liver function tests, urinalysis, electrolytes, erythrocyte sedimentation rate, C-reactive protein, and tests for SARS-CoV-2. Patients who are in good general condition, with stable vital signs, can be followed up on an outpatient basis. Hospital admissions are indicated for patients under investigation for MIS-C with the following symptoms or conditions1313. Henderson LA, Canna SW, Friedman KG, Gorelik M, Lapidus SK, Bassiri H, et al. American College of Rheumatology clinical guidance for multisystem inflammatory syndrome in children associated with SARS-CoV-2 and hyperinflammation in pediatric COVID-19: Version 2. Arthritis Rheumatol. 2021;73(4):e13-29. https://doi.org/10.1002/art.41616.
https://doi.org/10.1002/art.41616...
,2525 Sociedade Brasileira de Pediatria. Sociedade Brasileira de Pediatria. Notificação obrigatória no Ministério da Saúde dos casos de síndrome inflamatória multissistêmica pediátrica (SIM-P) potencialmente associada à COVID-19. Rio de Janeiro: Sociedade Brasileira de Pediatria; 2020. [cited on Aug. 21, 2020]. Available from: https://www.sbp.com.br/imprensa/detalhe/nid/notificacao-obrigatoria-no-ministerioda-saude-dos-casos-de-sindrome-inflamatoria-multissistemicapediatrica-sim-p-potencialmente-associada-a-covid-19/
https://www.sbp.com.br/imprensa/detalhe/...
:

  • Abnormal vital signs (tachycardia, tachypnea);

  • Respiratory distress of any severity;

  • Neurologic deficits or change in mental status (including subtle manifestations);

  • Even mild renal or hepatic injury;

  • Severe abdominal pain, uncontrollable vomiting, inability to eat;

  • Dehydration;

  • KD disease-like features (partial or complete);

  • Markedly elevated inflammatory markers;

  • Abnormal EKG, BNP, or troponin T;

  • Shock;

  • Comorbidities (lung diseases, chronic heart diseases, immunodeficiencies, neoplasms, and autoimmune diseases);

  • Impossibility of outpatient follow-up.

The need for admission to the intensive care unit will depend on the severity of the signs and symptoms of each patient2525 Sociedade Brasileira de Pediatria. Sociedade Brasileira de Pediatria. Notificação obrigatória no Ministério da Saúde dos casos de síndrome inflamatória multissistêmica pediátrica (SIM-P) potencialmente associada à COVID-19. Rio de Janeiro: Sociedade Brasileira de Pediatria; 2020. [cited on Aug. 21, 2020]. Available from: https://www.sbp.com.br/imprensa/detalhe/nid/notificacao-obrigatoria-no-ministerioda-saude-dos-casos-de-sindrome-inflamatoria-multissistemicapediatrica-sim-p-potencialmente-associada-a-covid-19/
https://www.sbp.com.br/imprensa/detalhe/...
. As MIS-C is a post-infectious and immune-mediated disease, the need for isolation must be based on positive RT-PCR or serological tests for SARS-CoV-22525 Sociedade Brasileira de Pediatria. Sociedade Brasileira de Pediatria. Notificação obrigatória no Ministério da Saúde dos casos de síndrome inflamatória multissistêmica pediátrica (SIM-P) potencialmente associada à COVID-19. Rio de Janeiro: Sociedade Brasileira de Pediatria; 2020. [cited on Aug. 21, 2020]. Available from: https://www.sbp.com.br/imprensa/detalhe/nid/notificacao-obrigatoria-no-ministerioda-saude-dos-casos-de-sindrome-inflamatoria-multissistemicapediatrica-sim-p-potencialmente-associada-a-covid-19/
https://www.sbp.com.br/imprensa/detalhe/...
. During hospitalization, patients under investigation for MIS-C must be followed by a multidisciplinary team, which includes pediatric rheumatologist, cardiologist, immunologist, infectious disease specialist, hematologist, and intensive care pediatrician1313. Henderson LA, Canna SW, Friedman KG, Gorelik M, Lapidus SK, Bassiri H, et al. American College of Rheumatology clinical guidance for multisystem inflammatory syndrome in children associated with SARS-CoV-2 and hyperinflammation in pediatric COVID-19: Version 2. Arthritis Rheumatol. 2021;73(4):e13-29. https://doi.org/10.1002/art.41616.
https://doi.org/10.1002/art.41616...
,2626. American Academy of Pediatrics. Multisystem inflammatory syndrome in children (MIS-C) interim guidance. Itasca: American Academy of Pediatrics; 2020. [cited on Aug. 14, 2020]. Available from: https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/multisystem-inflammatory-syndrome-in-children-mis-c-interim-guidance/
https://services.aap.org/en/pages/2019-n...
.

In addition to supportive care, treatment consists primarily of addressing the underlying systemic inflammatory state of the syndrome and its consequent complications. Figure 3 shows the basis of current proposed treatment1313. Henderson LA, Canna SW, Friedman KG, Gorelik M, Lapidus SK, Bassiri H, et al. American College of Rheumatology clinical guidance for multisystem inflammatory syndrome in children associated with SARS-CoV-2 and hyperinflammation in pediatric COVID-19: Version 2. Arthritis Rheumatol. 2021;73(4):e13-29. https://doi.org/10.1002/art.41616.
https://doi.org/10.1002/art.41616...
,2525 Sociedade Brasileira de Pediatria. Sociedade Brasileira de Pediatria. Notificação obrigatória no Ministério da Saúde dos casos de síndrome inflamatória multissistêmica pediátrica (SIM-P) potencialmente associada à COVID-19. Rio de Janeiro: Sociedade Brasileira de Pediatria; 2020. [cited on Aug. 21, 2020]. Available from: https://www.sbp.com.br/imprensa/detalhe/nid/notificacao-obrigatoria-no-ministerioda-saude-dos-casos-de-sindrome-inflamatoria-multissistemicapediatrica-sim-p-potencialmente-associada-a-covid-19/
https://www.sbp.com.br/imprensa/detalhe/...
,2626. American Academy of Pediatrics. Multisystem inflammatory syndrome in children (MIS-C) interim guidance. Itasca: American Academy of Pediatrics; 2020. [cited on Aug. 14, 2020]. Available from: https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/multisystem-inflammatory-syndrome-in-children-mis-c-interim-guidance/
https://services.aap.org/en/pages/2019-n...
.

Figure 3
Basis of current proposed treatment for multisystemic inflammatory syndrome in children.

FINAL CONSIDERATIONS

Since the beginning of the COVID-19 pandemic, much has been discussed and reported in the scientific community. Unlike adults, the vast majority of children with COVID-19 have mild symptoms. However, there are reported cases of children who present conditions related to a hyperinflammatory response, similar to that observed in adults. The full spectrum of MIS-C is not yet clear, as well as it is not clear yet if geographic distribution in North America and Europe reflects a true pattern or if the condition has simply not been recognized elsewhere. Therefore, there is an urgent need to collect standardized data describing clinical presentations, severity, outcomes, and epidemiology2121. World Health Organization. Multisystem inflammatory syndrome in children and adolescents temporally related to COVID-19. Geneva: World Health Organization; 2020. [cited on Aug. 12, 2020]. Available from: https://www.who.int/news-room/commentaries/detail/multisystem-inflammatory-syndrome-in-children-and-adolescents-with-covid-19
https://www.who.int/news-room/commentari...
. Until further robust data on the etiology of MIS-C is available, pediatricians should be alert to the rapid recognition of these cases, enabling appropriate management in emergency services, hospital wards, and intensive care units (ICUs).

Health professionals must receive information that can assist in the recognition of the MIS-C diagnosis. Common clinical features of MIS-C include fever and other clinical signs, such as findings of rash, conjunctivitis, hands and feet edema, red and / or chapped lips, “strawberry” tongue, myocardial dysfunction, cardiac conduction abnormalities, shock, gastrointestinal symptoms, and lymphadenopathy, as well as neurological changes. However, these findings can occur both in other infectious and in non-infectious diseases. Thus, the diagnostic evaluation must include other differential diagnoses more common in pediatric population and relate clinical presentation to the high prevalence of COVID-19 cases with patient’s geographic region. Distinguishing patients with MIS-C from those with acute COVID-19 and other hyperinflammatory conditions is essential for early diagnosis and appropriate treatment.

  • Funding: none.

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Publication Dates

  • Publication in this collection
    13 Aug 2021
  • Date of issue
    2021

History

  • Received
    22 Sept 2020
  • Accepted
    21 Oct 2020
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