Multi-system Inflammatory Syndrome in Children (MIS-C) and COVID-19

In Episode 10 of Dr. Dave On Call, we discuss with 2 pediatric specialists, Multi-system Inflammatory Syndrome in Children and its association with COVID-19.

Multi-system Inflammatory Syndrome in Children (MIS-C) has emerged as a concerning syndrome during the COVID-19 pandemic. Recently, the CDC issued a health care provider alert explaining the background information on several cases of reported MIS-C associated with COVID-19 and also provided a case definition for this syndrome.

We discuss MIS-C with Dr. Melissa Tesher, a pediatric rheumatology specialist and Dr. Julia Rosebush, a pediatric infectious disease specialist. Both physicians are Assistant Professors of Pediatric Medicine at the University of Chicago Medicine, Comer Children's Hospital, Chicago, Illinois. Both have treated cases of MIS-C during the past 2 months.

The following background of MIS-C will be important to our discussion on how clinicians quickly recognized this association with COVID-19. Toward the end of April 2020, doctors in the UK recognized that previously healthy kids were presenting to pediatric ERs and ICUs with a severe inflammation syndrome that had features of Kawasaki disease-like features.

Kawasaki’s disease is an illness that was first described by Dr. Tamisaku Kawasaki of Japan in 1967, of an unknown etiology. Kawasaki's disease primarily affects children that are younger the 5-6 years of age. Clinical signs include fever, rash, swelling of the hands and feet, irritation/redness of the eyes, swollen lymph glands and the neck and irritation and inflammation of the mouth, lips and throat.

Serious side effects of Kawasaki’s disease include inflammation of blood vessels, specifically of the heart that can cause coronary artery dilations and aneurysms. Treatment for Kawasaki’s disease is IVIG, aspirin and sometimes systemic steroids. 

As UK doctors recognized the increasing cases of healthy children who with severe inflammation with Kawasaki disease-like features, these children also tested positive for COVID-19 active or recent disease. Their symptoms included low blood pressure, multiorgan dysfunction and elevated inflammatory markers, but not one child had respiratory symptoms. The UK described eight cases, one of which died and all tested positive for COVID-19.

In early May 2020 in New York City, there were multiple reports of MIS-C in children and as of May 12, there were a reported 102 cases of MIS-C, many of whom tested positive for COVID-19.

According to the CDC, the case definition for MIS-C is as follows: Less than 21 years of age, presenting with: a) fever b) lab evidence of inflammation c) clinically severe illness affecting 2 or more major organ systems AND no other plausible cause AND current or recent diagnosis of COVID-19 within 4 weeks of presentation.

We know that MIS-C is a rare condition and that pediatric patients who are diagnosed early and treated aggressively do very well. Currently, we are still assessing the association of COVID-19 and MIS-C. This disease may be caused by a post-inflammatory process initiated by COVID-19, and more research will need to be conducted in the future to determine if the association between COVID-19 and MIS-C is strong or weak.

Through the guidance of experienced clinicians like Dr. Tesher and Dr. Rosebush, they can provide helpful information to public health entities so that parents can be prepared for particular warning signs of MIS-C, as early diagnosis is paramount.

We thank Dr. Tesher and Dr. Rosebush for their immense service to our pediatric patients and helping us navigate an aspect of the COVID-19 pandemic.

Citations:

https://emergency.cdc.gov/han/2020/han00432.asp

https://www.cdc.gov/kawasaki/index.html

Verdoni et al. doi: 10.1016/