Abstract
Question The effect of acute coronavirus disease 2019 (COVID-19) on morbidity and mortality in children has been relatively small. If a child presents to my office with persistent fever and systemic hyperinflammation but no known exposure to COVID-19, how likely are they to have multisystem inflammatory syndrome in children (MIS-C)? What is currently known about MIS-C and what is the prognosis for children affected by it?
Answer Amid the COVID-19 pandemic, the emergence of a novel condition presents yet another challenge to clinicians, public health professionals, and the pediatric population. Multisystem inflammatory syndrome in children is a rare but potentially severe condition seen in children with evidence of COVID-19 approximately 2 to 6 weeks before symptom onset. Common signs and symptoms include persistent fever, systemic hyperinflammation, gastrointestinal symptoms (eg, abdominal pain, vomiting, diarrhea), mucocutaneous changes (eg, rash, conjunctivitis), headache, or cardiac dysfunction. As many children present as asymptomatic or with mild symptoms of COVID-19, the development of MIS-C can seem sudden and surprising to families and providers. Although children with MIS-C usually require hospitalization, the outcomes are largely favourable with prompt recognition and intense therapy.
Since its emergence, the rapid transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), known to cause the novel coronavirus disease 2019 (COVID-19), has resulted in high morbidity and mortality worldwide.1 While the virus affects all age groups, children were thought to fare better during the COVID-19 illness, as this population accounted for only 1% to 5% of those diagnosed with the illness and rarely developed severe disease.2 Most children with COVID-19 present with a range of signs and symptoms that are not severe or specific enough to prompt disease testing.3 Some children and adolescents show no symptoms at all.3 The challenge with unrecognized COVID-19 cases is that asymptomatic children might become silent carriers in the community3,4 or be at risk of developing post–COVID-19 complications.
One of the rare, yet potentially life-threatening, complications of COVID-19 in children is a condition known as multisystem inflammatory syndrome in children (MIS-C),5 also referred to as pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 or PIMS-TS. Multisystem inflammatory syndrome in children is a febrile syndrome characterized by systemic hyperinflammation, persistent fever, and multisystem organ dysfunction.6,7 The first case of MIS-C was reported in the United Kingdom in April 2020.8 Since then, more than 4000 cases of MIS-C have been confirmed in the United States alone,9 with evidence suggesting MIS-C is likely a secondary consequence of COVID-19 in children. A concentration of subsequent cases was observed 4 to 6 weeks following the peak of adult COVID-19 cases in the United States and France5 and 2 to 5 weeks following the peaks of pediatric COVID-19 cases that occurred in early May and August 2020 in the United States.10 Further, more than 70% of MIS-C patients had seropositive test results for antibodies against SARS-CoV-2.11,12
Unknown pathogenesis
While the exact cause is currently unknown, children presenting with MIS-C symptoms demonstrate hyperinflammatory immune response secondary to the SARS-CoV-2 infection.11 A number of possible theories have been proposed. Yonker et al13 found significantly (P = .004) elevated levels of SARS-CoV-2 S1 protein in patients with MIS-C compared with healthy controls, and increased (P = .003) levels of zonulin in the blood—a protein that regulates gastrointestinal permeability by modulating intercellular tight junctions. The increased gut permeability, caused by elevated zonulin levels, allows for the leakage of SARS-CoV-2 antigens into the bloodstream.13 A recent discovery of a superantigenlike motif near the S1/S2 cleavage site on the SARS-CoV-2 spike protein supports this mechanism and has been hypothesized to trigger the MIS-C hyperinflammatory response by interacting with T cell receptors and major histocompatibility complex class II molecules.14 Additionally, a deep immune profiling of MIS-C patients by Vella et al15 found an increased activation of CX3CR1+ CD8+ T cells associated with persistent SARS-CoV-2 antigen and vascular surveillance. Further research into the immunology and pathophysiology of MIS-C is crucial to improving the diagnosis and treatment of children affected by this disease, as well as possibly understanding the different severity of acute COVID-19 in children and addressing future vaccination plans.
Recognition and symptoms
Contrary to the low rates of severe symptoms shown with COVID-19, children with MIS-C have presented with various symptoms from fever to cardiogenic shock.16 A study of 1733 MIS-C patients in the United States reported that 90.4% of patients had complications involving at least 4 organ systems and 58.2% were admitted for intensive care.10 Some of the most common signs and symptoms included abdominal pain (66.5%), vomiting (64.3%), rash (55.6%), diarrhea (53.7%), and conjunctival hyperemia (53.6%).10 A study endorsed by working groups for cardiac imaging and cardiovascular intensive care from the Association for European Paediatric and Congenital Cardiology reported that a cohort of 286 MIS-C patients across 17 European countries had myocardial involvement (93%), gastrointestinal symptoms (71%), shock (40%), and cardiac arrhythmia (35%).17 All patients presented with persistent fever (> 38°C) and had elevated laboratory markers of inflammation such as C-reactive protein, serum ferritin, procalcitonin, IL-6, and D-dimer levels.17 Most were previously healthy children and adolescents with no comorbidities.17
Differentiating MIS-C from other hyperinflammatory diseases, such as Kawasaki disease (KD) and toxic shock syndrome, has been challenging for clinicians. Patients with MIS-C tend to be older than those with KD (mean age 8 to 9 years vs 2 to 3 years, respectively), and present with elevated troponin levels.5 Prominent symptoms of abdominal pain and cardiac dysfunction might help to distinguish the condition from toxic shock syndrome and KD.5
Affecting minorities
Several studies18–20 from the United States highlight the disproportionate effect of MIS-C among children in Black and Hispanic communities. A retrospective analysis of the US Centers for Disease Control and Prevention MIS-C surveillance database found that the median age of patients with MIS-C was 8 years, 602 of 1080 (56%) patients were male, and 724 of 945 (77%) patients were either Hispanic or non-Hispanic Black.18 The study also found that intensive care unit admissions and decreased cardiac function were more likely in non-Hispanic Black patients compared with non-Hispanic White patients.18
Management
The American College of Rheumatology published clinical guidelines for MIS-C. They included a high level of consensus for administering high-dose intravenous immunoglobulin (IVIG) (2 g/kg based on ideal body weight), glucocorticoids, or both as first-tier agents.21 For patients with cardiac dysfunction, IVIG may be given as 1 g/kg daily over 2 days and might require close monitoring and diuretics.21 Methylprednisolone or other steroids may be used as first-line therapy at 1 to 2 mg/kg daily for patients who show highly elevated levels of B-type natriuretic peptides, unexplained tachycardia, or ill appearance, but who have not yet developed shock or organ-threatening conditions.21 A combination therapy might be favoured, as Ouldali et al22 found that patients treated with IVIG and methylprednisolone had a more favourable course, lower risk of treatment failure, and shorter duration of stay in the pediatric intensive care unit (4 vs 6 days) than patients who received IVIG alone. Additionally, low-dose cetylsalicylic acid (3 to 5 mg/kg daily up to 81 mg/d) is recommended as part of antiplatelet therapy in MIS-C patients without serious bleeding risk.21 Targeted neuralization of inflammatory cytokines with IL-1 receptor antagonist (eg, anakinra)21 or IL-6 receptor antagonist eg, tocilizumab)11 has also been found to be effective as second-line therapy. The median hospital stay was 6 days, with generally positive outcomes.11
A recently published multidisciplinary retrospective study23 of 46 adolescents with MIS-C provided insights into outcomes at 6 months’ follow-up. At 6 months, sysemic inflammation was resolved in 45 patients, echoardiogram findings were normal in 44 patients, and only patients reported gastrointestinal symptoms.23 Minor neurologic abnormalities were detected in 18 patients but these did not correlate with neurologic functional impairments.23 Other findings at 6 months included musular fatigue, anxiety, and emotional lability.23 Although the long-term consequences will become clearer with further follow-up, prompt recognition results in favourble outcomes for MIS-C.11
Conclusion
Multisystem inflammatory syndrome in children has losely followed in the footsteps of the COVID-19 pandemic and has presented itself as a rare, but potentially life-threatening, complication of the disease in children. Prompt recognition of this febrile syndrome and efforts to reduce the risk of exposure to COVID-19 in hildren and adolescents, especially those from minorty or socioeconomically disadvantaged populations, are key to limiting the incidence of MIS-C.
Notes
Child Health Update is produced by the Pediatric Research in Emergency Therapeutics (PRETx) program (www.pretx.org) at the BC Children’s Hospital in Vancouver, BC. Michelle M. Kim and Dr Srinivas Murthy are members and Dr Ran D. Goldman is Director of the PRETx program. The mission of the PRETx program is to promote child health through evidence-based research in therapeutics in pediatric emergency medicine.
Do you have questions about the effects of drugs, chemicals, radiation, or infections in children? We invite you to submit them to the PRETx program by fax at 604 875-2414; they will be addressed in future Child Health Updates. Published Child Health Updates are available on the Canadian Family Physician website (www.cfp.ca).
Footnotes
Competing interests
None declared
This article is eligible for Mainpro+ certified Self-Learning credits. To earn credits, go to www.cfp.ca and click on the Mainpro+ link.
La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro d’aoȗt 2021 à la page e224.
- Copyright © the College of Family Physicians of Canada
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