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Multisystem Inflammatory Syndrome in US Children and Adolescents
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The authors conducted targeted surveillance between March 15 and May 20, 2020 in pediatric centers across the United States for multisystem inflammatory syndrome in children (MIS-C). A total of 186 cases were identified that met criteria; 70% had positive viral testing for SARS-CoV-2, and 30% had a known epidemiologic contact. Among the 14 patients who had viral symptoms prior to the onset of MIS-C, the median interval between symptom onset was 25 days. Most commonly involved organ systems included gastrointestinal (92%), cardiovascular (80%), hematologic (76%), and mucocutaneous (74%). In those patients with only two to three Kawasaki-like clinical features, rash was present in 75% and oral mucosal changes in 44%. Most patients were treated with immunomodulatory therapies including IVIG (77%) and systemic glucocorticoids (49%). As of May 20, 2020, 70% of patients were discharged alive, 28% were still hospitalized, and 2% had died.
- MIS-C, a life-threatening hyperinflammatory syndrome involving multiorgan damage, including to the mucocutaneous system, is thought to be part of the spectrum of COVID-19–related disease and possibly due to immune-mediated injury triggered by SARS-CoV-2 infection.
abstract
This abstract is available on the publisher's site.
Access this abstract nowBACKGROUND
Understanding the epidemiology and clinical course of multisystem inflammatory syndrome in children (MIS-C) and its temporal association with coronavirus disease 2019 (Covid-19) is important, given the clinical and public health implications of the syndrome.
METHODS
We conducted targeted surveillance for MIS-C from March 15 to May 20, 2020, in pediatric health centers across the United States. The case definition included six criteria: serious illness leading to hospitalization, an age of less than 21 years, fever that lasted for at least 24 hours, laboratory evidence of inflammation, multisystem organ involvement, and evidence of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) based on reverse-transcriptase polymerase chain reaction (RT-PCR), antibody testing, or exposure to persons with Covid-19 in the past month. Clinicians abstracted the data onto standardized forms.
RESULTS
We report on 186 patients with MIS-C in 26 states. The median age was 8.3 years, 115 patients (62%) were male, 135 (73%) had previously been healthy, 131 (70%) were positive for SARS-CoV-2 by RT-PCR or antibody testing, and 164 (88%) were hospitalized after April 16, 2020. Organ-system involvement included the gastrointestinal system in 171 patients (92%), cardiovascular in 149 (80%), hematologic in 142 (76%), mucocutaneous in 137 (74%), and respiratory in 131 (70%). The median duration of hospitalization was 7 days (interquartile range, 4 to 10); 148 patients (80%) received intensive care, 37 (20%) received mechanical ventilation, 90 (48%) received vasoactive support, and 4 (2%) died. Coronary-artery aneurysms (z scores ≥2.5) were documented in 15 patients (8%), and Kawasaki’s disease–like features were documented in 74 (40%). Most patients (171 [92%]) had elevations in at least four biomarkers indicating inflammation. The use of immunomodulating therapies was common: intravenous immune globulin was used in 144 (77%), glucocorticoids in 91 (49%), and interleukin-6 or 1RA inhibitors in 38 (20%).
CONCLUSIONS
Multisystem inflammatory syndrome in children associated with SARS-CoV-2 led to serious and life-threatening illness in previously healthy children and adolescents. (Funded by the Centers for Disease Control and Prevention.)
Additional Info
Disclosure statements are available on the authors' profiles:
This important paper reports retrospective and prospective surveillance of COVID-19–associated multisystem inflammatory syndrome in children (MIS-C) in 186 patients in 26 states based on defined criteria. Most patients had involvement of at least four organ systems, 20% required mechanical ventilation, and 4% received ECMO support. The median age was 8.3 years, and 4 patients (2%) died. Intravenous IVIG and glucocorticoids were the most commonly used therapies.
MIS-C related to COVID-19 has gained media attention due to its similarity to Kawasaki’s disease (KD). Of note, more than one-third of the patients in this study had KD-like clinical features, but 60% of these patients did not meet criteria for complete or incomplete KD. Unlike KD, 50% of patients in this series presented in cardiovascular shock (seen in only 5% of KD patients). Nonetheless, both diseases require follow-up echocardiography due to risk of coronary artery aneurysms.
The authors suggest that MIS-C in pediatric patients is similar to the disease patterns seen in adults with COVID-19 multisystem disease. Severe disease starts after decline in viral load in the respiratory tract with a subsequent increase in markers of inflammation. This supports MIS-C as an immune-mediated disease triggered by SARS-CoV-2 infection.
Dermatologists should be aware of the cutaneous features in this life-threatening pediatric hyperinflammatory syndrome. The cutaneous features described in this paper include erythroderma, delayed desquamation, bilateral conjunctival infection, and oral mucosal and peripheral extremity changes.