COVID-19-associated multisystem inflammatory syndrome: Difference between revisions

Jump to navigation Jump to search
No edit summary
No edit summary
Line 97: Line 97:
*Two of the following:
*Two of the following:


#[[Rash]] or bilateral non-purulent [[conjunctivitis]] or muco-cutaneous inflammation signs (oral, hands or feet)
#[[Rash]] or bilateral non-purulent [[conjunctivitis]] or mucocutaneous inflammation signs (oral, hands or feet)
#Hypotension or shock
#Hypotension or shock
#Features of myocardial dysfunction, [[pericarditis]], [[valvulitis]], or coronary abnormalities (including ECHO findings or elevated [[Troponin]]/[[NT-proBNP]])
#Features of myocardial dysfunction, [[pericarditis]], [[valvulitis]], or coronary abnormalities (including ECHO findings or elevated [[Troponin]]/[[NT-proBNP]])
Line 128: Line 128:
=== Signs and Symptoms ===
=== Signs and Symptoms ===


*[[Fever]] lasting 24 hours or longer.
*[[Fever]] lasting 24 hours or longer.ref name=":2">{{cite web |url=https://www.rcpch.ac.uk/sites/default/files/2020-05/COVID-19-Paediatric-multisystem-%20inflammatory%20syndrome-20200501.pdf|title=Guidance: Paediatric multisystem inflammatory
syndrome temporally associated with COVID-19 |format= |work= |accessdate=}}</ref>
*[[Vomiting]]
*[[Vomiting]]
*[[Diarrhea]]
*[[Diarrhea]]

Revision as of 21:47, 11 July 2020

COVID-19 Microchapters

Home

Long COVID

Frequently Asked Outpatient Questions

Frequently Asked Inpatient Questions

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating COVID-19 from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Study of Choice

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X-ray

Echocardiography and Ultrasound

CT scan

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Interventions

Surgery

Primary Prevention

Vaccines

Secondary Prevention

Future or Investigational Therapies

Ongoing Clinical Trials

Case Studies

Case #1

COVID-19-associated multisystem inflammatory syndrome On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of COVID-19-associated multisystem inflammatory syndrome

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on COVID-19-associated multisystem inflammatory syndrome

CDC on COVID-19-associated multisystem inflammatory syndrome

COVID-19-associated multisystem inflammatory syndrome in the news

Blogs on COVID-19-associated multisystem inflammatory syndrome

Directions to Hospitals Treating Psoriasis

Risk calculators and risk factors for COVID-19-associated multisystem inflammatory syndrome

For COVID-19 frequently asked inpatient questions, click here

For COVID-19 frequently asked outpatient questions, click here

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Harmeet Kharoud M.D.[2]

Synonyms and keywords: Multisystem Inflammatory Syndrome in Children (MIS-C)

Overview

Multisystem Inflammatory Syndrome in Children (MIS-C) is a condition that causes inflammation of some parts of the body like heart, blood vessels, kidneys, digestive system, brain, skin, or eyes. According to recent evidence, it is suggested that children with MIS-C had antibodies against COVID-19 suggesting children had COVID-19 infection in the past. This syndrome appears to be similar in presentation to Kawasaki disease, hence also called Kawasaki -like a disease. It also shares features with staphylococcal and streptococcal toxic shock syndromes, bacterial sepsis, and macrophage activation syndromes.[1]

Historical Perspective

Classification of Disease Severity of MIS-C

  • Mild Disease
  • Children with MIS-C fall under this category who-
    • require minimal to no respiratory support.
    • minimal to no organ injury
    • normotensive
    • Do not meet the criteria for ICU admission.
  • Severe Disease
  • Children with MIS-C fall under this category who-
    • have significant oxygen requirements (HFNC, BiPAP, mechanical ventilation).
    • have a mild-severe organ injury and ventricular dysfunction.
    • have a vasoactive requirement.
    • meet the criteria for ICU admissions

Pathophysiology

Differentiating Any Disease from other disease

Epidemiology and Demographics

  • According to a recent study among the 186 children with MIS-C, the rate of hospitalization was 12% between March 16 and April 15 and 88% between April 16 and May 20.
  • 80% of the children were admitted to the intensive care unit and 20% of the children required mechanical ventilation.
  • 4% of the children required extracorporeal membrane oxygenation.
  • The mortality rate among 186 children with MIS-C was 2%.

Age

  • Among the 186 children with MIS-C distribution of age group was
    • <1yr-7%
    • 1-4yr-28%
    • 5-9yr-25%
    • 10-14yr-24%
    • 15-20yr-16%.

Gender

  • Among the 186 children with MIS-C

Comorbidities

  • Children with MIS-C had following underlying comorbidities.
    • Clinically diagnosed Obesity-8%
    • BMI-Based Obesity-29%
    • Cardiovascular diasease-3%
    • Respiratory disease-18%
    • Autoimmune disease or immunocompromising condition-5%

Organ System Involved

  • 71% of children had involvement of at least four organ systems.

The most common organ system involved in MIS-C children among a total of 183 children were.

  • Gastrointestinal(92%)
  • Cardiovascular(80%)
  • Hematologic(76%)
  • Mucocutaneous(74%)
  • Pulmonary(70%)
  • Historical perspective

Risk Factors

Natural History, Complications and Prognosis

Natural history

Complications

Prognosis

Diagnosis

Diagnostic Criteria

Preliminary WHO case definition: Children and adolescents
  • 0–19 years of age with fever >3 days

AND

  • Two of the following:
  1. Rash or bilateral non-purulent conjunctivitis or mucocutaneous inflammation signs (oral, hands or feet)
  2. Hypotension or shock
  3. Features of myocardial dysfunction, pericarditis, valvulitis, or coronary abnormalities (including ECHO findings or elevated Troponin/NT-proBNP)
  4. Evidence of coagulopathy (by PT, PTT, elevated D-Dimers)
  5. Acute gastrointestinal problems (diarrhea, vomiting, or abdominal pain)

AND

AND

AND

  • Evidence of COVID-19 (RT-PCR, antigen test or serology-positive), or likely contact with patients with COVID-19
CDC Case Definition for MIS-C
  • An individual aged <21 years presenting with fever, laboratory evidence of inflammation**, and evidence of clinically severe illness requiring hospitalization, with multisystem (>2) organ involvement (cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic or neurological);

AND

No alternative plausible diagnoses;

AND

Positive for current or recent SARS-CoV-2 infection by RT-PCR, serology, or antigen test; or exposure to a suspected or confirmed COVID-19 case within the 4 weeks prior to the onset of symptoms.

Signs and Symptoms

  • Fever lasting 24 hours or longer.ref name=":2">"Guidance: Paediatric multisystem inflammatory syndrome temporally associated with COVID-19" (PDF). line feed character in |title= at position 46 (help)</ref>
  • Vomiting
  • Diarrhea
  • Abdominal pain
  • Skin rash
  • Conjuctivitis
  • High ESR
  • Redness or swelling of the lips and tongue
  • Lethargy
  • Redness or swelling of the hands or feet
  • Confusion
  • Headache
  • Sore throat
  • Syncope
  • Lymphadenopathy

Emergency Warning Signs

Physical Examination

Laboratory Findings

Blood Investigations

Inflammatory biomarkers

Elevation of inflammatory markers including ESR, C reactive protein and procalcitonin are usually seen in MIS-C. Increased level of Interleukin-6 (IL-6), Interleukin-10(IL-10) d-dimer, serum ferritin, prothrombin time have also been seen in MIS-C.

Cardiac biomarkers

Elevation of cardic enzymes including cardiac troponins (cardiac troponin I(cTnI) and cardiac troponin T (cTnT)) and Brain natriuretic peptide (BNP)) has been observed in MIS-C patients.

Radiological Findings

  • Following Radiological Findings are observed in MIS-C patients.
Test Findings
Chest Xray patchy symmetrical infiltrates, pleural effusion
Echocardiogram and EKG myocarditis, valvulitis, pericardial effusion, coronary artery dilatation
Abdominal USG colitis, ileitis, lymphadenopathy, ascites, hepatosplenomegaly

Blood Culture, Viral PCR

  • Absence of other potential causative organisms. IgGlevels and IgM levels of SARS-CoV-2 are detected.

Treatment

Medical Therapy

  • All the children with MIS-C are treated as suspected COVID-19.
  • Mild to Moderate cases of MIS-C are managed supportively.
  • Supplemental oxygen is required in children with low oxygen saturation.
  • Fluid resuscitation in 10 ml/kg aliquots with reevaluation after each bolus. Maintain euvolemia. Avoid hypervolemia.
  • Anti-inflammatory treatments with Intravenous immunoglobulin(IVIG) with or without corticosteroids have shown a good response rate.
  • Aspirin has been used primarily for its antiplatelet effect. It is recommended in all patients with MIS-C.[2]
  • Anakinra is considered if fevers last more than 24 hours post steroids/IVIG or in the moderate or severe presentation.
  • Tocilizumab is also considered if fevers last more than 24 hours post steroids/IVIG or in the moderate or severe presentation.
  • Empiric antibiotics like vancomycin, ceftriaxone, and clindamycin are given for community-acquired shock presentation until cultures are negative for 48 hours.
Presentation Treatment
Mild Disease
  • Symptomatic Treatment
Severe Disease


Prevention of MIS-C

  • MIS-C can be prevented by reducing the risk of child exposure to COVID-19 infection.

References