A Novel Pediatric Multisystem Inflammatory Syndrome During the COVID-19 Pandemic

Abstract

In late March and early April, New York City was an epicenter of the COVID-19 pandemic. Citizens were ordered to stay at home to flatten the curve. The adult population was affected with a severe respiratory illness as well as acute kidney injury, cardiomyopathy, arrhythmia, and thromboembolism. Although children were not affected in the same manner, weeks after the peak, reports from other countries emerged about cases of pediatric patients presenting with a novel inflammatory syndrome. We present 4 patients along with their emergency department course, so providers will have a better understanding of the identification and workup of these patients. Currently, it is unclear when this inflammatory syndrome develops in respect to a COVID-19 infection. The clinical features of this syndrome seem to overlap between Kawasaki disease, toxic shock syndrome, and myocarditis. All patients presenting to our emergency department had fever, variable rash, abdominal pain, vomiting, and/or diarrhea. Patients remained persistently tachycardic and febrile despite being given proper doses of antipyretics. Severity of presentations varied among the 4 cases. All 4 patients were found to have antibodies to COVID-19. All patients required admission, but 2 required the pediatric intensive care unit for cardiac and/or respiratory support or closer monitoring. Upon follow-up on our patients, it seems that most patients are recovering with treatment, and overall, there is a low reported mortality rate.

Multisystem Inflammatory Syndrome in Children (MISC): a systematic review

“…Nine studies reported pro-BNP and BNP values (lowest median value of 410pg/ml and 120pg/ml, respectively). 11,13,19,32,33,35,37,40,41 Coagulation parameters as D-dimers and fibrinogen were reported in 27 studies with elevated median values in all patients. D-dimers median values were above 250ng/ml or 0.4mcg/ml and fibrinogen median values ranging from 503-931mg/dl.…”

“…The age at onset was reported in all included studies, except one. 32 Children were between one month to 21 years-old, including 24 infants and median age was nine years-old in most studies. 62% were male, with a male:female ratio of 1.6:1.…”

“…40 The proportion of hypotension was not specified in most studies, but in those which it had, more than 50% presented it. 11,16,18,21,25,28,32 Neurologic features were reported in ten studies, with aseptic meningitis being the most common and only two reported cases of seizures. 11,13,21,26,28,29,31,[34][35][36] Two studies addressed hepatitis and acute kidney injury related to MISC with a prevalence of 49% and 25%, respectively.…”

“…25 Besides six studies discussing clinical and laboratories features resembling toxic shock syndrome or macrophage activation syndrome, only one compared immunologic features of MISC and macrophage activation syndrome and found that children with MISC had lower levels of ferritin (median values of 4594ng/ml versus 537ng/ml) and lower levels of IL-2 receptor, IL-18 and CXCL9 (a surrogate marker for interferon). 24,25,[31][32][33]45 Four studies [19][20][21]25 compared children with MISC and with COVID-19 without MISC, and demonstrated that children with MISC had a predominance of male gender (80% versus51%) 25 , higher prevalence of gastrointestinal symptoms (67% versus 22%) 21 , and increased inflammatory markers such as CRP, ferritin and IL-6 and higher levels of D-dimers. [19][20][21]25 Diagnostic testing: SARS-CoV-2 and laboratory evaluation All included studies, except two 14,28 , reported results of SARS-CoV-2 RT-PCR or serology tests.…”

“…14,18,29,30,34,35,40,42 COVID-19 exposure within the four weeks prior to the onset of symptoms was mentioned in 12 studies for 139 patients (26%). 11,14,18,19,26,29,30,32,37,40,42 Table 2 summarizes SARS-CoV-2 testing results and exposure reported by each study.…”