Multisystem Inflammatory Syndrome in Children Associated With SARS-CoV-2 Infection in KwaZulu-Natal, South Africa

Abstract

Background: Multisystem inflammatory syndrome in children (MIS-C) following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been infrequently described in Africa. Objective: To describe the clinical characteristics, outcomes and associations of severe disease in children hospitalized with MIS-C in KwaZulu-Natal. Methods: Retrospective multicenter study of children (0–13 years) who met the Centers for Disease Control and Prevention criteria for MIS-C. Children with shock were compared with children without shock to determine the characteristics of severe MIS-C. Results: Twenty-nine children with MIS-C were identified, the mean age was 55 (SD ±45) months, 25 (86%) were Black-African, and 8 (28%) had pre-existing comorbidities. The predominant presenting symptoms included fever 29 (100%), gastrointestinal symptoms 25 (83%), skin rash 19 (65%), and shock 17 (59%). Children with shock had significantly increased CRP ( P = 0.01), ferritin ( P < 0.001), troponin-T ( P = 0.02), B-type natriuretic peptide (BNP) ( P = 0.01), and lower platelets ( P = 0.01). Acute kidney injury ( P = 0.01), cardiac involvement ( P = 0.02), and altered levels of consciousness ( P = 0.03) were more common in children with shock. The median length of hospital stay was 11 (IQR 7–19) days, with a mortality of 20.6%. Children who did not survive had significantly higher ferritin levels 1593 (IQR 1069–1650) ng/mL versus 540 (IQR 181–1156) ng/mL; P = 0.03) and significantly more required mechanical ventilation (OR 18; confidence interval 1.7–191.5; P = 0.005). Conclusions: Hospitalized children with MIS-C in KwaZulu-Natal had more aggressive disease and higher mortality than children in better-resourced settings. Markedly elevated biomarkers and critical organ involvement were associated with severe disease. Risk factors for poor outcomes include higher ferritin levels and the need for mechanical ventilation.

Short-term outcomes of South African children with multisystem inflammatory syndrome in children: a prospective cohort study

“…This study adds to expanding data on the outcomes of African children with MIS-C. As in the cohort from Nigeria10 and Kenya,28 overall outcomes were good, and no children required a biologic agent. It is, however, in contrast with data recently published from KwaZulu Natal, South Africa,13 Pakistan14 and Egypt,29 where the mortality was reported to be very high (20.6%, 20% and 33.3%, respectively). Critical shortage of intensive care beds is reported from Nigeria and KwaZulu Natal.…”

“…Three cases showed a reduction in ejection fraction, 1 case with persistent coronary artery dilatation and 3 of the 11 cases with abnormalities persisting throughout the 6-month follow-up phase. This contrasts the Nigerian cohort which demonstrated normalisation of cardiovascular manifestations by 6 months in all 13…”

“…In KwaZulu Natal, limited intensive care space and delay in access to specialised care may have contributed to the high mortality. In addition, African children may have more aggressive inflammation 13. We note that children from both the cohorts from Egypt and KwaZulu Natal had a median age <5 years.…”

“…Mortality appears to be higher in older children and those with comorbid diseases 12. In a recent report from KwaZulu Natal, South Africa, the mortality was reported much higher at 20.6%, similar to the 20% mortality in Pakistan 13 14. The mortality rate was 11.2% in a multicentre cohort including 135 children from India 15…”

Pediatric coronavirus disease 2019 in Africa

“…Five cohort studies describe 251 children with MIS-C from four countries, South Africa, Nigeria, Kenya and Egypt, with most data coming from South Africa (Table 2) [21 ▪▪ ,24 ▪▪ –27 ▪▪ ]. The median age of children across the studies was 4.0–7.5 years as opposed to 9 years in the USA [28].…”