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| __NOTOC__
| | [[Syncope]] is classified into three types: |
| == Diagnosis ==
| | * [[Cardiac]] |
| ===Diagnostic Criteria===
| | * [[Neurogenic]] |
| =====Preliminary [[World Health Organization|WHO]] case definition: Children and adolescents=====
| | * [[Vasovagal syncope|vasovagal]] |
| | |
| *0–19 years of age with [[fever]] >3 days<ref >{{Cite web|url=https://www.who.int/news-room/commentaries/detail/multisystem-inflammatory-syndrome-in-children-and-adolescents-with-covid-19|title=Multisystem inflammatory syndrome in children and adolescents temporally related to COVID-19|first=|date=|website=|archive-url=|archive-date=15 May 2020|dead-url=|access-date=}}</ref>
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| AND
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| *Two of the following:
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| #[[Rash]] or bilateral non-purulent [[conjunctivitis]] or mucocutaneous inflammation signs (oral, hands or feet)
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| #Hypotension or shock
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| #Features of myocardial dysfunction, [[pericarditis]], [[valvulitis]], or coronary abnormalities (including ECHO findings or elevated [[Troponin]]/[[NT-proBNP]])
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| #Evidence of [[coagulopathy]] (by PT, [[Partial thromboplastin time|PTT]], elevated [[D-dimer|D-Dimers]])
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| #Acute gastrointestinal problems ([[diarrhea]], [[vomiting]], or [[abdominal pain]])
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| AND
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| *Elevated markers of [[inflammation]] such as [[Erythrocyte sedimentation rate|ESR]], [[C-reactive protein]], or [[procalcitonin]]
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| AND
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| *No other obvious microbial cause of [[inflammation]], including bacterial [[sepsis]], [[staphylococcal]] or [[streptococcal]] shock syndromes
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| AND
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| *Evidence of [[COVID-19|COVID]]-19 ([[Reverse transcription-polymerase chain reaction|RT-PCR]], antigen test or serology-positive), or likely contact with patients with [[COVID-19|COVID]]-19
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| =====CDC Case Definition for MIS-C=====
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| *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);<ref >{{Cite web|url=https://www.cdc.gov/mis-c/hcp/|title=CDC case definationlast=|first=|date=|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref>
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| AND
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| No alternative plausible diagnoses;
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| AND
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| 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.
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| === Signs and Symptoms ===
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| *[[Fever]] lasting 24 hours or longer.<ref name="CC""/>
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| *[[Vomiting]]<ref name="CC""/>
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| *[[Diarrhea]]<ref name="CC""/>
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| *[[Abdominal pain]]<ref name="CC""/>
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| *[[Skin rash]]<ref name="CC""/>
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| *[[Conjuctivitis]]<ref name="CC""/>
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| *[[Erythrocyte sedimentation rate|High ESR]]<ref name="CC""/>
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| *Redness or swelling of the lips and tongue<ref name="CC""/>
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| *[[Lethargy]]<ref name="CC""/>
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| *[[Redness]] or swelling of the hands or feet<ref name="CC""/>
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| *[[Confusion]]<ref name="CC""/>
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| *[[Headache]]<ref name="CC""/>
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| *[[Sore throat]]<ref name="CC""/>
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| *[[Syncope]]<ref name="CC""/>
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| *[[Lymphadenopathy]]<ref name="CC""/> | |
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| '''Emergency Warning Signs'''
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| *[[Shortness of breath|Difficulty Breathing]]<ref name="CC""/>
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| *[[Chest pain]]
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| *[[Confusion|New onset confusion]]
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| *[[Lethargy]]
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| *[[Cyanosis]]
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| *[[Abdominal pain]]
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| === Physical Examination ===
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| '''Blood Investigations'''
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| *[[Lymphopenia]], [[Neutrophilia]], [[Anemia]], [[Thrombocytopenia]] have been seen in MIS-C pateints. [[Fibrinogen|Abnormal fibrinogen]], [[Hypoalbuminaemia]], elevated [[Creatine kinase|creatiine kinase]] (CK), [[Lactate dehydrogenase|LDH]], [[Triglyceride|triglycerides]] have been observed in MIS-C patients.<ref name="CC""/>
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| ==== Inflammatory biomarkers ====
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| 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.<ref name="CC""/>
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| ==== Cardiac biomarkers ====
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| Elevation of cardic enzymes including [[Cardiac troponin|cardiac troponins]] ([[Cardiac troponin I (cTnI) and T (cTnT)|cardiac troponin I(cTnI) and cardiac troponin T (cTnT)]]) and [[Brain natriuretic peptide]] ([[BNP]])) has been observed in MIS-C patients.<ref name="CC""/>
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| === Radiological Findings ===
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| * Following Radiological Findings are observed in MIS-C patients.<ref name="CC""/>
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| {| border="1" cellpadding="2"
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| ! width="225" |Test
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| ! width="225" |Findings
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| |-
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| |Chest Xray||patchy symmetrical infiltrates, [[pleural effusion]]
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| |-
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| |Echocardiogram and EKG||[[myocarditis]], valvulitis, [[pericardial effusion]], coronary artery dilatation
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| |-
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| |Abdominal USG||[[colitis]], [[ileitis]], [[lymphadenopathy]], [[ascites]], [[hepatosplenomegaly]]
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| |}
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| '''Blood Culture, Viral PCR'''
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| * Absence of other potential causative organisms. IgG levels and IgM levels of [[SARS-CoV-2]] are detected.
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| == Treatment ==
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| === Medical Therapy ===
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| *All the children with MIS-C are treated as suspected [[COVID-19|COVID-19.]]
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| *Mild to Moderate cases of MIS-C are managed supportively.<ref name="A1"">{{Cite web|url=https://www.chop.edu/clinical-pathway/multisystem-inflammatory-syndrome-mis-c-clinical-pathway|title=Emergency Department, ICU and Inpatient Clinical Pathway for
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| Evaluation of Possible Multisystem Inflammatory Syndrome (MIS-C)|last=|first=|date=|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref><ref name="A2">{{Cite web|url=https://www.chkd.org/uploadedFiles/Documents/COVID-19/CHKD%20MIS-C%20Guideline%20D2.pdf|title= Evaluation and Management of COVID-19 Multisystem Inflammatory
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| Syndrome in Children (MIS-C)|last=|first=|date=|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref>
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| *Supplemental [[oxygen]] is required in children with low oxygen saturation.<ref name="A2"/>
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| *[[Fluid replacement|Fluid resuscitation]] in 10 ml/kg aliquots with reevaluation after each bolus. Maintain euvolemia. Avoid hypervolemia.<ref name="A2"/>
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| *Anti-inflammatory treatments with [[Intravenous immunoglobulin|Intravenous immunoglobulin(IVIG]]) with or without [[Corticosteroid|corticosteroids]] have shown a good response rate.<ref name="A1""/><ref name="A2"/>
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| *[[Aspirin]] has been used primarily for its antiplatelet effect. It is recommended in all patients with [[MIS-C]].<ref name="A1""/><ref name="A2"/>
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| *[[Anakinra]] is considered if fevers last more than 24 hours post [[Steroid|steroids]]/[[Intravenous immunoglobulin|IVIG]] or in the moderate or severe presentation.<ref name="A1""/><ref name="A2"/>
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| *[[Tocilizumab]] is also considered if fevers last more than 24 hours post steroids/IVIG or in the moderate or severe presentation.<ref name="A1""/><ref name="A2"/>
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| *Empiric antibiotics like [[vancomycin]], [[ceftriaxone]], and [[clindamycin]] are given for community-acquired shock presentation until cultures are negative for 48 hours.<ref name="A1""/><ref name="A2"/>
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| {| border="1" cellpadding="2"
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| ! width="225" |Presentation
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| ! width="225" |Treatment
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| |-
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| |Mild Disease||
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| *Symptomatic Treatment | |
| |-
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| |Severe Disease||
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| *Symptomatic Treatment
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| *[[Intravenous immunoglobulin|IVIG(IV)]]
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| *[[Corticosteroid|Corticosteroids]](IV/PO)
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| *Consider adding [[Anakinra]] or [[Tocilizumab]] if [[fever]] persist for more than 24 hours post [[Steroid|steroids]] and I[[Intravenous immunoglobulin|VIG]] use.
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| |}
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| == Prevention of MIS-C ==
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| *MIS-C can be prevented by reducing the risk of child exposure to [[COVID-19|COVID]]-19 infection. | |
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| == References ==
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| {{Reflist|2}}
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| '''Bold text'''
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| ! colspan="10" style="background: #4479BA; width: 150px;" | {{fontcolor|#FFF|Wikidoc Textbook of Medicine}}
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| ! style="background: #4479BA; width: 150px;" |{{fontcolor|#FFF| Name/Project}}
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| ! style="background: #4479BA; width: 150px;" |{{fontcolor|#FFF| Cardiology}}
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| ! style="background: #4479BA; width: 150px;" |{{fontcolor|#FFF| Pulmonary}}
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| ! style="background: #4479BA; width: 150px;" |{{fontcolor|#FFF| Pediatrics}}
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| ! style="background: #4479BA; width: 150px;" |{{fontcolor|#FFF| Emergency}}
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| ! colspan="10" style="background: #4479BA; width: 150px;" | {{fontcolor|#FFF|'''Name of Scholars working on the project'''}}
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| ! style="background: #4479BA; width: 150px;" | {{fontcolor|#FFF| Name/Project}}
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| ! style="background: #4479BA; width: 150px;" | {{fontcolor|#FFF| Hematology}}
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| ! style="background: #4479BA; width: 150px;" | {{fontcolor|#FFF| Oncology}}
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| ! style="background: #4479BA; width: 150px;" | {{fontcolor|#FFF| Gastroenterology}}
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| <references />
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