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| __NOTOC__
| | [[Syncope]] is classified into three types: |
| == Diagnosis ==
| | * [[Cardiac]] |
| ===Diagnostic Criteria===
| | * [[Neurogenic]] |
| In May 2020, the Centers for Disease Control and Prevention (CDC) set the criteria for multisystem inflammatory syndrome in children (MIS-C):<ref name="FeldsteinRose2020">{{cite journal|last1=Feldstein|first1=Leora R.|last2=Rose|first2=Erica B.|last3=Horwitz|first3=Steven M.|last4=Collins|first4=Jennifer P.|last5=Newhams|first5=Margaret M.|last6=Son|first6=Mary Beth F.|last7=Newburger|first7=Jane W.|last8=Kleinman|first8=Lawrence C.|last9=Heidemann|first9=Sabrina M.|last10=Martin|first10=Amarilis A.|last11=Singh|first11=Aalok R.|last12=Li|first12=Simon|last13=Tarquinio|first13=Keiko M.|last14=Jaggi|first14=Preeti|last15=Oster|first15=Matthew E.|last16=Zackai|first16=Sheemon P.|last17=Gillen|first17=Jennifer|last18=Ratner|first18=Adam J.|last19=Walsh|first19=Rowan F.|last20=Fitzgerald|first20=Julie C.|last21=Keenaghan|first21=Michael A.|last22=Alharash|first22=Hussam|last23=Doymaz|first23=Sule|last24=Clouser|first24=Katharine N.|last25=Giuliano|first25=John S.|last26=Gupta|first26=Anjali|last27=Parker|first27=Robert M.|last28=Maddux|first28=Aline B.|last29=Havalad|first29=Vinod|last30=Ramsingh|first30=Stacy|last31=Bukulmez|first31=Hulya|last32=Bradford|first32=Tamara T.|last33=Smith|first33=Lincoln S.|last34=Tenforde|first34=Mark W.|last35=Carroll|first35=Christopher L.|last36=Riggs|first36=Becky J.|last37=Gertz|first37=Shira J.|last38=Daube|first38=Ariel|last39=Lansell|first39=Amanda|last40=Coronado Munoz|first40=Alvaro|last41=Hobbs|first41=Charlotte V.|last42=Marohn|first42=Kimberly L.|last43=Halasa|first43=Natasha B.|last44=Patel|first44=Manish M.|last45=Randolph|first45=Adrienne G.|title=Multisystem Inflammatory Syndrome in U.S. Children and Adolescents|journal=New England Journal of Medicine|year=2020|issn=0028-4793|doi=10.1056/NEJMoa2021680}}</ref>
| | * [[Vasovagal syncope|vasovagal]] |
| | |
| * Severe disease course leading to hospitalization
| |
| * Individuals younger than 21 years old
| |
| * Fever (body temperature, >38.0°C) or report of subjective fever present at least 24 hours
| |
| * Laboratory evidence of inflammation
| |
| * Multisystem organ involvement (at least two systems)
| |
| * Laboratory-confirmed SARS-CoV-2 infection
| |
| | |
| === History and Symptoms ===
| |
| COVID-19 associated multisystem inflammatory syndrome is associated with the following symptoms:<ref name="FeldsteinRose2020">{{cite journal|last1=Feldstein|first1=Leora R.|last2=Rose|first2=Erica B.|last3=Horwitz|first3=Steven M.|last4=Collins|first4=Jennifer P.|last5=Newhams|first5=Margaret M.|last6=Son|first6=Mary Beth F.|last7=Newburger|first7=Jane W.|last8=Kleinman|first8=Lawrence C.|last9=Heidemann|first9=Sabrina M.|last10=Martin|first10=Amarilis A.|last11=Singh|first11=Aalok R.|last12=Li|first12=Simon|last13=Tarquinio|first13=Keiko M.|last14=Jaggi|first14=Preeti|last15=Oster|first15=Matthew E.|last16=Zackai|first16=Sheemon P.|last17=Gillen|first17=Jennifer|last18=Ratner|first18=Adam J.|last19=Walsh|first19=Rowan F.|last20=Fitzgerald|first20=Julie C.|last21=Keenaghan|first21=Michael A.|last22=Alharash|first22=Hussam|last23=Doymaz|first23=Sule|last24=Clouser|first24=Katharine N.|last25=Giuliano|first25=John S.|last26=Gupta|first26=Anjali|last27=Parker|first27=Robert M.|last28=Maddux|first28=Aline B.|last29=Havalad|first29=Vinod|last30=Ramsingh|first30=Stacy|last31=Bukulmez|first31=Hulya|last32=Bradford|first32=Tamara T.|last33=Smith|first33=Lincoln S.|last34=Tenforde|first34=Mark W.|last35=Carroll|first35=Christopher L.|last36=Riggs|first36=Becky J.|last37=Gertz|first37=Shira J.|last38=Daube|first38=Ariel|last39=Lansell|first39=Amanda|last40=Coronado Munoz|first40=Alvaro|last41=Hobbs|first41=Charlotte V.|last42=Marohn|first42=Kimberly L.|last43=Halasa|first43=Natasha B.|last44=Patel|first44=Manish M.|last45=Randolph|first45=Adrienne G.|title=Multisystem Inflammatory Syndrome in U.S. Children and Adolescents|journal=New England Journal of Medicine|year=2020|issn=0028-4793|doi=10.1056/NEJMoa2021680}}</ref>
| |
| *[[Fever]] lasting 24 hours or longer.
| |
| *[[Vomiting]]
| |
| *[[Diarrhea]]
| |
| *[[Abdominal pain]]
| |
| *[[Shortness of breath|Difficulty Breathing]]
| |
| *[[Chest pain]]
| |
| *[[Headache]]
| |
| *[[Sore throat]]
| |
| *[[Confusion|New onset confusion]]
| |
| ===Physical Examination===
| |
| COVID-19 associated multisystem inflammatory syndrome is associated with the following physical examination findings:<ref name="FeldsteinRose2020">{{cite journal|last1=Feldstein|first1=Leora R.|last2=Rose|first2=Erica B.|last3=Horwitz|first3=Steven M.|last4=Collins|first4=Jennifer P.|last5=Newhams|first5=Margaret M.|last6=Son|first6=Mary Beth F.|last7=Newburger|first7=Jane W.|last8=Kleinman|first8=Lawrence C.|last9=Heidemann|first9=Sabrina M.|last10=Martin|first10=Amarilis A.|last11=Singh|first11=Aalok R.|last12=Li|first12=Simon|last13=Tarquinio|first13=Keiko M.|last14=Jaggi|first14=Preeti|last15=Oster|first15=Matthew E.|last16=Zackai|first16=Sheemon P.|last17=Gillen|first17=Jennifer|last18=Ratner|first18=Adam J.|last19=Walsh|first19=Rowan F.|last20=Fitzgerald|first20=Julie C.|last21=Keenaghan|first21=Michael A.|last22=Alharash|first22=Hussam|last23=Doymaz|first23=Sule|last24=Clouser|first24=Katharine N.|last25=Giuliano|first25=John S.|last26=Gupta|first26=Anjali|last27=Parker|first27=Robert M.|last28=Maddux|first28=Aline B.|last29=Havalad|first29=Vinod|last30=Ramsingh|first30=Stacy|last31=Bukulmez|first31=Hulya|last32=Bradford|first32=Tamara T.|last33=Smith|first33=Lincoln S.|last34=Tenforde|first34=Mark W.|last35=Carroll|first35=Christopher L.|last36=Riggs|first36=Becky J.|last37=Gertz|first37=Shira J.|last38=Daube|first38=Ariel|last39=Lansell|first39=Amanda|last40=Coronado Munoz|first40=Alvaro|last41=Hobbs|first41=Charlotte V.|last42=Marohn|first42=Kimberly L.|last43=Halasa|first43=Natasha B.|last44=Patel|first44=Manish M.|last45=Randolph|first45=Adrienne G.|title=Multisystem Inflammatory Syndrome in U.S. Children and Adolescents|journal=New England Journal of Medicine|year=2020|issn=0028-4793|doi=10.1056/NEJMoa2021680}}</ref>
| |
| *[[Skin rash]]
| |
| *[[Conjuctivitis]]
| |
| *Redness or swelling of the lips and tongue
| |
| *[[Redness]] or swelling of the hands or feet
| |
| *[[Lymphadenopathy]]
| |
| *[[Lethargy]]
| |
| *[[Cyanosis]]
| |
| ===Laboratory Findings===
| |
| COVID-19 associated multisystem inflammatory syndrome is associated with the following laboratory findings:<ref name="FeldsteinRose2020">{{cite journal|last1=Feldstein|first1=Leora R.|last2=Rose|first2=Erica B.|last3=Horwitz|first3=Steven M.|last4=Collins|first4=Jennifer P.|last5=Newhams|first5=Margaret M.|last6=Son|first6=Mary Beth F.|last7=Newburger|first7=Jane W.|last8=Kleinman|first8=Lawrence C.|last9=Heidemann|first9=Sabrina M.|last10=Martin|first10=Amarilis A.|last11=Singh|first11=Aalok R.|last12=Li|first12=Simon|last13=Tarquinio|first13=Keiko M.|last14=Jaggi|first14=Preeti|last15=Oster|first15=Matthew E.|last16=Zackai|first16=Sheemon P.|last17=Gillen|first17=Jennifer|last18=Ratner|first18=Adam J.|last19=Walsh|first19=Rowan F.|last20=Fitzgerald|first20=Julie C.|last21=Keenaghan|first21=Michael A.|last22=Alharash|first22=Hussam|last23=Doymaz|first23=Sule|last24=Clouser|first24=Katharine N.|last25=Giuliano|first25=John S.|last26=Gupta|first26=Anjali|last27=Parker|first27=Robert M.|last28=Maddux|first28=Aline B.|last29=Havalad|first29=Vinod|last30=Ramsingh|first30=Stacy|last31=Bukulmez|first31=Hulya|last32=Bradford|first32=Tamara T.|last33=Smith|first33=Lincoln S.|last34=Tenforde|first34=Mark W.|last35=Carroll|first35=Christopher L.|last36=Riggs|first36=Becky J.|last37=Gertz|first37=Shira J.|last38=Daube|first38=Ariel|last39=Lansell|first39=Amanda|last40=Coronado Munoz|first40=Alvaro|last41=Hobbs|first41=Charlotte V.|last42=Marohn|first42=Kimberly L.|last43=Halasa|first43=Natasha B.|last44=Patel|first44=Manish M.|last45=Randolph|first45=Adrienne G.|title=Multisystem Inflammatory Syndrome in U.S. Children and Adolescents|journal=New England Journal of Medicine|year=2020|issn=0028-4793|doi=10.1056/NEJMoa2021680}}</ref>
| |
| *[[Erythrocyte sedimentation rate|High ESR]]
| |
| *[[Lymphopenia]]
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| * [[Neutrophilia]]
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| *[[Anemia]]
| |
| *[[Thrombocytopenia]]
| |
| Less common laboratory findings include:
| |
| * [[Fibrinogen|Abnormal fibrinogen]] | |
| * [[Hypoalbuminaemia]]
| |
| * Elevated [[Creatine kinase|creatiine kinase]] (CK)
| |
| * Elevated [[Lactate dehydrogenase|LDH]]
| |
| * Elevated [[Triglyceride|triglycerides]]
| |
| ==== 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 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.
| |
| * To view the complete physical examination in COVID-19, [[COVID-19 physical examination|click here]].
| |
| * To view the laboratory findings on COVID-19, [[COVID-19 laboratory findings|click here]].
| |
| ===Electrocardiogram===
| |
| * To view the electrocardiogram findings on COVID-19, [[COVID-19 electrocardiogram|click here]].<br />
| |
| ===X-ray===
| |
| * X-ray of patients with COVID-19 associated multiorgan system inflammatory syndrome may be normal. When abnormal, findings may include the followings:<ref name="HameedElbaaly2020">{{cite journal|last1=Hameed|first1=Shema|last2=Elbaaly|first2=Heba|last3=Reid|first3=Catriona E. L.|last4=Santos|first4=Rui M. F.|last5=Shivamurthy|first5=Vinay|last6=Wong|first6=James|last7=Jogeesvaran|first7=K. Haran|title=Spectrum of Imaging Findings on Chest Radiographs, US, CT, and MRI Images in Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with COVID-19|journal=Radiology|year=2020|pages=202543|issn=0033-8419|doi=10.1148/radiol.2020202543}}</ref>
| |
| **Peribronchial cuffing
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| **Perihilar interstitial thickening
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| **Perihilar opacification
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| **Perihilar consolidation
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| **Low volume pleural effusion affecting both lungs
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| **Left lower lobe atelectasis
| |
| ===Echocardiography or Ultrasound===
| |
| | |
| *
| |
| * To view the echocardiographic findings on COVID-19, [[COVID-19 echocardiography and ultrasound|click here]].<br />
| |
| | |
| ===CT scan===
| |
| | |
| *
| |
| *To view the CT scan findings on COVID-19, [[COVID-19 CT scan|click here]].
| |
| | |
| ===MRI===
| |
| | |
| *
| |
| * To view the MRI findings on COVID-19, [[COVID-19 MRI|click here]].<br />
| |
| | |
| ===Other Imaging Findings===
| |
| | |
| *
| |
| * To view other imaging findings on COVID-19, [[COVID-19 other imaging findings|click here]].<br />
| |
| | |
| ===Other Diagnostic Studies===
| |
| | |
| * To view other diagnostic studies for COVID-19, [[COVID-19 other diagnostic studies|click here]].<br />
| |
| | |
| | |
| == Treatment ==
| |
| === Medical Therapy ===
| |
| | |
| *All the children with MIS-C are treated as suspected [[COVID-19|COVID-19.]]
| |
| *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
| |
| 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
| |
| Syndrome in Children (MIS-C)|last=|first=|date=|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref>
| |
| *Supplemental [[oxygen]] is required in children with low oxygen saturation.<ref name="A2"/>
| |
| *[[Fluid replacement|Fluid resuscitation]] in 10 ml/kg aliquots with reevaluation after each bolus. Maintain euvolemia. Avoid hypervolemia.<ref name="A2"/>
| |
| *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"/>
| |
| *[[Aspirin]] has been used primarily for its antiplatelet effect. It is recommended in all patients with [[MIS-C]].<ref name="A1""/><ref name="A2"/>
| |
| *[[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"/>
| |
| *[[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"/>
| |
| *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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| |-
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| |Severe Disease||
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| *Symptomatic Treatment
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| *[[Intravenous immunoglobulin|IVIG(IV)]] | |
| *[[Corticosteroid|Corticosteroids]](IV/PO) | |
| *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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| == Prevention of MIS-C ==
| |
| | |
| *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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| ! style="padding: 5px 5px; background: #DCDCDC; " align="left"|
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| |-
| |
| ! style="padding: 5px 5px; background: #DCDCDC;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| |-
| |
| ! style="padding: 5px 5px; background: #DCDCDC;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| |-
| |
| ! style="padding: 5px 5px; background: #DCDCDC;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| |-
| |
| ! style="padding: 5px 5px; background: #DCDCDC;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| |-
| |
| ! style="padding: 5px 5px; background: #DCDCDC; " align="left" |
| |
| | |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| | style="padding: 5px 5px; background: #F5F5F5;" align="left" |
| |
| |-
| |
| ! style="padding: 5px 5px; background: #DCDCDC; " align="left"|
| |
| !
| |
| !
| |
| !
| |
| !
| |
| !
| |
| !
| |
| !
| |
| !
| |
| !
| |
| |-
| |
| !
| |
| !
| |
| !
| |
| !
| |
| !
| |
| !
| |
| !
| |
| !
| |
| !
| |
| !
| |
| |}
| |
| <references />
| |