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== Diagnosis ==
===Diagnostic Criteria===
=====Preliminary [[World Health Organization|WHO]] case definition: Children and adolescents=====


*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>
AND
*Two of the following:
#[[Rash]] or bilateral non-purulent [[conjunctivitis]] or mucocutaneous inflammation signs (oral, hands or feet)
#Hypotension or shock
#Features of myocardial dysfunction, [[pericarditis]], [[valvulitis]], or coronary abnormalities (including ECHO findings or elevated [[Troponin]]/[[NT-proBNP]])
#Evidence of [[coagulopathy]] (by PT, [[Partial thromboplastin time|PTT]], elevated [[D-dimer|D-Dimers]])
#Acute gastrointestinal problems ([[diarrhea]], [[vomiting]], or [[abdominal pain]])
AND
*Elevated markers of [[inflammation]] such as [[Erythrocyte sedimentation rate|ESR]], [[C-reactive protein]], or [[procalcitonin]]
AND
*No other obvious microbial cause of [[inflammation]], including bacterial [[sepsis]], [[staphylococcal]] or [[streptococcal]] shock syndromes
AND
*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
=====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);<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>
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="CC""/>
*[[Vomiting]]<ref name="CC""/>
*[[Diarrhea]]<ref name="CC""/>
*[[Abdominal pain]]<ref name="CC""/>
*[[Skin rash]]<ref name="CC""/>
*[[Conjuctivitis]]<ref name="CC""/>
*[[Erythrocyte sedimentation rate|High ESR]]<ref name="CC""/>
*Redness or swelling of the lips and tongue<ref name="CC""/>
*[[Lethargy]]<ref name="CC""/>
*[[Redness]] or swelling of the hands or feet<ref name="CC""/>
*[[Confusion]]<ref name="CC""/>
*[[Headache]]<ref name="CC""/>
*[[Sore throat]]<ref name="CC""/>
*[[Syncope]]<ref name="CC""/>
*[[Lymphadenopathy]]<ref name="CC""/>
'''Emergency Warning Signs'''
*[[Shortness of breath|Difficulty Breathing]]<ref name="CC""/>
*[[Chest pain]]
*[[Confusion|New onset confusion]]
*[[Lethargy]]
*[[Cyanosis]]
*[[Abdominal pain]]
=== Physical Examination ===
'''Blood Investigations'''
*[[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""/>
==== 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.<ref name="CC""/>
==== 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.<ref name="CC""/>
=== Radiological Findings ===
* Following Radiological Findings are observed in MIS-C patients.<ref name="CC""/>
{| border="1" cellpadding="2"
! width="225" |Test
! width="225" |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. IgG levels and IgM levels of [[SARS-CoV-2]] are detected.
== 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"/>
{| border="1" cellpadding="2"
! width="225" |Presentation
! width="225" |Treatment
|-
|Mild Disease||
*Symptomatic Treatment
|-
|Severe Disease||
*Symptomatic Treatment
*[[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.
|}
== Prevention of MIS-C ==
*MIS-C can be prevented by reducing the risk of child exposure to [[COVID-19|COVID]]-19 infection.
== References ==
{{Reflist|2}}




Revision as of 19:52, 13 July 2020

Diagnosis

Diagnostic Criteria

Preliminary WHO case definition: Children and adolescents
  • 0–19 years of age with fever >3 days[1]

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);[2]

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

Emergency Warning Signs

Physical Examination

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.[3]

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.[3]

Radiological Findings

  • Following Radiological Findings are observed in MIS-C patients.[3]
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. IgG levels 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.[4][5]
  • Supplemental oxygen is required in children with low oxygen saturation.[5]
  • Fluid resuscitation in 10 ml/kg aliquots with reevaluation after each bolus. Maintain euvolemia. Avoid hypervolemia.[5]
  • Anti-inflammatory treatments with Intravenous immunoglobulin(IVIG) with or without corticosteroids have shown a good response rate.[4][5]
  • Aspirin has been used primarily for its antiplatelet effect. It is recommended in all patients with MIS-C.[4][5]
  • Anakinra is considered if fevers last more than 24 hours post steroids/IVIG or in the moderate or severe presentation.[4][5]
  • Tocilizumab is also considered if fevers last more than 24 hours post steroids/IVIG or in the moderate or severe presentation.[4][5]
  • Empiric antibiotics like vancomycin, ceftriaxone, and clindamycin are given for community-acquired shock presentation until cultures are negative for 48 hours.[4][5]
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

  1. ↑ "Multisystem inflammatory syndrome in children and adolescents temporally related to COVID-19".
  2. ↑ "CDC case definationlast=".
  3. ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14 3.15 3.16 3.17 3.18 3.19
  4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 "Emergency Department, ICU and Inpatient Clinical Pathway for Evaluation of Possible Multisystem Inflammatory Syndrome (MIS-C)". line feed character in |title= at position 61 (help)
  5. ↑ 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 "Evaluation and Management of COVID-19 Multisystem Inflammatory Syndrome in Children (MIS-C)" (PDF). line feed character in |title= at position 63 (help)



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