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[[COVID-19]] patients with [[cardiovascular]] [[comorbidities]] have higher [[mortality]]. According to a recent [[systematic review]] and [[meta-analysis]],[[acute cardiac injury]] with [[troponin]] levels greater than 28 pg/ml was detected in 12.4% of confirmed [[COVID-19]] patients.''<ref name="NasiriHaddadi2020">{{cite journal|last1=Nasiri|first1=Mohammad Javad|last2=Haddadi|first2=Sara|last3=Tahvildari|first3=Azin|last4=Farsi|first4=Yeganeh|last5=Arbabi|first5=Mahta|last6=Hasanzadeh|first6=Saba|last7=Jamshidi|first7=Parnian|last8=Murthi|first8=Mukunthan|last9=Mirsaeidi|first9=Mehdi|year=2020|doi=10.1101/2020.03.24.20042903}}</ref>Acute [[Myocardial Infarction]] is defined as an acute [[myocardial injury]] with clinical evidence of acute myocardial [[ischemia]] plus rise and/or fall of cardiac [[troponin]] values with at least one value above the 99th percentile upper reference limit and at least one of the following:Symptoms of [[myocardial ischemia]] including new ischemic [[ECG]] changes, development of pathological [[Q waves]], imaging evidence of new loss of viable [[myocardium]] or new regional wall motion abnormality in a pattern consistent with an ischemic [[etiology]]. Identification of a [[coronary]] [[thrombus]] by [[angiography]] or [[autopsy]] (not for type 2 or 3 MI).<ref name="pmid30153967">{{cite journal| author=Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA | display-authors=etal| title=Fourth Universal Definition of Myocardial Infarction (2018). | journal=J Am Coll Cardiol | year= 2018 | volume= 72 | issue= 18 | pages= 2231-2264 | pmid=30153967 | doi=10.1016/j.jacc.2018.08.1038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30153967  }} </ref>
[[COVID-19]] patients with [[cardiovascular]] [[comorbidities]] have higher [[mortality]]. According to a recent [[systematic review]] and [[meta-analysis]],[[acute cardiac injury]] with [[troponin]] levels greater than 28 pg/ml was detected in 12.4% of confirmed [[COVID-19]] patients.<ref name="NasiriHaddadi2020">{{cite journal|last1=Nasiri|first1=Mohammad Javad|last2=Haddadi|first2=Sara|last3=Tahvildari|first3=Azin|last4=Farsi|first4=Yeganeh|last5=Arbabi|first5=Mahta|last6=Hasanzadeh|first6=Saba|last7=Jamshidi|first7=Parnian|last8=Murthi|first8=Mukunthan|last9=Mirsaeidi|first9=Mehdi|year=2020|doi=10.1101/2020.03.24.20042903}}</ref>Acute [[Myocardial Infarction]] is defined as an acute [[myocardial injury]] with clinical evidence of acute myocardial [[ischemia]] plus rise and/or fall of cardiac [[troponin]] values with at least one value above the 99th percentile upper reference limit and at least one of the following:Symptoms of [[myocardial ischemia]] including new ischemic [[ECG]] changes, development of pathological [[Q waves]], imaging evidence of new loss of viable [[myocardium]] or new regional wall motion abnormality in a pattern consistent with an ischemic [[etiology]]. Identification of a [[coronary]] [[thrombus]] by [[angiography]] or [[autopsy]] (not for type 2 or 3 MI).<ref name="pmid30153967">{{cite journal| author=Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA | display-authors=etal| title=Fourth Universal Definition of Myocardial Infarction (2018). | journal=J Am Coll Cardiol | year= 2018 | volume= 72 | issue= 18 | pages= 2231-2264 | pmid=30153967 | doi=10.1016/j.jacc.2018.08.1038 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30153967  }} </ref>




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*All the children with MIS-C are treated as suspected [[COVID-19|COVID-19.]]
*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
*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
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>
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"/>
*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"/>
*[[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"/>
*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"/>
*[[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"/>
*[[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"/>
*[[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"/>
*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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Revision as of 13:58, 14 July 2020


COVID-19 patients with cardiovascular comorbidities have higher mortality. According to a recent systematic review and meta-analysis,acute cardiac injury with troponin levels greater than 28 pg/ml was detected in 12.4% of confirmed COVID-19 patients.[1]Acute Myocardial Infarction is defined as an acute myocardial injury with clinical evidence of acute myocardial ischemia plus rise and/or fall of cardiac troponin values with at least one value above the 99th percentile upper reference limit and at least one of the following:Symptoms of myocardial ischemia including new ischemic ECG changes, development of pathological Q waves, imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in a pattern consistent with an ischemic etiology. Identification of a coronary thrombus by angiography or autopsy (not for type 2 or 3 MI).[2]





Diagnosis

Diagnostic Criteria

In May 2020, the Centers for Disease Control and Prevention (CDC) set the criteria for multisystem inflammatory syndrome in children (MIS-C):[3]

  • 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:[3]

Physical Examination

COVID-19 associated multisystem inflammatory syndrome is associated with the following physical examination findings:[3]

Laboratory Findings

COVID-19 associated multisystem inflammatory syndrome is associated with the following laboratory findings:[3]

Less common laboratory findings include:

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 troponins (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, click here.
  • To view the laboratory findings on COVID-19, click here.

Electrocardiogram

  • To view the electrocardiogram findings on COVID-19, click here.

X-ray

  • X-ray of patients with COVID-19 associated multiorgan system inflammatory syndrome may be normal. When abnormal, findings may include the followings:[4]
    • Peribronchial cuffing
    • Perihilar interstitial thickening
    • Perihilar opacification
    • Perihilar consolidation
    • Low volume pleural effusion affecting both lungs
    • Left lower lobe atelectasis

Echocardiography or Ultrasound

  • To view the echocardiographic findings on COVID-19, click here.

CT scan

  • To view the CT scan findings on COVID-19, click here.

MRI

  • To view the MRI findings on COVID-19, click here.

Other Imaging Findings

  • To view other imaging findings on COVID-19, click here.

Other Diagnostic Studies

  • To view other diagnostic studies for COVID-19, click here.


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.[5][6]
  • Supplemental oxygen is required in children with low oxygen saturation.[6]
  • Fluid resuscitation in 10 ml/kg aliquots with reevaluation after each bolus. Maintain euvolemia. Avoid hypervolemia.[6]
  • Anti-inflammatory treatments with Intravenous immunoglobulin(IVIG) with or without corticosteroids have shown a good response rate.[5][6]
  • Aspirin has been used primarily for its antiplatelet effect. It is recommended in all patients with MIS-C.[5][6]
  • Anakinra is considered if fevers last more than 24 hours post steroids/IVIG or in the moderate or severe presentation.[5][6]
  • Tocilizumab is also considered if fevers last more than 24 hours post steroids/IVIG or in the moderate or severe presentation.[5][6]
  • Empiric antibiotics like vancomycin, ceftriaxone, and clindamycin are given for community-acquired shock presentation until cultures are negative for 48 hours.[5][6]
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. ↑ Nasiri, Mohammad Javad; Haddadi, Sara; Tahvildari, Azin; Farsi, Yeganeh; Arbabi, Mahta; Hasanzadeh, Saba; Jamshidi, Parnian; Murthi, Mukunthan; Mirsaeidi, Mehdi (2020). doi:10.1101/2020.03.24.20042903. Missing or empty |title= (help)
  2. ↑ Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA; et al. (2018). "Fourth Universal Definition of Myocardial Infarction (2018)". J Am Coll Cardiol. 72 (18): 2231–2264. doi:10.1016/j.jacc.2018.08.1038. PMID 30153967.
  3. ↑ 3.0 3.1 3.2 3.3 Feldstein, Leora R.; Rose, Erica B.; Horwitz, Steven M.; Collins, Jennifer P.; Newhams, Margaret M.; Son, Mary Beth F.; Newburger, Jane W.; Kleinman, Lawrence C.; Heidemann, Sabrina M.; Martin, Amarilis A.; Singh, Aalok R.; Li, Simon; Tarquinio, Keiko M.; Jaggi, Preeti; Oster, Matthew E.; Zackai, Sheemon P.; Gillen, Jennifer; Ratner, Adam J.; Walsh, Rowan F.; Fitzgerald, Julie C.; Keenaghan, Michael A.; Alharash, Hussam; Doymaz, Sule; Clouser, Katharine N.; Giuliano, John S.; Gupta, Anjali; Parker, Robert M.; Maddux, Aline B.; Havalad, Vinod; Ramsingh, Stacy; Bukulmez, Hulya; Bradford, Tamara T.; Smith, Lincoln S.; Tenforde, Mark W.; Carroll, Christopher L.; Riggs, Becky J.; Gertz, Shira J.; Daube, Ariel; Lansell, Amanda; Coronado Munoz, Alvaro; Hobbs, Charlotte V.; Marohn, Kimberly L.; Halasa, Natasha B.; Patel, Manish M.; Randolph, Adrienne G. (2020). "Multisystem Inflammatory Syndrome in U.S. Children and Adolescents". New England Journal of Medicine. doi:10.1056/NEJMoa2021680. ISSN 0028-4793.
  4. ↑ Hameed, Shema; Elbaaly, Heba; Reid, Catriona E. L.; Santos, Rui M. F.; Shivamurthy, Vinay; Wong, James; Jogeesvaran, K. Haran (2020). "Spectrum of Imaging Findings on Chest Radiographs, US, CT, and MRI Images in Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with COVID-19". Radiology: 202543. doi:10.1148/radiol.2020202543. ISSN 0033-8419.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 5.5 "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)
  6. ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 "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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Disease Name Age of Onset Gender Preponderance Signs/Symptoms Imaging Feature(s) Macroscopic Feature(s) Microscopic Feature(s) Laboratory Findings(s) Other Feature(s) ECG view
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