Sandbox:Sahar

Diagnosis

Diagnostic Criteria

Preliminary WHO case definition: Children and adolescents

• 0–19 years of age with fever >3 days

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

• Elevated markers of inflammation such as 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 (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);

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.
• Vomiting
• Diarrhea
• Abdominal pain
• Skin rash
• Conjuctivitis
• High ESR
• Redness or swelling of the lips and tongue
• Lethargy
• Redness or swelling of the hands or feet
• Confusion
• Headache
• Sore throat
• Syncope
• Lymphadenopathy

Emergency Warning Signs

• Difficulty Breathing
• Chest pain
• New onset confusion
• Lethargy
• Cyanosis
• Abdominal pain

Physical Examination

Blood Investigations

• Lymphopenia, Neutrophilia, Anemia, Thrombocytopenia have been seen in MIS-C pateints. Abnormal fibrinogen, Hypoalbuminaemia, elevated creatiine kinase (CK), LDH, triglycerides have been observed in MIS-C patients.

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.

Radiological Findings

• Following Radiological Findings are observed in MIS-C patients.

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

Presentation	Treatment
Mild Disease	Symptomatic Treatment
Severe Disease	Symptomatic Treatment IVIG(IV) Corticosteroids(IV/PO) Consider adding Anakinra or Tocilizumab if fever persist for more than 24 hours post steroids and IVIG use.

Prevention of MIS-C

• MIS-C can be prevented by reducing the risk of child exposure to COVID-19 infection.

References

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Wikidoc Textbook of Medicine
Name/Project	Cardiology	Pulmonary	Infectious	Pediatrics	Emergency	ENT	Ob/Gyn	Dermatology	Rare disease
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Wikidoc Textbook of Medicine
Name/Project	Hematology	Oncology	Gastroenterology	Nephrology	Neurology	Psychology	Endocrinology
Leader of the project
N of Chapters
N of complete Chapters
N of Incomplete Chapters
N to be reviewed Chapters
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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