Sandbox:Sahar

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.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).

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):

• 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:

• Fever lasting 24 hours or longer.
• Vomiting
• Diarrhea
• Abdominal pain
• Difficulty Breathing
• Chest pain
• Headache
• Sore throat
• New onset confusion

Physical Examination

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

• 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:

• High ESR
• Lymphopenia
• Neutrophilia
• Anemia
• Thrombocytopenia

Less common laboratory findings include:

• Abnormal fibrinogen
• Hypoalbuminaemia
• Elevated creatiine kinase (CK)
• Elevated LDH
• Elevated 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 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:
  • 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.
• 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

Bold text

Wikidoc Textbook of Medicine
Name/Project	Cardiology	Pulmonary	Infectious	Pediatrics	Emergency	ENT	Ob/Gyn	Dermatology	Rare disease
Leader of the Project
N of Chapters
N of Complete Chapters
N of Incomplete Chapters
N to be Reviewed
Name of Scholars working on the project

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
Name of Scholars working on the project

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