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 Table of Contents  
COMMENTARY
Year : 2022  |  Volume : 9  |  Issue : 2  |  Page : 105-106

SARS-CoV-2-related multisystem inflammatory syndrome in children and adolescents


Department of Pediatrics, Maulana Azad Medical College, New Delhi, India

Date of Submission14-Jun-2021
Date of Acceptance09-Aug-2021
Date of Web Publication20-Dec-2022

Correspondence Address:
Arpita Gupta
Department of Pediatrics, Maulana Azad Medical College, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_71_21

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How to cite this article:
Gupta A. SARS-CoV-2-related multisystem inflammatory syndrome in children and adolescents. CHRISMED J Health Res 2022;9:105-6

How to cite this URL:
Gupta A. SARS-CoV-2-related multisystem inflammatory syndrome in children and adolescents. CHRISMED J Health Res [serial online] 2022 [cited 2023 Jan 30];9:105-6. Available from: https://www.cjhr.org/text.asp?2022/9/2/105/364535



Since the first reported case in China, SARS-CoV-2 has spread all over the world, accounting for approximately 17.5 crore cases and 37.6 lakh deaths as of June 9, 2021.[1] India alone has reported around 3 crore cases, majorly affecting the adult population and causing severe illness in them. Initial reports all over the world suggested that children were less severely affected than adults, usually bypassing the deadly disease by either being asymptomatic or with mild illness. However, evolving literature from various parts of the world including India have highlighted emergence of COVID-19-associated multisystem involvement in children and adolescents requiring admission to intensive care, occurring few days to weeks after the peak of the infection in affected population. This entity is termed as multisystem inflammatory syndrome in children and adolescents (MIS-C) or pediatric inflammatory multisystem syndrome.

According to available literature, the spectrum of MIS-C is a combination of typical/atypical Kawasaki disease, toxic shock syndrome, and macrophage activation syndrome/hemophagocytic lymphohistiocytosis predominantly involving cardiovascular, gastrointestinal (GI), mucocutaneous, or neurological systems. The World Health Organization defines a preliminary case of MIS-C as a patient aged 0–19 years presenting with high fever ≥3 days, epidemiological evidence of SARS-CoV-2 (reverse transcription–polymerase chain reaction [RT-PCR], antigen test or serology positive, or likely contact with patients with COVID-19), evidence of inflammation (elevated markers of inflammation such as erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], or procalcitonin), and clinical features of multisystem involvement (any two of the following: (i) rash or bilateral nonpurulent conjunctivitis or mucocutaneous inflammatory signs, (ii) hypotension or shock, (iii) features of myocardial dysfunction, pericarditis, valvulitis, or coronary abnormalities including ECHO findings or elevated troponin/NT-proBNP, (iv) evidence of coagulopathy by prothrombin time, partial thromboplastin time, elevated D-dimers, and (v) acute GI complaints such as diarrhea, vomiting, or abdominal pain) in the absence of other obvious microbial cause of inflammation.[2] The Centers for Disease Control has given a broader definition of MIS-C which includes patients under the age of 21 years with fever for >24 h, laboratory evidence of inflammation, severe illness requiring hospitalization, involvement of ≥2 organ systems (cardiac, renal, respiratory, hematological, GI, dermatological, or neurological), and positive SARS-CoV-2 infection (RT-PCR, serology, or antigen test) or exposure to a COVID-19 case within 4 weeks prior to symptom onset.[3]

Globally, common presentation of MIS-C is reported to be mucocutaneous rashes, conjunctivitis, GI symptoms, shock, and myocardial dysfunction. However, there are reports of predominant neurological involvement in MIS-C presenting with encephalitis-like illness.[4] In the previous issue also, central nervous system symptoms such as seizures and altered mental status, as the initial presentation of MIS-C is highlighted upon. Male preponderance is seen with median age group involved being ≥7 years, however, younger children are also reported to be affected.[5] Recent report has mentioned about the occurrence of MIS-C in newborn, wherein the baby whose mother had recovered from the virus before delivery was detected with the disease within 12 h of its birth.[6]

The article published in the previous issue of journal has carefully described clinical and laboratory findings along with treatment and outcome of hospitalized children with MIS-C from Northern India. As illustrated in the previous issue, the biomarkers of inflammation and infection (CRP, ESR, white blood cell, procalcitonin, interleukin-6, D-dimer, and ferritin) are usually elevated in nearly all patients who fit diagnostic criteria for MIS-C. Furthermore, the findings are concordant with other recent studies which have specifically addressed about the cardiac manifestations of MIS-C, including the possible progression to cardiogenic shock. It has been suggested that the myocardial dysfunction mechanism in MIS-C due to SARS-CoV-2 may be closely associated with the inflammatory process resulting in myocardial fiber distention and subsequent activation of cardiac enzymes, instead of a sequela of direct cardiac damage.

Government of India has given a comprehensive guideline on management of pediatric COVID including MIS-C.[7] Apart from appropriate supportive care preferably in intensive care unit, drugs recommended to be used in MIS-C are steroids and intravenous immunoglobulin. Aspirin or low-molecular-weight heparin is added if patient has thrombosis/low left ventricular ejection fraction. Steroids have to be tapered over 2–3 weeks while monitoring inflammatory markers. In addition, recent studies have indicated the effectiveness of biologicals such as anakinra, tocilizumab/infliximab, and canakinumab that target specific inflammatory cytokines which play a vital role in the pathogenesis of MIS-C.

MIS-C is generally reported to have a favorable outcome with a mortality ranging from 2% to 5%, if identified and treated timely.[8]

The emergence of MIS-C serves as a reminder, that although initial infection with SARS-CoV-2 may have a milder presentation in children, there may be much serious implications requiring critical care with resultant long-term consequences. Thus, considering the complexity of this disease process along with the paucity in the existing knowledge about predicting its course and sequelae, the most effective current strategy would be to teach children about COVID appropriate behaviors to protect themselves.



 
  References Top

1.
WHO Coronavirus (COVID-19) Dashboard | WHO Coronavirus (COVID-19) Dashboard with Vaccination Data. Availablefrom: https://covid19.who.int/. [Last accessed on 2021 Jun 09].  Back to cited text no. 1
    
2.
WHO. Multisystem Inflammatory Syndrome in Children and Adolescents with COVID-19; 2020. Available from: https://www.who.int/publications/i/item/multisystem-inflammatory-syndrome-in-children-and-adolescents-with-covid-19. [Last accessed on 2021 Jun 09].  Back to cited text no. 2
    
3.
Centre for Disease Control (CDC). Information for Healthcare Providers about Multisystem Inflammatory Syndrome in Children (MIS-C).  Back to cited text no. 3
    
4.
Gupta S, Chopra N, Singh A, Gera R, Chellani H, Pandey R, et al. Unusual clinical manifestations and outcome of multisystem inflammatory syndrome in children (MIS-C) in a tertiary care hospital of North India. J Trop Pediatr 2021;67:fmaa127.  Back to cited text no. 4
    
5.
Feldstein LR, Tenforde MW, Friedman KG, Newhams M, Rose EB, Dapul H, et al. Characteristics and outcomes of US children and adolescents with multisystem inflammatory syndrome in children (MIS-C) compared with severe acute COVID-19. JAMA 2021;325:1074-87.  Back to cited text no. 5
    
6.
Baig M. Newborn Detected With MIS-C Hours After Birth; Cases Spiking in Gujarat. News 18, 01 June, 2021.  Back to cited text no. 6
    
7.
Government of India Ministry of Health and Family Welfare Protocol for Management of Covid-19 in the Paediatric Age Group. Available from: https://www.mohfw.gov.in/pdf/ProtocolforManagementofCovid19inthePaediatricAg Group.pdf. [Last accessed on 2021 Jun 13].  Back to cited text no. 7
    
8.
Elias MD, McCrindle BW, Larios G, Choueiter NF, Dahdah N, Harahsheh AS, et al. Management of multisystem inflammatory syndrome in children associated with COVID-19: A survey from the International Kawasaki Disease Registry. CJC Open 2020;2:632-40.  Back to cited text no. 8
    




 

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