Multisystem Inflammatory Syndrome In Children (MIS-C)

INTRODUCTION

The Multisystem Inflammatory Syndrome in Children (MIS-C) is a disorder observed in kids who were previously diagnosed with COVID-19 or were in contact with someone else who had the infection. MIS-C presents as mild rashes on the body, fever, diarrhea and redness in eyes and can worsen in a matter of few days, causing inflammation in the heart, lungs, kidneys, brain, skin, eyes and the gastrointestinal tract.

ETIOLOGY

The exact etiology of the syndrome is not very well understood. From the clinical cases studied till date what has been understood is that the syndrome manifests in patients due to abnormally high immune response to the SARS-CoV-2 coronavirus as suggested by the increased immunoglobulin G (IgG) and reduced T-cell count in the patient’s bloodwork. It has also been observed that the disease presents symptoms similar to those of Kawasaki Disease, Toxic Shock Syndrome, Macrophage Activation Syndrome and Cytokine Release Syndrome.

The case definition for MIS-C as described by the U.S. Center for Disease Control (CDC) Health Advisory is as follows:

  • An individual younger than 21 years presenting with fever (>38.0°C for ≥24 hours), laboratory evidence of inflammation and evidence of clinically severe illness requiring hospitalization involving >2 organ systems (cardiac, respiratory, gastrointestinal, renal, hematologic, dermatological or neurological); &
  • No possibility of alternate diagnoses; &
  • Currently or recently positive for COVID-19 by RT-PCR, serology, or antigen test; or contact with confirmed or suspected COVID-19 case within 4 weeks from the onset of symptoms.

SYMPTOMS

The most common symptoms observed in children affected with MIS-C are:

  • Prolonged fever (for more than 24 hours)
  • Vomiting
  • Diarrhea
  • Stomachache
  • Unusual fatigue
  • Low blood pressure
  • Neck pain
  • Tightness in the chest
  • Rapid breathing
  • Increased heart rate
  • Red eyes
  • Swelling or redness of the lips and tongue, hands or feet
  • Headache, nausea and dizziness
  • Swelling and enlargement of lymph nodes
  • As the syndrome progresses in severity, the following emergency signs should be looked for:
    • Difficulty in breathing
    • Severe pain in the stomach
    • Discoloration of the skin – pale, grey or blue depending on the skin tone
    • Inability to stay conscious
    • Confusion which was non-existent earlier

RISK FACTORS

Studies conducted in various parts of the world suggest that children with certain underlying conditions are at a higher risk for developing severe MIS-C than those who are otherwise normal. Some of the risk factors affecting the severity of MIS-C in children include:

  • Bacterial infection of the throat, large intestine or urinary tract
  • Viral infection in the upper respiratory system
  • Skin rashes or abdominal pain or ulcers of the mucous membranes
  • Underlying Cardiac issues
  • Increased levels of iron in the body

PREVENTION

Currently, exposure to SARS-CoV-2 is the only clinically attributed reason for the occurrence of MIS-C; as a result, preventing the chances of occurrence of MIS-C means limiting exposure to COVID-19. This can be achieved by the following methods:

  • Getting vaccinated against SARS-CoV-2. Although vaccination is not available for all age groups at the moment, as and when new vaccine candidates get authorized for emergency use – especially for children under the age of 12 – parents should make it a point to get their kids vaccinated at the earliest.
  • Frequently washing hands
  • Practicing social distancing
  • Wearing mask in public
  • Avoid touching eyes, nose or mouth
  • Covering the mouth with tissue, handkerchief or the elbow while coughing or sneezing
  • Regularly disinfecting surfaces frequently touched
  • Washing clothes and other items after each use.

DIAGNOSIS

Diagnosis of MIS-C is made possible by the help of imaging techniques, laboratory tests and differential diagnosis (tests to differentiate from other diseases with similar symptoms); these are:

  • Imaging
    • Chest X-ray and CT (Computed Tomography) scan
    • Abdominal imaging using ultrasound or CT scan
  • Laboratory tests – [1-3 for mild symptoms & all for severe symptoms]
    • Complete Blood Count (CBC)
    • Serum electrolytes & Renal Function Tests
    • C-reactive protein (CRP) & Erythrocyte Sedimentation Rate (ESR)
    • Ferritin test
    • Liver Function Test
    • Coagulation studies
    • Urine analysis
    • Troponin test
    • Brain Natriuretic Peptide (BNP) test
  • Differential diagnosis for similarly presenting diseases such as:
    • Kawasaki Disease
    • Acute COVID-19
    • Bacterial sepsis
    • Toxic Shock Syndrome
    • Appendicitis
    • Other viral, bacterial or fungal infections
    • Macrophage Activation Syndrome (MAS)
    • Systemic Lupus Erythematosus (SME)
    • Vasculitis

TREATMENT

Although studies are yet to decipher the exact reason for the occurrence of MIS in children, experts have suggested that the syndrome is treatable provided attention is brought to it on time and appropriate healthcare facilities are available.

At present, studies comparing the clinical efficacy of various treatment strategies are not available. The management of patients with MIS-C is being done by treating the underlying inflammation in the affected individuals. Treatment / management strategies for MIS-C include:

  • Administration of intravenous immunoglobulin (IVIG) & steroids
  • Fluid resuscitation i.e., replenishing the body fluids lost due to sweating, bleeding or other reasons.
  • Inotropic support i.e., treatment with agents that alter the force of muscular contractions
  • Respiratory support – high flow nasal oxygenation (HFNO) & non-invasive ventilation
  • Extracorporeal Membranous Oxygenation (ECMO) – for pumping & oxygenation of blood outside the body – used when the heart and lungs are too weak to function at their optimum; endangering the patient’s life

COMPLICATIONS

As mentioned earlier, MIS-C is treatable on early diagnosis. In case the syndrome is not diagnosed on time, it can cause severe damage to essential organs of the body like the heart, lungs, liver and the kidneys. In certain patients the damage to the organs is so severe that it can even result in death.

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