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As the COVID-19 pandemic spreads, a new multisystem inflammatory syndrome in children (MIS-C) has emerged. In mid-March, a case definition was created (NEJM JW Pediatrics and Adolescent Medicine Jun 17 2020 and JAMA 2020 Jun 8; [e-pub]). MIS-C shares many signs and symptoms of Kawasaki disease (KD) and toxic shock syndrome but is clearly a unique condition.
A New York State study describes 95 patients <21 years of age with confirmed and 4 with suspected MIS-C between March 1 and May 10, 2020. The cases followed the state's SARS-CoV-2 infection peak by 1 month, occurring at a rate of 2 per 100,000 (the SARS-CoV-2 infection rate for those <21 years was 322 per 100,000).
Overall, 54% were male, 42% were 6 to 12 years of age, and 26% were 13 to 20 years. Eighty percent reported gastrointestinal symptoms. Symptoms consistent with KD were common, including rash (62%) and mucocutaneous changes (61%); children <12 years were more likely than older children to present with KD-like symptoms. Only 40% reported respiratory symptoms. Cardiac involvement was common: ventricular dysfunction (52%), pericardial effusion (32%), and coronary artery aneurysm (9%). Overall, 67% had evidence of recent SARS-CoV-2 infection (PCR or serology). Eighty percent required intensive care, with 10% requiring mechanical ventilation. Two patients died, and at publication, 21% remained hospitalized.
A CDC study describes 186 patients <21 years with MIS-C reported from 26 states following initiation of surveillance in April. Seventy percent had laboratory confirmation of SARS-CoV-2 infection and the others had an epidemiologic link to a case. Median age was 8.3 years, 62% were male, and 73% were previously healthy. Common symptoms were gastrointestinal (92%), cardiovascular (80%), hematologic (76%), mucocutaneous (74%), and respiratory (70%). Eighty percent required intensive care, and four died.
Dufort EM et al. Multisystem inflammatory syndrome in children in New York state. N Engl J Med 2020 Jun 29; [e-pub]. (https://doi.org/10.1056/NEJMoa2021756)
Feldstein LR et al. Multisystem inflammatory syndrome in U.S. children and adolescents. N Engl J Med 2020 Jun 29; [e-pub]. (https://doi.org/10.1056/NEJMoa2021680)
Comment
These findings further the evidence for a link between MIS-C and recent infection with SARS-CoV-2. They illustrate a clearer picture: MIS-C has features similar to KD but occurs mostly in older children and commonly presents with gastrointestinal symptoms. As COVID-19 spreads, more cases of MIS-C will likely follow. Physicians should be alert for the constellation of symptoms and be prepared to manage them aggressively, anticipating the need for intensive care unit admission. We still need a better understanding of which SARS-CoV-2-infected patients are likely to develop this inflammatory response and how best to manage them.