Multisystem Inflammatory Syndrome in Children (MIS-C)



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Multisystem Inflammatory Syndrome in Children (MIS-C)

Consider other diagnosis

Admit to floor or ICU depending on clinical status

Echocardiogram

Discharge home. Close follow up in 24-48 hours with PCP.

Signs of shock or ill-appearing

Evaluate supplementary criteria for MIS-C

  • CRP ≥ 3 mg/dL  AND/OR ESR ≥ 40 mm/hr

AND

  • Lymphopenia < 1k OR Thrombocytopenia < 150k OR Na < 135 OR Abnormal creatinine for age

Meets discharge criteria

Admit to PICU

 MIS-C Presenting Symptoms from Case Reports 

CategoryPresenting SymptomFrequency (%)
Systemic
  • Fever (median duration 4 days)
  • Myalgia
  • Lymphadenopathy
  • Shock
  • 100
  • -
  • 50-80
Mucocutaneous
  • Rash/skin desquamation
  • Conjunctivitis
  • Lip redness / swelling
  • 21-76
  • -
  • -

Respiratory

  • Cough
  • Dyspnea
  • Hypoxia
  • -
  • -
  • -
Cardiovascular
  • Myocardia dysfunction
  • 51-100
Gastrointestinal
  • Abdominal pain
  • Vomiting
  • Diarrhea
  • 60-100
  • -
  • -
Renal
  • Acute kidney injury
  • 22-70
Neurologic
  • Headache
  • Lethargy
  • Confusion
  • Stiff neck
  • Vision changes
  • 29-58
  • -
  • -
  • -
  • -
Musculoskeletal
  • Swollen hands & feet
  • 16


Echo should evaluate:

  • Coronaries: left main, proximal and distal left anterior descending, proximal and distal right, and posterior descending coronary arteries for dilation, course (tapering or not tapering), aneurysm, echo bright walls, thrombus
  • Valvar function
  • Ventricular function
  • Pericardial effusion

Initial screening labs. Other evaluation should be based on patient's presenting symptoms (e.g. UA/UCx., neuroimaging, CSF studies, etc.)

Complete Blood Count, Serum
Complete Metabolic Panel, Serum
C-Reactive Protein (CRP), Serum
Erythrocyte Sedimentation Rate (ESR), Serum

Resuscitate as if sepsis. Include additional MIS-C labs. Consult MIS-C team if unclear labs, history or exam findings (ID, Rheum, Cardiology, etc.)

Coronavirus 2019 (SARS-CoV-2) IgM, IgG, Serum
pro-BNP, Serum
Ferritin, Serum
2019 Novel Coronavirus (SARS-CoV-2), RT PCR
ECG 12-Lead
D-Dimer, Quantitative
Troponin I
Complete Blood Count, Serum
Complete Metabolic Panel, Serum
C-Reactive Protein (CRP), Serum
Erythrocyte Sedimentation Rate (ESR), Serum
Prothrombin time (PT)
Partial Thromboplastin Time (PTT)
Echocardiogram

Criteria for Echocardiogram (any of the following)

  • Hemodynamic instability
  • Elevated troponin or pro-BNP
  • Abnormal EKG
  • Suspicion for complete/ incomplete KD
Inclusion Criteria
  • Age <21 years
  • Fever > 38.0 for ≥ 3 days or ≥ 1 day if ill appearing
  • Presence of > 3 symptoms reported with MIS-C
  • No alternative plausible diagnosis
  • Patients in whom there is concern for Kawasaki disease (KD)
  • Positive for current or recent SARS-CoV-2 infection by RT-PCR, serology, or antigen test; or COVID-19 exposure within the 4 weeks prior to the onset of symptoms
Exclusion Criteria
  • None

Admit to inpatient

Include additional MIS-C labs. Consult MIS-C team if unclear labs, history or exam findings (ID, Rheum, Cardiology, etc.)

ECG 12-Lead
D-Dimer, Quantitative
Troponin I
Prothrombin time (PT)
Partial Thromboplastin Time (PTT)
Ferritin, Serum
pro-BNP, Serum
Coronavirus 2019 (SARS-CoV-2) IgM, IgG, Serum

Differences between Kawasaki disease and MIS-C

  1. Age of presentation – MIS-C presents in older children compared with Kawasaki disease (7 years vs 3 years).
  2. Race/Ethnicity – There is an increased incidence of MIS-C in patients of African, Afro-Caribbean, and possibly Hispanic descent, but a lower incidence in those of East Asian descent.
  3. Gastrointestinal symptoms – Compared to Kawasaki disease patients, MIS-C patients more commonly have GI symptoms at presentation and can be severe.
  4. Cardiac dysfunction and shock – While shock presents in 5% of Kawasaki disease, shock and myocardial dysfunction has been more common in MIS-C (30-80%).
  5. Laboratory abnormalities – MIS-C patients have significantly elevated troponin I and brain natriuretic peptide, higher inflammatory markers (D-dimer, CRP, ESR, IL-6), lower absolute lymphocyte count, and thrombocytopenia instead of thrombocytosis compared with patients with Kawasaki disease.



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