Update on SARS-CoV-2 in Children and Multisystem Inflammatory Syndrome in Children

A 12-year-old boy presented to the emergency department with 3 days of fever, vomiting for one day and rash. On presentation he was febrile to 38.5 C, tachycardic to 122, and had normal blood pressure, oxygen saturations and respiration rate. His exam was notable for a sandpaper rash and mild conjunctivitis. He later tested positive for SARS-CoV-2 antibodies. This is an example of a patient who was determined to have Multisystem Inflammatory Syndrome in Children (MIS-C), understood to be a post-viral inflammatory response to SARS-CoV-2. This article will briefly review SARS-CoV-2 infections in children, the MIS-C phenomenon, and recommendations for transfer.

While the majority of children exhibit mild symptoms when infected with SARS-CoV-2, a unique picture of how the virus impacts children continues to evolve. Early epidemiological studies from China and Italy showed that up to one-fifth of infected children were asymptomatic, half were mild and had only upper respiratory symptoms, about a third had pneumonia but without respiratory distress or hypoxemia, and 1% had severe infections.

In late March, physicians in Italy and the United Kingdom noticed higher numbers children presented to their hospitals with some stigmata of Kawasaki disease. Some became very ill with vasodilatory shock and some showed signs of severe inflammatory reactions consistent with macrophage activation syndrome. Many exhibited cardiovascular compromise and needed various forms of support: intubation, inotropes, and even extracorporeal membrane oxygenation. They tended to be lymphopenic and thrombocytopenic, with high inflammatory markers like CRP, ESR, ferritin, d-dimer, and cardiac markers if the disease progressed to the cardiovascular system. They tended to be older than traditional Kawasaki disease pateints.4,5

Soon after, similar cases were noticed in the United States, initially in New York. To better define this phenomenon, it was given the name MIS-C Associated with Coronavirus Disease 2019. The New York experience largely corroborates the European experience and adds that many of these children were resistant to intravenous immunoglobulin (IVIG), the typical treatment for Kawasaki disease, and needed steroids and sometimes immunomodulatory medication. Judicious fluid administration was also emphasized as many of these children have cardiovascular compromise. 6

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