American College of Rheumatology Clinical Guidance for Multisystem Inflammatory Syndrome in Children Associated With SARS-CoV-2 and Hyperinflammation in Pediatric COVID-19: Version 1

Risk Factors Associated with Intensive Care Admission in Children with Severe Acute Respiratory Syndrome Coronavirus 2-Related Multisystem Inflammatory Syndrome (MIS-C) in Latin America: A Multicenter Observational Study of the REKAMLATINA Network

Background: Multisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease 2019 varies widely in its presentation and severity, with low mortality in high-income countries. In this study in 16 Latin American countries, we sought to characterize patients with MIS-C in the pediatric intensive care unit (PICU) compared with those hospitalized on the general wards and analyze the factors associated with severity, outcomes, and treatment received. Study Design: An observational ambispective cohort study was conducted including children 1 month to 18 years old in 84 hospitals from the REKAMLATINA network from January 2020 to June 2022. Results: A total of 1239 children with MIS-C were included. The median age was 6.5 years (IQR 2.5-10.1). Eighty-four percent (1043/1239) were previously healthy. Forty-eight percent (590/1239) were admitted to the PICU. These patients had more myocardial dysfunction (20% vs 4%; P < 0.01) with no difference in the frequency of coronary abnormalities (P = 0.77) when compared to general ward subjects. Of the children in the PICU, 83.4% (494/589) required vasoactive drugs, and 43.4% (256/589) invasive mechanical ventilation, due to respiratory failure and pneumonia (57% vs 32%; P = 0.01). On multivariate analysis, the factors associated with the need for PICU transfer were age over 6 years (aOR 1.76 95% CI 1.25-2.49), shock (aOR 7.06 95% CI 5.14-9.80), seizures (aOR 2.44 95% CI 1.14-5.36), thrombocytopenia (aOR 2.43 95% CI 1.77-3.34), elevated C-reactive protein (aOR 1.89 95% CI 1.29-2.79), and chest x-ray abnormalities (aOR 2.29 95% CI 1.67-3.13). The overall mortality was 4.8%. Conclusions: Children with MIS-C who have the highest risk of being admitted to a PICU in Latin American countries are those over age six, with shock, seizures, a more robust inflammatory response, and chest x-ray abnormalities. The mortality rate is five times greater when compared with high-income countries, despite a high proportion of patients receiving adequate treatment.

Comparison of early characteristics of multisystemic inflammatory syndrome and Kawasaki disease in children and the course of Kawasaki disease in the pandemic

INTRODUCTION

Multisystemic inflammatory syndrome (MIS-C) is a newly described disease manifestation in children associated with the novel coronavirus SARS-CoV-2 infection and can be easily confused with Kawasaki disease with its clinical and laboratory findings. In this study, the clinical findings, organ involvements, similarities, and differences in laboratory and imaging of the children with MIS-C and KD at the time of admission will be revealed in detail, and the treatment methods and follow-up results will be revealed.

MATERIAL AND METHOD

Our study was a single-center study and included pediatric patients who were treated with a diagnosis of MIS-C between March 2020 and July 2023 in the pediatric cardiology, pediatric emergency, pediatric infection, and pediatric intensive care clinics at Celal Bayar University and who were treated with a diagnosis of KD (complete/incomplete) between January 2015 and July 2023. MIS-C diagnosis was made according to the Turkish Ministry of Health COVID-19 guidelines. Sociodemographic characteristics, clinical, laboratory, and echocardiography findings, treatments given, and clinical course of all patients included in the study were evaluated.

RESULTS

The median age was 30 months (7-84) in KD and 96 months (6-204) in MIS-C, and it was significantly higher in the MIS-C group (p = 0.000). Symptom duration was significantly longer in the MIS-C group (p = 0.000). In terms of clinical features, gastrointestinal syndrome findings (nausea, vomiting, abdominal pain) and respiratory findings (dyspnea) were significantly higher in the MIS-C group (p = 0.007, p = 0.000, p = 0.002, respectively). Regarding cardiovascular system involvement, coronary involvement was significantly higher in the KD group. However, valvular involvement, left ventricular systolic dysfunction, and pericardial effusion were significantly higher in the MIS-C group (p = 0.000, p = 0.001, p = 0.003, p = 0.023, respectively). In terms of laboratory findings, white blood cell count was higher in KD (p = 0.000), absolute lymphocyte count, platelet level, blood sodium, and albumin levels were lower in MIS-C group (p = 0.000, p = 0.000, p = 0.000, p = 0.000, p = 0.003, respectively), ferritin and troponin levels were significantly higher in MIS-C group. These results were statistically significant (p = 0.000, p = 0.000, respectively). D-dimer and fibrinogen levels were high in both groups, and no significant statistical difference was detected between the two groups. There was no significant difference between the two groups regarding the length of hospitalization and mortality, but steroid use was significantly higher in the MIS-C group (p = 0.000).

CONCLUSION

In conclusion, this study has demonstrated the similarities and differences between MIS-C and KD regarding clinical findings, organ involvement, and laboratory and imaging results. The results of our study have important implications in terms of contributing to the data in the existing literature on these two diseases and for the correct diagnosis and better management of pediatric patients presenting with these disorders.

WHAT IS KNOWN

Multisystemic inflammatory syndrome (MIS-C) is a newly described disease manifestation in children associated with the novel coronavirus SARS-CoV-2 infection and can be easily confused with Kawasaki disease with its clinical and laboratory findings.

WHAT IS NEW

Although MIS-C and KD have many similarities, their symptoms, disease processes, possible complications, and treatment regimens may differ.

Plasmapheresis as therapeutic option in a 16-year-old with EVALI: A case report

Since 2019 when a cluster of cases with acute respiratory distress syndrome (ARDS) associated with e-cigarettes in the United States was reported, there have been increasing numbers of reports. Electronic-cigarette or Vaping Use-associated Lung Injury (EVALI) represents a recent entity of respiratory clinical syndromes, primarily in young adults. We report a previously healthy 16-year-old boy who developed severe ARDS following a brief nonspecific prodromal phase after excessive consumption of e-cigarettes. Despite maximum intensive care therapy, including several weeks of venovenous extracorporeal membrane oxygenation, plasmapheresis and repeated administration of immunoglobulins seemed the only way to achieve therapeutic success. Although many case reports have been published, to our knowledge, there are none to date on the therapeutic use of plasmaphoresis in severe EVALI. This case highlights the clinical features of EVALI and the diagnostic dilemma that can arise with EVALI occurring against the background of an expired SARS-CoV-2 infection, with a paediatric inflammatory syndrome (PIMS) as differential diagnosis. EVALI is a diagnosis of exclusion, and the medical history of vaping and e-cigarette use can provide valuable clues. Ethical approval for this case report (protocol number 23-145 RS) was provided by the Ethical Committee of the Department of Medicine, Philipps-Universität Marburg, Germany on 13 th of June 2023. Written informed consent to publish this case and the associated images was obtained from the patient and his mother.

The Association Between Early Initiation of Systemic Corticosteroids and the Hospital Length of Stay in Patients With Multisystem Inflammatory Syndrome in Children

OBJECTIVE

Patients with multisystem inflammatory syndrome in children (MIS-C) often require hospital admission. Treatment of MIS-C has included intravenous immunoglobulin, systemic corticosteroids, and/or immunomodulators. There is no standardized approach to when steroids should be initiated during treatment. The study objective was to determine whether early initiation of steroids in patients with MIS-C is associated with the duration of hospital length of stay (LOS).

METHODS

This is a single-center retrospective cohort study of patients younger than 21 years who were hospitalized with MIS-C between March 2020 and September 2021 and received steroids. Cases were obtained from an institutional MIS-C log. Patients with culture proven sepsis and/or those who received intravenous immunoglobulin or steroids within the previous 30 days were excluded. We used a multivariable linear regression model, controlling for potential confounders, to assess the association between early steroids and LOS.

RESULTS

A total of 56 patients hospitalized with MIS-C were identified; 38 received systemic corticosteroids and were included in the study. The mean time from admission to steroid administration was 9.8 hours (SD = 7.7) in the early group and 44.6 hours (SD = 14.2) in the late group. There was a statistically significant difference in baseline characteristics of patients receiving early versus late steroids in initial C-reactive peptide, procalcitonin, brain natriuretic peptide, and cardiac dysfunction. After controlling for confounders, initiating steroids within 24 hours of admission for MIS-C was associated with a decreased hospital LOS: in patients treated with early steroids, LOS was 58.3 hours less (95% confidence interval, -100.0 to -16.6; P = 0.007) than in those who received late steroids.

CONCLUSIONS

Among patients with MIS-C, initiating systemic corticosteroids within 24 hours of admission was associated with decreased hospital LOS.

Insights Into MRI Neuroimaging Patterns of COVID-19 in Children: A Retrospective Comprehensive Analysis

RATIONALE AND OBJECTIVES

Neurological complications associated with coronavirus disease (COVID-19) have been reported in children; however, data on neuroimaging findings remain limited. This study aimed to comprehensively examine neuroimaging patterns of COVID-19 in children and their relationship with clinical outcomes.

MATERIALS AND METHODS

This retrospective cross-sectional study involved reviewing the medical records and MRI scans of 95 children who developed new neurological symptoms within 2-4 weeks of clinical and laboratory confirmation of COVID-19. Patients were categorized into four groups based on guidelines approved by the Centers for Disease Control and Prevention (CDC). Initial brain/spinal MRI was performed. Images were reviewed by three blinded radiologists, and the findings were analyzed and categorized based on the observed patterns in the brain and spinal cord. Follow-up MRI was performed and analyzed to track lesion progression.

RESULTS

Encephalopathy was the most common neurological symptom (50.5%). The most common initial MRI involvement patterns were non-confluent multifocal hyperintense white matter (WM) lesions (36.8%) and ischemia (18.9%). Most patients who underwent follow-up MRI (n = 56) showed complete resolution (69.9%); however, some patients developed encephalomalacia and myelomalacia (23.2% and 7.1%, respectively). Non-confluent hyperintense WM lesions were associated with good outcomes (45.9%, P = 0.014), whereas ischemia and hemorrhage were associated with poor outcomes (44.1%, P < 0.001).

CONCLUSION

This study revealed diverse neuroimaging patterns in pediatric COVID-19 patients. Non-confluent WM lesions were associated with good outcomes, whereas ischemia and hemorrhage were associated with poorer prognoses. Understanding these patterns is crucial for their early detection, accurate diagnosis, and appropriate management.

Fatal Arrhythmic Complications of Multisystemic Inflammatory Syndrome (MIS-C) in a Pediatric Patient

In 2019, the emergence of the coronavirus disease 2019 (COVID-19) virus triggered a global pandemic, reminiscent of the magnitude witnessed during the flu pandemic of 1918. Initially, children often presented with either asymptomatic or mild upper respiratory tract infection symptoms. However, in the post-acute phase, a distinct syndrome affecting multiple organ systems emerged, sharing similarities with Kawasaki's disease. This syndrome was later classified as multisystem inflammatory syndrome in children (MIS-C) by the Pediatric Intensive Care Society in April 2020. Notably, cardiac manifestations and complications associated with COVID-19 constitute a significant source of morbidity and mortality, characterized by left ventricular dysfunction, cardiac conduction abnormalities, and arrhythmias. Although cases of arrhythmias with MIS-C are rare in the literature, we present a unique case involving a 14-year-old without known cardiac risk factors who presented with conduction abnormalities and fatal arrhythmias secondary to MIS-C.

Diagnostic testing for chest pain in a pediatric emergency department and rates of cardiac disease before and during the COVID-19 pandemic: a retrospective study

Objectives

Chest pain is a common chief complaint in pediatric emergency departments (EDs). Coronavirus disease-2019 (COVID-19) has been shown to increase the risk of cardiac disease. It remains unclear how COVID-19 changed how pediatric emergency clinicians approach patients presenting with chest pain. The goal of this study was to characterize the diagnostic testing for chest pain in a pediatric ED before and during the COVID-19 pandemic.

Methods

This was a retrospective study of children between the ages of 2-17 years presenting to a pediatric ED from 1/1/2018-2/29/2020 (Pre-COVID-19) and 3/1/2020-4/30/2022 (COVID-19) with chest pain. We excluded patients with a previous history of cardiac disease.

Results

Of the 10,721 encounters during the study period, 5,692 occurred before and 5,029 during COVID-19. Patient demographics showed minor differences by age, weight, race and ethnicity. ED encounters for chest pain consisted of an average of 18% more imaging studies during COVID-19, including 14% more EKGs and 11% more chest x-rays, with no difference in the number of echocardiograms. Compared to Pre-COVID-19, 100% more diagnostic tests were ordered during COVID-19, including cardiac markers Troponin I (p < 0.001) and BNP (p < 0.001). During COVID-19, 1.1% of patients had a cardiac etiology of chest pain compared with 0.7% before COVID-19 (p = 0.03).

Conclusions

During COVID-19, pediatric patients with chest pain underwent more diagnostic testing compared to Pre-COVID-19. This may be due to higher patient acuity, emergence of multisystem inflammatory syndrome in children (MIS-C) that necessitated more extensive testing and possible changes in ED clinician behavior during COVID-19.

Multisystem inflammatory syndrome in children (MIS-C) post-COVID-19 in Iran: clinical profile, cardiac features, and outcomes

BACKGROUND

In April 2020, an association between multisystem inflammatory syndromes (MIS-C) was observed in children with severe acute respiratory syndrome coronavirus infection (SARS-CoV-2). Most patients had heart involvement alone, and most patients had pericardial effusion. This study aimed to express and emphasize cardiac involvement in pediatric patients with respiratory symptoms who were diagnosed with COVID-19.

METHODS

This study was conducted in July 2021 in Kerman province, Southeastern Iran, during a notable surge in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections. The study included 904 pediatric patients diagnosed with COVID-19. Data collection involved a comprehensive assessment of clinical symptoms and manifestations. Patients with fever lasting more than five days were admitted to the hospital. Echocardiography was utilized for cardiac involvement diagnosis, with 47 patients undergoing this diagnostic procedure.

RESULTS

Of the 904 patients, most of them had high fevers (74%). Fifty-five patients had a fever for more than five days and were hospitalized. Of the 47 patients who underwent echocardiography, 45 (81%) had heart involvement. In 75% of patients, pericardial effusion was the only cardiac involvement. Patients with pericardial effusion were treated with dexamethasone up to 3 mg every 8 h for 72 h.

CONCLUSIONS

MIS-C has a wide range of clinical symptoms. In cases where the fever is prolonged and there are gastrointestinal symptoms, physicians have clinical suspicion to diagnose this syndrome. Most cases of pericardial effusion are alone and improve with treatment with glucocorticosteroids.

CLINICAL UTILITY OF INTERLEUKIN-1 INHIBITORS IN PEDIATRIC SEPSIS

ABSTRACT

The pathophysiology of pediatric sepsis is characterized by increased innate immune activation earlier in life. Interleukin-1 is a proinflammatory cytokine implicated in the pathophysiology of sepsis, and ferritin is a stable surrogate biomarker for elevated IL-1 levels. Data in adult sepsis have shown that use of anakinra, an anti-IL-1 receptor antagonist, led to improved clinical outcomes in patients with features of macrophage activation and hyperferritinemia. However, data in pediatric sepsis are lacking. Our narrative review sought to highlight the current understanding of using IL-1 inhibitors in pediatric sepsis. We identified five studies including one case report and four retrospective case series that described clinical outcomes in relation to use of anakinra for secondary hemophagocytic lymphohistiocytosis (HLH). A few patients in this pooled heterogenous cohort of 72 patients had concomitant infection meeting the criteria for sepsis. All studies measured ferritin levels and reported a decrease in ferritin after initiating anakinra. Twelve patients died after treatment initiation. There was no clear comparison in clinical outcomes between infected and noninfected patients. The pathophysiology of pediatric sepsis suggests that there is a need for blinded clinical trials using targeted immunomodulation such as IL-1 inhibitors in pediatric sepsis cohort with an immunophenotype suggesting increased innate immune activation.

Subcutaneous anakinra in the management of refractory MIS-C in France

Introduction

Multisystemic inflammatory syndrome in children (MIS-C) is a therapeutic emergency and can lead to myocardial dysfunction (17%-75%) and heart failure (52%-53%). Intravenous immunoglobulins (IVIG) and corticosteroids (CST) have been validated for the management of this condition. Recent reports suggest that an interleukin-1 (IL-1) receptor antagonist, namely anakinra, may be a valuable add-on to the 2019 novel coronavirus disease (COVID-19) treatment for refractory patients. The purpose of this study was to describe the clinico-biological characteristics of patients treated with anakinra as well as the efficacy and safety of subcutaneous anakinra therapy in this condition.

Methods

The prospective multicentre study of children hospitalized for MIS-C between March 2020 and September 2022, including 23 international paediatric centres, followed for a mean duration of 3.072 ± 3.508 months. The patient data were extracted from the Juvenile Inflammatory Rheumatism (JIR) cohort. The clinico-pathological characteristics, cardiac ultrasound data, and adverse events were reported in patients receiving anakinra.

Results

Of the 470 children admitted with MIS-C, 18 French patients (50% girls) with a mean age of 10.06 ± 3.9 years were treated with subcutaneous anakinra. Anakinra was used in two situations, macrophage activation syndrome (MAS) (4 patients) and heart failure (14 patients) with a median left ventricular ejection fraction (LVEF) of 39.5% (30%-45%). The average dose of anakinra received was 2.53 ± 1.3 mg/kg/day for a median duration of 3 days. Prior to introduction, 78% (n = 14/18) of the patients had received CST and 56% (n = 10/18) had received IVIG. Only two patients received IVIG alone and six received CST alone plus anakinra. In 10% of cases, IVIG was poorly tolerated from a cardiovascular point of view and was discontinued. Transient elevations in serum transaminases were noted in four patients on anakinra without the need for treatment or dose modification. In all patients, rapid (48 h) improvement in myocardial function was observed (LVEF > 55%) with a concomitant significant decrease in myocardial enzymes (p < 0.05). All patients survived with complete recovery of cardiac function without sequelae.

Conclusions

Subcutaneous anakinra appears to be a safe and effective treatment for the management of heart failure or MAS in MIS-C patients. The value of IVIG in these two situations remains to be reviewed.

Comparison of Eosinophil Counts in Inflammatory Conditions: Multisystem Inflammatory Syndrome in Children, Kawasaki Disease, and Infectious Mononucleosis

This study examined the distinctions between multisystem inflammatory syndrome associated with coronavirus disease 2019, Kawasaki disease, and infectious mononucleosis. These three inflammatory disorders have commonalities according to clinical and laboratory results, particularly in relation to eosinophil levels. In this retrospective, single-center study, we documented the examination records (acute phase reactants and complete blood count) and clinical and cardiological findings of 130 patients diagnosed with multisystem inflammatory syndrome, Kawasaki disease, and infectious mononucleosis. These patients were treated and received follow-up care in our hospital from March 12, 2020, to September 13, 2022, as per the hospital records. Statistical analyses were performed using NCSS 2007, version 1 software. Eosinopenia was more prevalent in children with multisystem inflammatory syndrome than in those with Kawasaki disease, who showed normal or elevated eosinophil counts. The eosinophil counts in patients with infectious mononucleosis typically fell within the normal range. Our study found no correlation between the eosinophil counts and cardiac involvement in pediatric patients with either condition. These findings indicate a higher prevalence of eosinopenia in patients with multisystem inflammatory syndrome, irrespective of cardiac involvement, than in those with Kawasaki disease. Despite similarities in clinical findings, Kawasaki disease and multisystem inflammatory syndrome in children necessitate further studies for distinct characteristic elucidation.

One-Year Follow-Up Results of MIS-C Patients with Coronary Artery Involvement: A Multi-center Study

Multisystem inflammatory syndrome (MIS-C) in children is a rare complication of SARS-CoV-2 infection. Knowing the course of the affected or unaffected coronary arteries in the patients under follow-up is important in terms of defining the long-term prognosis of the disease and determining the follow-up plan. This is a multicenter and retrospective study. The data were obtained from nine different centers. Between May 2020 and August 2022, 68 of 790 patients had coronary artery involvement. One-year echocardiographic data of 67 of 789 MIS-C patients with coronary artery involvement were analyzed. Existing pathologies of the coronary arteries were grouped as increased echogenicity, dilatation and aneurysm according to Z scores, and their changes over a 1-year period were determined. The data of all three groups are defined as frequency. SPSS Statistics version 22 was used to evaluate the data. In our study, aneurysm was observed in 16.4%, dilatation in 68.7% and increased echogenicity in 13.4% of the patients. All of the patients with involvement in the form of increased echogenicity recovered without sequelae by the end of the first month. No progression to aneurysm was observed in any of the patients with dilatation. No new-onset involvement was observed in patients with previously healthy coronary arteries during the convalescent period. In addition, from the sixth month follow-up period, there was no worsening in the amount of dilatation in any of the patients. At least 94% of the patients who completed the 12th month control period returned to normal.

Glucocorticoid activates STAT3 and NF-κB synergistically with inflammatory cytokines to enhance the anti-inflammatory factor TSG6 expression in mesenchymal stem/stromal cells

Glucocorticoid (GC) is essential for maintaining immune homeostasis. While GC is known to regulate the expression of genes related to inflammation in immune cells, the effects of GC, especially in the presence of inflammation, on non-immune cells remain largely unexplored. In particular, the impact of GC on inflammatory cytokine-induced immune modulatory responses of tissue stromal cells is unknown, though it has been widely used to modulate tissue injuries. Here we found that GC could enhance the expression of TSG6, a vital tissue repair effector molecule, in IFNγ and TNFα treated human umbilical cord (UC)-MSCs. NF-κB activation was found to be required for GC-augmented TSG6 upregulation. STAT3, but not STAT1, was also found to be required for the TSG6 upregulation in MSCs exposed to IFNγ, TNFα and GC. Moreover, the phosphorylation (activation) of STAT3 was attenuated when NF-κB was knocked down. Importantly, human UC-MSCs pretreated with a cocktail containing GC, IFNγ, and TNFα could significantly enhance the therapeutic effect of human UC-MSCs in an acute lung injury mouse model, as reflected by reduced infiltration of immune cells and down-regulation of iNOS in macrophages in the lung. Together, the findings reveal a novel link between GR, NF-κB and STAT3 in regulating the immunomodulatory and regenerative properties of MSCs, providing novel information for the understanding and treatment of inflammatory conditions.

[Multisystem inflammatory syndrome in children in the context of coronavirus disease 2019 pandemic]

Multisystem inflammatory syndrome in children (MIS-C) is a complex syndrome characterized by multi-organ involvement that has emerged in the context of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak. The clinical presentation of MIS-C is similar to Kawasaki disease but predominantly presents with fever and gastrointestinal symptoms, and severe cases can involve toxic shock and cardiac dysfunction. Epidemiological findings indicate that the majority of MIS-C patients test positive for SARS-CoV-2 antibodies. The pathogenesis and pathophysiology of MIS-C remain unclear, though immune dysregulation following SARS-CoV-2 infection is considered a major contributing factor. Current treatment approaches for MIS-C primarily involve intravenous immunoglobulin therapy and symptomatic supportive care. This review article provides a comprehensive overview of the definition, epidemiology, pathogenesis, clinical presentation, diagnosis, treatment, and prognosis of MIS-C.

Rickettsia rickettsii and Rickettsia typhi in hospitalized children diagnosed with Pediatric Multisystemic Inflammatory Syndrome in Merida, Yucatan

Multisystem Inflammatory Syndrome in Children (MIS-C) presents with fever, fatigue, elevated inflammatory markers (acute phase reactants), and a history of exposure to SARS-CoV-2 or positive antibodies to SARS-CoV-2. As the COVID-19 pandemic unfolded, the risk of MIS-C in the pediatric population increased. However, exposure to other viruses and the presence of SARS-CoV-2 positive antibodies in children hospitalized for various pathogen-associated illnesses will also remain common and may complicate differential diagnoses with diseases endemic to the region such as rickettsial diseases. The objective was to highlight the desirability of medical personnel systematically incorporating rickettsiosis as a differential diagnosis for MIS-C when studying a child with fever, non-specific symptoms, and elevated inflammatory markers. In conclusion MIS-C should be considered in children with elevated inflammatory markers when there is a history of COVID-19 and they also meet criteria that have already been established by international agencies, such as CDC and WHO.

Blood-derived product therapies for SARS-CoV-2 infection and long COVID

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is capable of large-scale transmission and has caused the coronavirus disease 2019 (COVID-19) pandemic. Patients with COVID-19 may experience persistent long-term health issues, known as long COVID. Both acute SARS-CoV-2 infection and long COVID have resulted in persistent negative impacts on global public health. The effective application and development of blood-derived products are important strategies to combat the serious damage caused by COVID-19. Since the emergence of COVID-19, various blood-derived products that target or do not target SARS-CoV-2 have been investigated for therapeutic applications. SARS-CoV-2-targeting blood-derived products, including COVID-19 convalescent plasma, COVID-19 hyperimmune globulin, and recombinant anti-SARS-CoV-2 neutralizing immunoglobulin G, are virus-targeting and can provide immediate control of viral infection in the short term. Non-SARS-CoV-2-targeting blood-derived products, including intravenous immunoglobulin and human serum albumin exhibit anti-inflammatory, immunomodulatory, antioxidant, and anticoagulatory properties. Rational use of these products can be beneficial to patients with SARS-CoV-2 infection or long COVID. With evidence accumulated since the pandemic began, we here summarize the progress of blood-derived product therapies for COVID-19, discuss the effective methods and scenarios regarding these therapies, and provide guidance and suggestions for clinical treatment.

Anesthetic Considerations in Multisystem Inflammatory Syndrome in Children: A Case Series

Multisystem inflammatory syndrome in children (MIS-C) is an immune response inciting multiorgan dysfunction and a shock-like state which is typically seen in children 2 to 6 weeks after either a coronavirus disease-19 infection or exposure. When such a child comes for any surgery, perioperative anesthetic management demands multidisciplinary involvement and individualized case-based decision-making. Due to the novelty of the condition, there are limited data on anesthetic implications in these patients. Anesthetic management in the affected children is dynamic depending on the organ systems involved and the progression of the disease state. Though the long-term effects of the syndrome are largely unknown, we hope that awareness of the MIS-C-associated complications may help anesthesiologists involved in childcare. Herein, we put forward challenges and clinical dilemmas we faced during the anesthetic management of three children with MIS-C presenting for emergency and elective surgery.

Paediatric inflammatory multisystem syndrome in Canada: population-based surveillance and role of SARS-CoV-2 linkage

BACKGROUND

Paediatric inflammatory multisystem syndrome (PIMS) is a rare condition temporally associated with SARS-CoV-2 infection. Using national surveillance data, we compare presenting features and outcomes among children hospitalized with PIMS by SARS-CoV-2 linkage, and identify risk factors for intensive care (ICU).

METHODS

Cases were reported to the Canadian Paediatric Surveillance Program by a network of >2800 pediatricians between March 2020 and May 2021. Patients with positive versus negative SARS-CoV-2 linkages were compared, with positive linkage defined as any positive molecular or serologic test or close contact with confirmed COVID-19. ICU risk factors were identified with multivariable modified Poisson regression.

RESULTS

We identified 406 children hospitalized with PIMS, including 49.8% with positive SARS-CoV-2 linkages, 26.1% with negative linkages, and 24.1% with unknown linkages. The median age was 5.4 years (IQR 2.5-9.8), 60% were male, and 83% had no comorbidities. Compared to cases with negative linkages, children with positive linkages experienced more cardiac involvement (58.8% vs. 37.4%; p < 0.001), gastrointestinal symptoms (88.6% vs. 63.2%; p < 0.001), and shock (60.9% vs. 16.0%; p < 0.001). Children aged ≥6 years and those with positive linkages were more likely to require ICU.

CONCLUSIONS

Although rare, 30% of PIMS hospitalizations required ICU or respiratory/hemodynamic support, particularly those with positive SARS-CoV-2 linkages.

IMPACT

We describe 406 children hospitalized with paediatric inflammatory multisystem syndrome (PIMS) using nationwide surveillance data, the largest study of PIMS in Canada to date. Our surveillance case definition of PIMS did not require a history of SARS-CoV-2 exposure, and we therefore describe associations of SARS-CoV-2 linkages on clinical features and outcomes of children with PIMS. Children with positive SARS-CoV-2 linkages were older, had more gastrointestinal and cardiac involvement, and hyperinflammatory laboratory picture. Although PIMS is rare, one-third required admission to intensive care, with the greatest risk amongst those aged ≥6 years and those with a SARS-CoV-2 linkage.

The 2022 EULAR/ACR Points to Consider at the Early Stages of Diagnosis and Management of Suspected Haemophagocytic Lymphohistiocytosis/Macrophage Activation Syndrome (HLH/MAS)

OBJECTIVE

Haemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) are life-threatening systemic hyperinflammatory syndromes that can develop in most inflammatory contexts. They can progress rapidly, and early identification and management are critical for preventing organ failure and mortality. This effort aimed to develop evidence-based and consensus-based points to consider to assist clinicians in optimising decision-making in the early stages of diagnosis, treatment and monitoring of HLH/MAS.

METHODS

A multinational, multidisciplinary task force of physician experts, including adult and paediatric rheumatologists, haematologist/oncologists, immunologists, infectious disease specialists, intensivists, allied healthcare professionals and patients/parents, formulated relevant research questions and conducted a systematic literature review (SLR). Delphi methodology, informed by SLR results and questionnaires of experts, was used to generate statements aimed at assisting early decision-making and optimising the initial care of patients with HLH/MAS.

RESULTS

The task force developed 6 overarching statements and 24 specific points to consider relevant to early recognition of HLH/MAS, diagnostic approaches, initial management and monitoring of HLH/MAS. Major themes included the simultaneous need for prompt syndrome recognition, systematic evaluation of underlying contributors, early intervention targeting both hyperinflammation and likely contributors, careful monitoring for progression/complications and expert multidisciplinary assistance.

CONCLUSION

These 2022 EULAR/American College of Rheumatology points to consider provide up-to-date guidance, based on the best available published data and expert opinion. They are meant to help guide the initial evaluation, management and monitoring of patients with HLH/MAS in order to halt disease progression and prevent life-threatening immunopathology.

The 2022 EULAR/ACR points to consider at the early stages of diagnosis and management of suspected haemophagocytic lymphohistiocytosis/macrophage activation syndrome (HLH/MAS)

OBJECTIVE

Haemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) are life-threatening systemic hyperinflammatory syndromes that can develop in most inflammatory contexts. They can progress rapidly, and early identification and management are critical for preventing organ failure and mortality. This effort aimed to develop evidence-based and consensus-based points to consider to assist clinicians in optimising decision-making in the early stages of diagnosis, treatment and monitoring of HLH/MAS.

METHODS

A multinational, multidisciplinary task force of physician experts, including adult and paediatric rheumatologists, haematologist/oncologists, immunologists, infectious disease specialists, intensivists, allied healthcare professionals and patients/parents, formulated relevant research questions and conducted a systematic literature review (SLR). Delphi methodology, informed by SLR results and questionnaires of experts, was used to generate statements aimed at assisting early decision-making and optimising the initial care of patients with HLH/MAS.

RESULTS

The task force developed 6 overarching statements and 24 specific points to consider relevant to early recognition of HLH/MAS, diagnostic approaches, initial management and monitoring of HLH/MAS. Major themes included the simultaneous need for prompt syndrome recognition, systematic evaluation of underlying contributors, early intervention targeting both hyperinflammation and likely contributors, careful monitoring for progression/complications and expert multidisciplinary assistance.

CONCLUSION

These 2022 EULAR/American College of Rheumatology points to consider provide up-to-date guidance, based on the best available published data and expert opinion. They are meant to help guide the initial evaluation, management and monitoring of patients with HLH/MAS in order to halt disease progression and prevent life-threatening immunopathology.

Pathophysiological and clinical point of view on Kawasaki disease and MIS-C

This article compares two important pathophysiological states, Kawasaki disease, and multisystem inflammatory syndrome, in children associated with COVID-19 (MIS-C). Both occur predominantly in children, have a temporal association with an infectious agent, and are associated with immune-system alteration and systemic inflammation under certain circumstances. The two share common pathophysiology, including enhancement of interleukin-1 neutrophils, activation of the inflammasome, pyroptosis, or NETosis. Moreover, the clinical presentation of the diseases overlaps. However, they are indeed two separate diseases, proven by the differences in the epidemiological and etiological aspects and the pathophysiological processes involved in the development and frequency of some clinical signs. This article highlights potentially exciting areas that have not yet been studied in detail, which could help better understand the development of these diseases.

A global systematic review and meta-analysis on the emerging evidence on risk factors, clinical characteristics, and prognosis of multisystem inflammatory syndrome in adults (MIS-A)

Background

The multisystem inflammatory syndrome in adults (MIS-A) has emerged, similar to those in children associated with SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) [multisystem inflammatory syndrome in children (MIS-C)]. This review aimed to analyze the risk factors, clinical course, and prognosis of MIS-A.

Methods

A comprehensive literature search was conducted using several databases for cases reporting MIS-A from 1 December 2019 till 9 September 2021. The case definitions used to identify potential cases were those recommended by the World Health Organization, Center for Disease Control, and individual country/physician classification. The meta-analysis was performed using Comprehensive Meta-Analysis (CMA) 2.2.027 and Review Manager (RevMan) 5.4.1, employing 95% confidence intervals (CI).

Results

Seventy studies were assessed for full-text eligibility, out of which 37 were included. The mean age of the study population was 32.52±10.29 years. The most common symptoms were fever (89.8%, 95% CI: 77.7-95.7%) and diarrhea (49%, 95% CI: 35.4-62.7%). Ventricular tachycardia (57.1%, 95% CI: 43.1-70.1%) was the most common electro-cardiac abnormality. The most common inflammatory marker was elevated C-reactive protein (89.8%, 95% CI: 77.7-95.7%). Abnormal echocardiogram was the most common imaging test result (commonly, ventricular dysfunction and arrhythmias), while steroids were the most administered treatment. Severe cases had a higher need for vasopressor and inotropic support and antibiotic therapy compared to the non-severe cases. One death was reported due to cardiovascular failure.

Conclusion

Our collated findings will help clinicians identify the typical presenting symptoms and optimal management of MIS-A. Further research is required to understand the long-term prognosis and the correlation between coronavirus disease 2019 (COVID-19) and MIS-A to understand its pathogenesis and clinical spectrum.

Echocardiographic Findings in Children with Multisystem Inflammatory Syndrome from Initial Presentation to the First Years after Discharge

OBJECTIVE

We aimed to evaluate clinical and echocardiographic features of the children diag- nosed with multisystem inflammatory syndrome related to severe acute respiratory syndrome coronavirus-2 infection and determine early and mid-term cardiovascular outcomes.

MATERIALS AND METHODS

We retrospectively evaluated 38 children who were diagnosed with multisystem inflammatory syndrome in our hospital between November 2020 and November 2021. Cardiovascular evaluations were performed during hospitalization, at the first, the second, and the third months after discharge, and then cardiac evaluation was repeated at 3-month intervals until a median of 24 weeks (range: 9-56 weeks).

RESULTS

The mean age of patients was 9.6 years and 25 patients had cardiovascular involve- ment. Echocardiography showed that there was left ventricular dysfunction in 11 cases and any coronary abnormalities in 11 cases on admission. Cardiovascular involvement was most fre- quently seen in patients older than 10 years and of male sex. Severe clinical courses occurred in half of them. The mortality rate was 2.6% during hospitalization. At discharge, complete recovery was achieved in 30 cases and partial recovery was seen in 6 cases; there were 1 case with ventricular dysfunction and 5 cases with coronary abnormalities. At the last polyclinic visit, there was no case with symptoms or myocardial dysfunction, there was only 1 case with persist- ing coronary aneurysms.

CONCLUSION

Cardiovascular abnormalities in patients with multisystem inflammatory syndrome show rapid resolution within the first month. We recommend long-term follow-up evaluation for coronary arteries.

Short- and mid-term outcomes of multisystem inflammatory syndrome in children: a longitudinal prospective single-center cohort study

Background

Multisystem inflammatory syndrome in children (MIS-c) emerged during the coronavirus disease 2019 pandemic and is associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Despite the extensively studied clinical manifestation of acute condition, the short- and long-term effects of MIS-c on children's health are unknown.

Methods

This was a prospective longitudinal cohort study. Children aged <18 years who met the Centers for Disease Prevention and Control (CDC) diagnostic criteria and who were admitted to the Children's Clinical University Hospital of Latvia (CCUH) between July 1, 2020, and April 15, 2022, were enrolled in the study. An outpatient follow-up program was initiated in July 2020. All children were evaluated at 2 weeks, 2 months (1-3 months), and 6 months (5-7 months) after discharge. The face-to-face interviews comprised four domains as follows: symptom assessment, physical examination, laboratory testing, and cardiological investigation [including electrocardiogram (ECG) and echocardiography (echo)].

Results

Overall, 21 patients with MIS-c were enrolled. The median age of the study group was 6 years. At the 2-week follow-up, almost half of the patients (N = 10, 47.6%) reported exercise intolerance with provoked tiredness. Laboratory tests showed a considerable increase in blood cell count, with a near doubling of leukocyte and neutrophil counts and a tripling of thrombocyte levels. However, a decline in the levels of inflammatory and organ-specific markers was observed. Cardiological investigation showed significant improvement with gradual resolution of the acute-phase pathological findings. Within 2 months, improvement in exercise capacity was observed with 5-fold and 2-fold reductions in physical intolerance (N = 2, 9.5%) and physical activity-induced fatigue (N = 5, 23.8%), respectively. Normalization of all blood cell lines was observed, and cardiological investigation showed no persistent changes. At the 6-month visit, further improvement in the children's exercise capacity was observed, and both laboratory and cardiological investigation showed no pathological changes.

Conclusions

Most persistent symptoms were reported within the first 2 weeks after the acute phase, with decreased physical activity tolerance and activity-induced fatigue as the main features. A positive trend was observed at each follow-up visit as the spectrum of the children's complaints decreased. Furthermore, rapid normalization of laboratory markers and cardiac abnormalities was observed.

Acute neurological symptoms in multisystem inflammatory syndrome in children: A case series

Introduction

Severe acute respiratory syndrome coronavirus-2 infection mostly involves pediatrics lesser than adults; however, the multisystem inflammatory syndrome in children is shown to be the following condition in children infected with SARS-CoV-2, even asymptomatic ones. To date, there is few evidence of the association of multisystem inflammatory syndrome in children with acute neurological symptoms.

Case presentations

This case series was recorded demographic, clinical, laboratory, radiographic and EEG data of patients with the multisystem inflammatory syndrome in children who diagnosed simultaneously with acute neurological symptoms. Children with the multisystem inflammatory syndrome in children and evidence of central nervous system involvements participated in the study. Data are reported as median (interquartile ranges) for quantitative data without normal distributions. The present study was conducted at the children's referral hospital of Isfahan province, Iran between March 1, 2020, and December 28, 2021. Simultaneous diagnosis of multisystem inflammatory syndrome in children and acute neurological symptoms was made in 12 children. The median age of patients was 4.5 years (10-144 months). The most common symptoms were seizures (58%). Cerebrospinal fluid analysis showed that only one patient had pleocytosis. In addition, one patient had a low glucose level. Finally, 11 patients were discharged in good condition and one patient died after full recovery from acute neurological symptoms due to her underlying disease.

Conclusion

According to our series and other studies, children with MIS-C may present signs and symptoms of acute neurological symptoms. Although its pathophysiology is unclear, studies showed that immunomodulatory agents, i.e., intravenous immunoglobulins and corticosteroids, provide a relatively good prognosis.

Multisystem inflammatory syndrome in children: another COVID-19 sequel

With the rapid expansion of the COVID-19 pandemic, the disease burden and its consequences on the paediatric population has been progressively recognised. Although COVID-19 infection in children presents as asymptomatic to mild illness, instances of hyperinflammation and multi-organ involvement following the viral infection have been described. This condition, known as the multisystem inflammatory syndrome in children (MIS-C), has gained a wide global attention. Despite the global efforts to uncover the disease characteristics and management, a clear pathogenesis and a unified treatment regimen have not been reached yet. This paper tackles the epidemiology of the MIS-C, discusses its suggested pathogenesis, drives through its varying clinical presentations, and evaluates the different treatment regimens employed in managing MIS-C.

Multisystem inflammatory syndrome in children and Kawasaki disease; comparison of their clinical findings and one-year follow-up-a cross-sectional study

BACKGROUND

Studies on Multisystem Inflammatory Syndrome in Children (MIS-C) and Kawasaki Disease (KD) have yielded inconsistent results and are lacking in Asian and African countries. This study aimed to compare the laboratory and clinical features, short-term outcomes, and one-year follow-ups of a large cohort of MIS-C and KD patients.

METHODS

Data from 176 MIS-C and 56 KD patients admitted to Tehran Children's Medical Center between January 2021 and January 2022 were collected. Patients were followed up until January 2023.

RESULTS

While lymphopenia and thrombocytopenia were more prevalent in MIS-C (73.2% vs. 20% in KD, p < 0.001), KD patients exhibited a higher median white blood cell count and prevalence of anemia, along with higher fibrinogen and erythrocyte sedimentation rate levels (p < 0.001, p < 0.001, p = 0.005, p < 0.001, respectively). MIS-C patients also exhibited lower ejection fraction, a greater occurrence of pericardial effusion, and a higher incidence of coronary aneurysms and ectasia, and ascites. Echocardiography after seven days of treatment showed a reduction in pathologies for both groups, but it was significant only for MIS-C. After one year, coronary artery abnormalities remained in only six cases.

CONCLUSIONS

In conclusion, this study highlights differences between MIS-C and KD, including laboratory indices as well as echocardiographic and abdominal ultrasound findings. These findings contribute valuable data on Iranian patients to the existing literature on this topic and have significant implications for accurate diagnosis and improved management of pediatric patients presenting with these conditions.

Cardiovascular Manifestations of Multisystem Inflammatory Syndrome in Children (MIS-C) Associated With COVID-19

Since 2019, the global pandemic caused by the SARS-CoV-2 virus, also known as COVID-19, has dramatically affected every aspect of health and society. With wide-ranging socio-economic ramifications and the morbidity/mortality associated with the disease, a lot of research has been done on this disease. With recent surges and new variants of the COVID-19 virus, we must have regularly updated information on this disease to effectively manage this disease and to maximize outcomes for patients. Worldwide data, so far, has suggested that children have milder or asymptomatic acute infectious phase, most often presenting with mild upper respiratory infection (URI) symptoms compared to the adult population. However, in the post-acute phase, it was observed that children presented with a syndrome that strongly resembled Kawasaki's disease (KD), and like in KD, they could potentially develop severe life-threatening complications. The significant difference between KD and this syndrome is the association with COVID-19 infection. This syndrome was observed to affect almost all organ systems including cardiovascular, gastrointestinal, and integumentary and was later named multisystem inflammatory syndrome in children (MIS-C) by the Pediatric Intensive Care Society in April 2020. The cardiovascular manifestations of this clinical entity have been associated with significant morbidity and mortality. This review is an attempt to give consolidated information from the studies done so far about the cardiac changes that occur from SARS-CoV-2 infection/MIS-C.

The Effect of Biologics in the Treatment of Multisystem Inflammatory Syndrome in Children (Mis-C): A Single-Center Propensity-Score-Matched Study

Multisystem inflammatory syndrome in children (MIS-C) is a serious condition characterized by excessive inflammation that can arise as a complication of SARS-CoV-2 infection in children. While our understanding of COVID-19 and MIS-C has been advancing, there is still uncertainty regarding the optimal treatment for MIS-C. In this study, we aimed to compare the clinical and laboratory outcomes of MIS-C patients treated with IVIG plus corticosteroids (CS) to those treated with IVIG plus CS and an additional biologic drug. We used the propensity score (PS)-matching method to assess the relationships between initial treatment and outcomes. The primary outcome was a left ventricular ejection fraction of less than 55% on day 2 or beyond and/or the requirement of inotrope support on day 2 or beyond. We included 79 MIS-C patients (median age 8.51 years, 33 boys) followed in our center. Among them, 50 children (25 in each group) were allocated to the PS-matched cohort sample. The primary outcome was observed in none of the patients in the IVIG and CS group, while it occurred in eight patients in the IVIG plus CS and biologic group (p = 0.04). MIS-C is a disorder that may progress rapidly and calls for extensive care. For definitive recommendations, further studies, including randomized control trials, are required.

Platelet role in the prediction of MIS-C severity

Introduction

Multisystem inflammatory syndrome in children (MIS-C) has been reported as one of the cytokine storm syndromes associated with COVID-19. Despite the several proposed diagnostic criteria, MIS-C remains a diagnostic and clinical challenge. Recent studies have demonstrated that platelets (PLTs) play a crucial role in COVID-19 infection and its prognosis. This study aimed to investigate the clinical importance of PLT count and PLT indices in predicting MIS-C severity in children.

Patients and methods

We conducted a retrospective single-center study at our university hospital. A total of 43 patients diagnosed with MIS-C during a 2-year period (from October 2020 to October 2022) were included in the study. MIS-C severity was evaluated according to the composite severity score.

Results

Half of the patients were treated in the pediatric intensive care unit. No single clinical sign was associated with a severe condition, except for shock (p = 0.041). All the routine biomarkers, such as complete blood count (CBC) and C-reactive protein (CRP), used for MIS-C diagnosis were significant in predicting MIS-C severity. Single PLT parameters, such as mean PLT volume, plateletcrit, or PLT distribution width, did not differ between the severity groups. However, we found that a combination of PLT count and the previously mentioned PLT indices had the potential to predict MIS-C severity.

Conclusions

Our study emphasizes the importance of PLT in MIS-C pathogenesis and severity. It revealed that together with routine biomarkers (e.g., CBC and CRP), it could highly improve the prediction of MIS-C severity.

Multi-Inflammatory Syndrome in Children (MIS-C) in 2023: Is It Time to Forget about It?

Multisystem inflammatory syndrome in children (MIS-C) is defined as a clinically serious condition requiring hospitalization involving fever, multi-system organ dysfunction, and an increase in inflammatory biomarkers. The syndrome was originally described as a post-infectious complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, which usually causes COVID-19. During the COVID-19 pandemic, not only did the virus undergo mutations but vaccines against SARS-CoV-2 were also developed. Both these conditions led to a decrease in the incidence of MIS-C. This narrative review summarizes the recent updates for MIS-C, particularly regarding the change in incidence, the link between the SARS-CoV-2 vaccine and MIS-C, and new updates of MIS-C treatments.

Multisystemic Inflammatory Syndrome in Children and Kawasaki Disease: Parallels in Pathogenesis and Treatment

PURPOSE OF REVIEW

Since it first appeared, multisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease 2019 (COVID-19) has been compared to Kawasaki disease (KD). Although there were early parallels between MIS-C and KD, key differences emerged over time. Here, we aim to compare the pathogenesis, clinical presentation, treatment, and outcomes of MIS-C and KD.

RECENT FINDINGS

In this article, we review and compare MIS-C and KD, highlighting differentiating features. We discuss the epidemiological and immunological factors along with clinical and laboratory features which discern MIS-C from KD. We also compare treatment and our understanding of long-term outcomes. Though parallels exist between MIS-C and KD, distinguishing the two is important for clinical management of patients, counseling about natural history, and determining long-term monitoring. While both MIS-C and KD are characterized by profound inflammation and inflammatory vasculopathy, further study is needed to determine whether they are distinct immunopathogenic disorders.

Identifying and Validating Pediatric Hospitalizations for MIS-C Through Administrative Data

BACKGROUND

Individual children's hospitals care for a small number of patients with multisystem inflammatory syndrome in children (MIS-C). Administrative databases offer an opportunity to conduct generalizable research; however, identifying patients with MIS-C is challenging.

METHODS

We developed and validated algorithms to identify MIS-C hospitalizations in administrative databases. We developed 10 approaches using diagnostic codes and medication billing data and applied them to the Pediatric Health Information System from January 2020 to August 2021. We reviewed medical records at 7 geographically diverse hospitals to compare potential cases of MIS-C identified by algorithms to each participating hospital's list of patients with MIS-C (used for public health reporting).

RESULTS

The sites had 245 hospitalizations for MIS-C in 2020 and 358 additional MIS-C hospitalizations through August 2021. One algorithm for the identification of cases in 2020 had a sensitivity of 82%, a low false positive rate of 22%, and a positive predictive value (PPV) of 78%. For hospitalizations in 2021, the sensitivity of the MIS-C diagnosis code was 98% with 84% PPV.

CONCLUSION

We developed high-sensitivity algorithms to use for epidemiologic research and high-PPV algorithms for comparative effectiveness research. Accurate algorithms to identify MIS-C hospitalizations can facilitate important research for understanding this novel entity as it evolves during new waves.

Scrotal pain as a novel symptom of multisystem inflammatory syndrome in children (MIS-C): Report from Riyadh, Saudi Arabia

A previously healthy child, presented with severe abdominal and scrotal pain with scrotal swelling for five days. There was associated fever, vomiting, and diarrhea. There was history of COVID-19 infection in the previous month. The patient was febrile (39°C), and in pain. His other vitals were unremarkable. Testicular torsion and appendicitis were ruled out by ultrasound. Abdominal CT scan showed signs indicating terminal ileitis. His MIS-C panel revealed elevated inflammatory markers and cardiac enzymes and positive SARS-CoV-2 IgG levels. All cultures and RT-PCR COVID-19 were negative. Echocardiogram showed only minor mitral and tricuspid regurgitation. The patient was diagnosed as a case of MIS-C. and recovered completely on management. Our patient showed an inexplicable previously unreported complaint of scrotal pain and swelling as a symptom of MIS-c. Further research tackling MIS-C's different presentations and comparing the efficacy of the different treatment methods will help us better manage this disease.

Acute febrile illness in a teenage female with history of Graves' disease

Thyroid storm is a rare, life-threatening condition that is usually precipitated by Graves' disease in children and adolescents. COVID-19 (SARS-CoV-2) can cause multisystem inflammatory syndrome in children (MIS C), which shares some features of Graves' disease. We present a case of acute thyroid storm following SARS-CoV-2 infection in a 16-year-old female with poorly controlled Graves' disease. She initially presented to the emergency department for fever and palpitations. Initial laboratory results suggested thyroid storm, for which she was started on propranolol. She remained tachycardic with new gallop rhythm on exam. An echocardiogram demonstrated a depressed left ventricular ejection fraction and mild pulmonary hypertension. Her SARS-CoV-2 antibodies were positive. She was started on intravenous immunoglobulin for suspected MIS-C. She responded to combined treatment of thyroid storm and MIS-C. She was discharged home on propranolol, methimazole, cholestyramine and aspirin.

Clinical and Laboratory Features of Patients with Multisystem Inflammatory Syndrome in Children (MIS-C): An Experience From Queen Rania Children's Hospital, Jordan

Background Multisystem inflammatory syndrome in children (MIS-C) is a new clinical observation that emerged during the coronavirus pandemic of 2019 (COVID-19) and has similar manifestations to Kawasaki disease and toxic shock syndrome. In this study, we aim to describe the characteristics of MIS-C patients in a single center in Jordan. Methods A retrospective analysis of electronic medical records of pediatric patients diagnosed with MIS-C at the pediatric rheumatology division of Queen Rania Children's Hospital, Amman, Jordan, between January 2021 and December 2022. Data collected included age, gender, clinical and laboratory data on presentation, and treatment options, which were compared in two different age groups. Results A total of 80 patients were included in this cohort (53 males and 27 females). The mean age at presentation was 84.4 months (ranging between nine months and 16 years). The most common presenting symptoms included fever (100%), abdominal pain (76.2%), skin rash (75%), conjunctivitis (72.5%), and mucosal changes (62.5%). Lymphopenia was present in 66.2% of patients. The majority of patients (98.7%) showed elevated C-reactive protein (CRP); 72 patients showed elevated erythrocyte sedimentation rate (ESR) (92.5%); ferritin was elevated in 70% of patients; the median fibrinogen level was 390 (interquartile range (IQR) 0.6-20) mg/dL; and the D-dimer level was 3.9 (IQR 0.6-20) mg/dL. Pericardial effusion was present in 23.8% of patients, and five patients (6.3%) had coronary artery dilatation. Conclusion To the best of our knowledge, this study is the first large case series of MIS-C in Jordan, with a wide spectrum of clinical presentation and evidence of hyperinflammation.

Immunoglobulin, glucocorticoid, or combination therapy for multisystem inflammatory syndrome in children: a propensity-weighted cohort study

Background

Multisystem inflammatory syndrome in children (MIS-C), a hyperinflammatory condition associated with SARS-CoV-2 infection, has emerged as a serious illness in children worldwide. Immunoglobulin or glucocorticoids, or both, are currently recommended treatments.

Methods

The Best Available Treatment Study evaluated immunomodulatory treatments for MIS-C in an international observational cohort. Analysis of the first 614 patients was previously reported. In this propensity-weighted cohort study, clinical and outcome data from children with suspected or proven MIS-C were collected onto a web-based Research Electronic Data Capture database. After excluding neonates and incomplete or duplicate records, inverse probability weighting was used to compare primary treatments with intravenous immunoglobulin, intravenous immunoglobulin plus glucocorticoids, or glucocorticoids alone, using intravenous immunoglobulin as the reference treatment. Primary outcomes were a composite of inotropic or ventilator support from the second day after treatment initiation, or death, and time to improvement on an ordinal clinical severity scale. Secondary outcomes included treatment escalation, clinical deterioration, fever, and coronary artery aneurysm occurrence and resolution. This study is registered with the ISRCTN registry, ISRCTN69546370.

Findings

We enrolled 2101 children (aged 0 months to 19 years) with clinically diagnosed MIS-C from 39 countries between June 14, 2020, and April 25, 2022, and, following exclusions, 2009 patients were included for analysis (median age 8·0 years [IQR 4·2-11·4], 1191 [59·3%] male and 818 [40·7%] female, and 825 [41·1%] White). 680 (33·8%) patients received primary treatment with intravenous immunoglobulin, 698 (34·7%) with intravenous immunoglobulin plus glucocorticoids, 487 (24·2%) with glucocorticoids alone; 59 (2·9%) patients received other combinations, including biologicals, and 85 (4·2%) patients received no immunomodulators. There were no significant differences between treatments for primary outcomes for the 1586 patients with complete baseline and outcome data that were considered for primary analysis. Adjusted odds ratios for ventilation, inotropic support, or death were 1·09 (95% CI 0·75-1·58; corrected p value=1·00) for intravenous immunoglobulin plus glucocorticoids and 0·93 (0·58-1·47; corrected p value=1·00) for glucocorticoids alone, versus intravenous immunoglobulin alone. Adjusted average hazard ratios for time to improvement were 1·04 (95% CI 0·91-1·20; corrected p value=1·00) for intravenous immunoglobulin plus glucocorticoids, and 0·84 (0·70-1·00; corrected p value=0·22) for glucocorticoids alone, versus intravenous immunoglobulin alone. Treatment escalation was less frequent for intravenous immunoglobulin plus glucocorticoids (OR 0·15 [95% CI 0·11-0·20]; p<0·0001) and glucocorticoids alone (0·68 [0·50-0·93]; p=0·014) versus intravenous immunoglobulin alone. Persistent fever (from day 2 onward) was less common with intravenous immunoglobulin plus glucocorticoids compared with either intravenous immunoglobulin alone (OR 0·50 [95% CI 0·38-0·67]; p<0·0001) or glucocorticoids alone (0·63 [0·45-0·88]; p=0·0058). Coronary artery aneurysm occurrence and resolution did not differ significantly between treatment groups.

Interpretation

Recovery rates, including occurrence and resolution of coronary artery aneurysms, were similar for primary treatment with intravenous immunoglobulin when compared to glucocorticoids or intravenous immunoglobulin plus glucocorticoids. Initial treatment with glucocorticoids appears to be a safe alternative to immunoglobulin or combined therapy, and might be advantageous in view of the cost and limited availability of intravenous immunoglobulin in many countries.

Funding

Imperial College London, the European Union's Horizon 2020, Wellcome Trust, the Medical Research Foundation, UK National Institute for Health and Care Research, and National Institutes of Health.

Mortality indicators with clinical profile of multisystem inflammatory syndrome in children during SARS-CoV-2 second wave in India: A tertiary referral center experience

Background

Post-COVID-19 cases are being reported with features of hyperinflammatory state causing multiple system dysfunctions in previously healthy children.

Objectives

To describe clinical characteristics, laboratory, and radiological profile of children affected with COVID-19-related multisystem inflammatory syndrome postsecond wave in India and compare them with respect to adverse outcome.

Materials and Methods

This prospective, observational study was conducted in the department of pediatrics of a tertiary care center in Eastern India over a period of 3 months. Demographic data, clinical details, biochemical parameters, and treatment with clinical outcome were recorded. Children who survived the clinical course were compared with those died during hospital stay.

Results

Thirty-five children with a median age of 4.8 (3.9) years were included who were admitted between June 16 and September 15, 2021. Only 17.14% had reverse transcription-polymerase chain reaction positivity previously with 77.14% had positive COVID-19 serology. Most common features were fever (100%), edema (68.6%), gastrointestinal (71.4%), mucocuteneous (65.7%), cardiovascular (57.1%), and neurological symptoms (45.7%). Twenty (57.1%) children had shock at presentation. Decreased ejection fraction (<55%) was the most common echocardiographic feature (37.14%) followed by coronary dilatation (20%). Majority (77.14%) of the patients required intensive care with inotrope requirement in 62.86% cases. Forty percent patients were intubated with mean duration of 9.94 (±10.5) days. All patients received methylprednisolone and 76% were given intravenous immunoglobulin. Tocilizumab was used in three patients. Nine patients died (25.7%) with overall median pediatric intensive care unit stay of 13 (14) days.

Conclusion

Of the parameters described, we have found shock, heart failure, neurological involvement at presentation, infancy, and laboratory parameters such as C-reactive protein, CPK, D-Dimer, and lactate dehydrogenase were the predictors of mortality.

Comparison of the course of multisystem inflammatory syndrome in children during different pandemic waves

The purpose of this study is to assess the rate, clinical picture, and management of multisystem inflammatory syndrome in children (MIS-C) during the different COVID-19 variants of concern (VOC) domination periods. This was a retrospective analysis of prospectively collected data. The incidence and clinical picture of MIS-C during the original/Alpha (group 1) and Delta/Omicron (Group 2) variant domination periods were compared. Among 108 eligible patients, 74 (68.5%) were hospitalized during the group 1 domination period, and 34 (31.5%) were hospitalized during the group 2 domination period. The median (Me) patient ages were 76 months (interquartile range [IQR] 35-130) and 73 months (IQR 45-118), and 61% and 65% of patients were male, respectively. There was no significant difference in the presence of positive SARS-CoV 2 antibody test results (IgM or IgG) between the groups (84 vs. 90%; p = 0.54).No differences between groups were observed in fever duration prior to admission (Me [IQR]: 5 days [3-6] vs. 5 days [4-6]; p = 0.26) or the presence of mucocutaneous (95 vs. 100%; p = 0.41), circulatory (70.3 vs. 61.8%; p = 0.86), neurological (6.8 vs. 2.9%; p = 0.662), or gastrointestinal symptoms (84 vs. 79%; p = 0.59). Respiratory symptoms were more common in group 2 (70 vs. 91%; p = 0.015). The need for intensive care unit admission was similar in both groups (16.2 vs. 17.6%, p = 1.0). No deaths occurred in the entire cohort. The studied children were characterized by high C-reactive protein and procalcitonin levels, concentrations of ferritin within normal limits, lymphopenia, moderate hypoalbuminemia, and high B-type natriuretic peptide/brain natriuretic peptide (NT-proBNP) concentrations; however, there were no differences between the groups. Intravenous immunoglobulins were administered as a first-line treatment for almost all patients. There was no significant difference in corticosteroid administration between the groups (87% vs. 74%; p = 0.11); however, the summary dose of methylprednisolone was higher in group 2 (Me [IQR]″ 12.6 mg/kg [10.5-17.8] vs. 16.4 mg/kg [13.3-19.5]; p = 0.03). The median length of stay was 11 days [IQR]: [9-14] and 10 days [8-12], respectively (p = 0.065).

CONCLUSION

The clinical course of MIS-C is similar in subsequent pandemic waves; however, the incidence of MIS-C seems to be decreasing.

WHAT IS KNOWN

• The clinical picture of COVID-19 is evolving. Multisystem inflammatory syndrome in children (MIS-C) is a relatively new serious disease connected with SARS-CoV-2 infection, and in subsequent waves of the pandemic, new cases of the disease have been recorded.

WHAT IS NEW

• The clinical picture of MIS-C is not specific, but the course is still severe. • The incidence of MIS-C during the different pandemic waves is decreasing and the diagnosis in the period of lower prevalance is challenging.

Comparison of Characteristics and Outcomes of Multisystem Inflammatory Syndrome, Kawasaki Disease and Toxic Shock Syndrome in Children

Background and Objectives: Since the first cases of multisystem inflammatory syndrome in children (MIS-C) in April 2020, the diagnostic challenge has been to recognize this syndrome and to differentiate it from other clinically similar pathologies such as Kawasaki disease (KD) and toxic shock syndrome (TSS). Our objective is to compare clinical signs, laboratory data and instrumental investigations between patients with MIS-C, KD and TSS. Materials and Methods: This retrospective observational study was conducted at the Children's Clinical University Hospital, Latvia (CCUH). We collected data from all pediatric patients <18 years of age, who met the Centers for Disease Control and Prevention case definition for MIS-C, and who presented to CCUH between December 2020 and December 2021. We also retrospectively reviewed data from inpatient medical records of patients <18 years of age diagnosed as having KD and TSS at CCUH between December 2015 and December 2021. Results: In total, 81 patients were included in this study: 39 (48.1%) with KD, 29 (35.8%) with MIS-C and 13 (16.1%) with TSS. In comparison with TSS and KD, patients with MIS-C more often presented with gastrointestinal symptoms (abdominal pain (p < 0.001), diarrhea (p = 0.003)), shortness of breath (p < 0.02) and headache (p < 0.003). All MIS-C patients had cardiovascular involvement and 93.1% of MIS-C patients fulfilled KD criteria, showing higher prevalence than in other research. Patients with KD had higher prevalence of cervical lymphadenopathy (p < 0.006) and arthralgias (p < 0.001). In comparison with KD and TSS, MIS-C patients had higher levels of ferritin (p < 0.001), fibrinogen (p = 0.04) and cardiac biomarkers, but lower levels of platelets and lymphocytes (p < 0.001). KD patients tended to have lower peak C-reactive protein (CRP) (p < 0.001), but higher levels of platelets. Acute kidney injury was more often observed in TSS patients (p = 0.01). Pathological changes in electrocardiography (ECG) and echocardiography were significantly more often observed in MIS-C patients (p < 0.001). Conclusions: This research shows that MIS-C, KD and TSS have several clinical similarities and additional investigations are required for reaching final diagnosis. All the patients with suspected MIS-C diagnosis should be examined for possible cardiovascular involvement including cardiac biomarkers, ECG and echocardiography.

Immunology of Multisystem Inflammatory Syndrome after COVID-19 in Children: A Review of the Current Evidence

Immune responses following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in children are still under investigation. Even though coronavirus disease 2019 (COVID-19) is usually mild in the pediatric population, some children exhibit severe clinical manifestations, require hospitalization, or develop the most severe condition: a multisystem inflammatory syndrome in children (MIS-C) associated with SARS-CoV-2 infection. The activated innate, humoral and T-cell-mediated immunological pathways that lead certain pediatric populations to present with MIS-C or remain asymptomatic after SARS-CoV-2 infection are yet to be established. This review focuses on the immunological aspects of MIS-C with respect to innate, humoral, and cellular immunity. In addition, presents the role of the SARS-CoV-2 Spike protein as a superantigen in the pathophysiological mechanisms, discusses the great heterogeneity among the immunological studies in the pediatric population, and highlights possible reasons why some children with a certain genetic background present with MIS-C.

Post-COVID-19 Sequelae in Children

Coronavirus disease 19 (COVID-19), caused by the severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2), has been implicated in having post-COVID-19 sequelae in both adults and children. There is a lack of good data on the prevalence and risk factors for post-COVID-19 sequelae in children. The authors aimed to review the current literature on post-COVID sequelae. The prevalence of post-COVID sequelae in children is highly variable among studies, with an average of 25%. The sequelae may affect many organ systems, though mood symptoms, fatigue, cough, dyspnea, and sleep problems are common. In many studies, it is difficult to establish a causal association due to the lack of a control group. Furthermore, it is difficult to differentiate whether the neuropsychiatric symptoms in children after COVID-19 are due to infection or a result of lockdowns and social restrictions imposed by the pandemic. Children with COVID-19 should be followed by a multidisciplinary team and screened for symptoms, followed by focused laboratory evaluations as needed. There is no specific treatment for the sequelae. Only symptomatic and supportive treatment is required in most cases. More research is necessary to standardize the definitions of sequelae, establish a causal association, assess various treatment options, and the effects of different virus variants, and finally, see the impact of vaccination on the sequelae.

Clinical profile and outcome of cardiac manifestations in patients presenting with multisystem inflammatory syndrome in children associated with SARS-CoV-2 infection

Multisystem inflammatory syndrome in children (MIS-C) can cause significant morbidity and mortality in children. This study was conducted to assess the pattern and outcome of cardiac abnormalities in MIS-C. This retrospective study was conducted in children with MIS-C between 1 month and 18 years. We enrolled 53 children with a mean age of 7.78 ± 4.62 years. Overall, 35.8% of children with MIS-C had cardiac manifestations in the form of coronary artery abnormalities (CAAs) or left ventricular (LV) dysfunction. Younger age (P 0.009) and high C-reactive protein at admission (P = 0.001) were significant predictors of cardiac involvement. CAAs were seen in 11.3% of children. On follow-up, 67% and 83% of children showed regression of CAA at 1 and 6 months, respectively. 24.5% of patients had presented with LV dysfunction. LV ejection fraction improved significantly at 1 month (P = 0.002) and 6 months (P = 0.001). Cardiac outcomes in MIS-C were favorable with timely identification and treatment.

Immune and coagulation profiles in 3 adults with multisystem inflammatory syndrome

Introduction: There is a paucity of information on the cytokine, complement, endothelial activation, and coagulation profiles of multisystem inflammatory syndrome in adults (MIS-A), a rare but serious complication following recovery from SARS-CoV-2 infection. We aim to examine the immune biomarker and coagulation profiles in association with the clinical presentation and course of MIS-A. Method: The clinical features of MIS-A patients admitted to our tertiary hospital were documented. Their levels of interleukin (IL)-1β, IL-6, IL-10, IL-17, IL-18, interferon-α (IFN-α), IFN-γ, interferon gamma-induced protein 10 (IP-10), tumour necrosis factor (TNF)-α, monocyte chemoattractant protein (MCP)-1, complement activation product (complement 5a [C5a]), and endothelial biomarker intercellular adhesion molecule-1 (ICAM-1) levels were assayed. The haemostatic profile was assessed with standard coagulation testing and thromboelastography. Results: Three male patients were diagnosed with MIS-A at our centre from January to June 2022 with a median age of 55 years. All had tested positive for SARS-CoV-2 12–62 days prior to MIS-A presentation, with gastrointestinal and cardiovascular systems as the most commonly involved. Levels of IL-6, IL-10, IL-18, IP-10 and MCP-1 were raised whereas IL-1β, IFN-α, IFN-γ, IL-17 and TNF-α remained normal. Markedly elevated levels of C-reactive protein (CRP), ferritin and ICAM-1 were present in all. C5a was elevated in 2 patients. A hypercoagulable state was demonstrated by raised levels of D-dimer, factor VIII, von Willebrand factor antigen, and ristocetin cofactor with corresponding raised parameters in thromboelastography in the 2 patients who had their coagulation profile assessed. Conclusion: MIS-A patients demonstrate activation of pro-inflammatory cytokines, endotheliopathy, complement hyperactivation and hypercoagulability. Keywords: COVID-19, cytokines, hypercoagulability, hyperinflammatory syndrome

The role of indices in predicting disease severity and outcomes of multisystem inflammatory syndrome in children

BACKGROUND

The aim of this study was to evaluate the role of the systemic immune inflammation index (SII), C-reactive protein/albumin ratio (CAR), the monocyte/lymphocyte ratio (MLR), and the neutrophil/lymphocyte ratio (NLR) in predicting disease severity, treatment, and prognosis in multisystem inflammatory syndrome in children (MIS-C).

METHODS

This medical record review retrospectively evaluated the clinical and laboratory findings of 191 MIS-C patients followed in the Department of Pediatric Rheumatology at Ankara City Hospital, Turkey. The patients were grouped by disease severity: mild, moderate, and severe. SII, CAR, MLR, and NLR were calculated for each group.

RESULTS

All patients had fever at the time of admission; 153 (80.1%) had gastrointestinal tract involvement, 74 (38.7%) had rash, 63 (33%) had conjunctivitis, 107 (56%) had cardiac involvement, 32 (15.6%) had renal involvement, and 143 (74.9%) had hematological involvement. According to logistic regression analysis, SII, NLR, MLR, and CAR were found to be predictive indexes for disease severity, need for intensive care, need for inotropes, and anakinra treatment in MIS-C. The cut-off values of ≥1605.3 for SII, ≥9.1 for NLR, and ≥3.9 for CAR increased the risk of severe disease by 3.4, 7.1, and 5.7 times, respectively.

CONCLUSION

NLR, SII, MLR, and CAR are effective and useful for predicting the severity of MIS-C, the need for intensive care, and the need for anakinra treatment.

Research trends on causes of Kawasaki disease in the COVID-19 era: focus on viral infections

Despite studies on the etiology of Kawasaki disease (KD) ongoing for half a century since its discovery, its cause has not yet been clearly identified. Although the clinical, epidemiological, and pathophysiological characteristics of KD are presumed to be closely related to infectious diseases, studies of various pathogens to identify its etiology have been actively conducted. To date, bacteria, fungi, and viruses have been investigated to determine the relationship between KD and infection, among which viruses have attracted the most attention. In particular, during the coronavirus disease 2019 pandemic, there were many reports in Europe of a sharp increase in cases of Kawasaki-like disease (KLD), while conflicting reports that the prevalence of KD decreased due to thorough "social distancing" or "wearing mask" in Asian countries drew more attention regarding the association between KD and viral infection. Therefore, the differential diagnosis of KD from KLD with these similar spectra has become a very important issue; simultaneously, research to solve questions about the association between KD and viral infections, including sudden acute respiratory syndrome coronavirus 2, is drawing attention again. Moreover, a new concept has emerged that immune responses occurring in patients with KD can be caused by the pathogen itself as well as host cells damaged by infection. This paper summarizes the research trends into KD etiology and related pathophysiology, especially its association with viral infections, and present future research tasks to increase our understanding of KD.