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Abbas Q, Ali H, Amjad F, Hussain MZH, Rahman AR, Khan MH, Padhani ZA, Abbas F, Imam D, Alikhan Z, Belgaumi SM, Mohsin S, Sattar F, Siddiqui A, Lassi ZS, Das JK. Clinical presentation, diagnosis and management of multisystem inflammatory syndrome in children (MIS-C): a systematic review. BMJ Paediatr Open 2024; 8:e002344. [PMID: 38844384 PMCID: PMC11163633 DOI: 10.1136/bmjpo-2023-002344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 04/16/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND Knowledge about multisystem inflammatory syndrome in children (MIS-C) is evolving, and evidence-based standardised diagnostic and management protocols are lacking. Our review aims to summarise the clinical and diagnostic features, management strategies and outcomes of MIS-C and evaluate the variances in disease parameters and outcomes between high-income countries (HIC) and middle-income countries (MIC). METHODS We searched four databases from December 2019 to March 2023. Observational studies with a sample size of 10 or more patients were included. Mean and prevalence ratios for various variables were pooled by random effects model using R. A mixed generalised linear model was employed to account for the heterogeneity, and publication bias was assessed via funnel and Doi plots. The primary outcome was pooled mean mortality among patients with MIS-C. Subgroup analysis was conducted based on the income status of the country of study. RESULTS A total of 120 studies (20 881 cases) were included in the review. The most common clinical presentations were fever (99%; 95% CI 99.6% to 100%), gastrointestinal symptoms (76.7%; 95% CI 73.1% to 79.9%) and dermatological symptoms (63.3%; 95% CI 58.7% to 67.7%). Laboratory investigations suggested raised inflammatory, coagulation and cardiac markers. The most common management strategies were intravenous immunoglobulins (87.5%; 95% CI 82.9% to 91%) and steroids (74.7%; 95% CI 68.7% to 79.9%). Around 53.1% (95% CI 47.3% to 58.9%) required paediatric intensive care unit admissions, and overall mortality was 3.9% (95% CI 2.7% to 5.6%). Patients in MIC were younger, had a higher frequency of respiratory distress and evidence of cardiac dysfunction, with a longer hospital and intensive care unit stay and had a higher mortality rate than patients in HIC. CONCLUSION MIS-C is a severe multisystem disease with better mortality outcomes in HIC as compared with MIC. The findings emphasise the need for standardised protocols and further research to optimise patient care and address disparities between HIC and MIC. PROSPERO REGISTRATION NUMBER CRD42020195823.
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Affiliation(s)
- Qalab Abbas
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Sind, Pakistan
| | - Haider Ali
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Sind, Pakistan
| | - Fatima Amjad
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Sind, Pakistan
| | | | - Abdu R Rahman
- Department of Biological and Biomedical Sciences, The Aga Khan University, Karachi, Pakistan
| | - Maryam Hameed Khan
- Institute for Global Health and Development, The Aga Khan University, Karachi, Sind, Pakistan
| | - Zahra A Padhani
- School of Public Health, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Robinson Research Institute, University of Adelaide, Adelaide, South Australia, Australia
| | - Fatima Abbas
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Sind, Pakistan
| | - Danyal Imam
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Sind, Pakistan
| | - Zuviya Alikhan
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Sind, Pakistan
| | - Sameer M Belgaumi
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Sind, Pakistan
| | - Shazia Mohsin
- Department of Pediatric cardiology, Division of cardiothoracic sciences, Sindh institute of Urology and Transplantation (SIUT), Karachi, Sind, Pakistan
| | - Faiza Sattar
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Sind, Pakistan
| | - Arsalan Siddiqui
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Sind, Pakistan
| | - Zohra S Lassi
- School of Public Health, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Robinson Research Institute, University of Adelaide, Adelaide, South Australia, Australia
| | - Jai K Das
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Sind, Pakistan
- Institute for Global Health and Development, The Aga Khan University, Karachi, Sind, Pakistan
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Tseng CT, Lin JJ, Huang JL, Chiu CH, Wu CY. Clinical manifestations and outcomes associated with PICU admission in children with multisystem inflammatory syndrome in Taiwan: A retrospective cohort study. Int J Rheum Dis 2024; 27:e14970. [PMID: 37947261 DOI: 10.1111/1756-185x.14970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 10/23/2023] [Accepted: 10/27/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Multisystem inflammatory syndrome in children (MIS-C) is a rare and serious systemic inflammatory disorder that occurs following a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. This study aims to investigate the clinical manifestations, risk factors associated with pediatric intensive care unit (PICU) admission, and outcome among children with MIS-C in Taiwan. METHODS A retrospective analysis was conducted among pediatric patients diagnosed with MIS-C between June 2022 and February 2023 at Chang Gung Memorial Hospital, Linkou, Taiwan. Data on demographics, clinical features, laboratory findings, treatment modalities, and outcomes were collected and analyzed. RESULTS Twenty-eight MIS-C patients, including 9 boys and 19 girls, with an average age of 5.3 ± 3.8 years old, were enrolled. Most of the cases (78.6%) were diagnosed following the first pandemic wave of COVID-19 in Taiwan. The leading clinical manifestations observed were fever (100%), skin rash (64.3%), tachycardia (46.4%), and vomiting (46.4%). Nine patients (32.1%) were admitted to the PICU due to hypotension or neurological manifestations. Higher levels of band-form white blood cells, procalcitonin, ferritin, d-dimer, prothrombin time, NT-proBNP, and lower platelet levels on arrival were associated with PICU admission (p = 3.9 × 10-2 ,9 × 10-3 , 4 × 10-3 ,1 × 10-3 , 5 × 10-3 , 4.1 × 10-2 , and 3.4 × 10-2 , respectively). Arrhythmia in one case (3.5%) and coronary artery abnormalities, including dilatation in two cases (7.1%) and small aneurysms in one case (3.5%) were identified. Regardless of ICU admission, no patients experienced systolic dysfunction or mortality following treatment. CONCLUSION MIS-C cases in Taiwan have a favorable outcome. Although one-third of the patients required PICU admission, none of the MIS-C cases resulted in severe cardiovascular morbidity or mortality. This study provides valuable insights into the clinical manifestations and outcomes associated with PICU admission in children with MIS-C in Taiwan.
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Affiliation(s)
- Chi-Teng Tseng
- Division of Allergy, Asthma, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan city, Taiwan
| | - Jainn-Jim Lin
- College of Medicine, Chang Gung University, Taoyuan city, Taiwan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Taoyuan city, Taiwan
| | - Jing-Long Huang
- Division of Allergy, Asthma, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan city, Taiwan
- College of Medicine, Chang Gung University, Taoyuan city, Taiwan
- Department of Pediatrics, New Taipei Municipal TuCheng Hospital, New Taipei city, Taiwan
| | - Cheng-Hsun Chiu
- College of Medicine, Chang Gung University, Taoyuan city, Taiwan
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan city, Taiwan
| | - Chao-Yi Wu
- Division of Allergy, Asthma, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan city, Taiwan
- College of Medicine, Chang Gung University, Taoyuan city, Taiwan
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COVID-19 Heart Lesions in Children: Clinical, Diagnostic and Immunological Changes. Int J Mol Sci 2023; 24:ijms24021147. [PMID: 36674665 PMCID: PMC9866514 DOI: 10.3390/ijms24021147] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 01/02/2023] [Accepted: 01/03/2023] [Indexed: 01/11/2023] Open
Abstract
In the beginning of COVID-19, the proportion of confirmed cases in the pediatric population was relatively small and there was an opinion that children often had a mild or asymptomatic course of infection. Our understanding of the immune response, diagnosis and treatment of COVID-19 is highly oriented towards the adult population. At the same time, despite the fact that COVID-19 in children usually occurs in a mild form, there is an incomplete understanding of the course as an acute infection and its subsequent manifestations such as Long-COVID-19 or Post-COVID-19, PASC in the pediatric population, correlations with comorbidities and immunological changes. In mild COVID-19 in childhood, some authors explain the absence of population decreasing T and B lymphocytes. Regardless of the patient's condition, they can have the second phase, related to the exacerbation of inflammation in the heart tissue even if the viral infection was completely eliminated-post infectious myocarditis. Mechanism of myocardial dysfunction development in MIS-C are not fully understood. It is known that various immunocompetent cells, including both resident inflammatory cells of peripheral tissues (for example macrophages, dendritic cells, resident memory T-lymphocytes and so on) and also circulating in the peripheral blood immune cells play an important role in the immunopathogenesis of myocarditis. It is expected that hyperproduction of interferons and the enhanced cytokine response of T cells 1 and 2 types contribute to dysfunction of the myocardium. However, the role of Th1 in the pathogenesis of myocarditis remains highly controversial. At the same time, the clinical manifestations and mechanisms of damage, including the heart, both against the background and after COVID-19, in children differ from adults. Further studies are needed to evaluate whether transient or persistent cardiac complications are associated with long-term adverse cardiac events.
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