1
|
Henderson LA, Canna SW, Friedman KG, Gorelik M, Lapidus SK, Bassiri H, Behrens EM, Kernan KF, Schulert GS, Seo P, Son MBF, Tremoulet AH, VanderPluym C, Yeung RSM, Mudano AS, Turner AS, Karp DR, Mehta JJ. American College of Rheumatology Clinical Guidance for Multisystem Inflammatory Syndrome in Children Associated With SARS-CoV-2 and Hyperinflammation in Pediatric COVID-19: Version 3. Arthritis Rheumatol 2022; 74:e1-e20. [PMID: 35118829 PMCID: PMC9011620 DOI: 10.1002/art.42062] [Citation(s) in RCA: 128] [Impact Index Per Article: 64.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 12/22/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To provide guidance on the management of Multisystem Inflammatory Syndrome in Children (MIS-C), a condition characterized by fever, inflammation, and multiorgan dysfunction that manifests late in the course of SARS-CoV-2 infection. Recommendations are also provided for children with hyperinflammation during COVID-19, the acute, infectious phase of SARS-CoV-2 infection. METHODS The Task Force is composed of 9 pediatric rheumatologists and 2 adult rheumatologists, 2 pediatric cardiologists, 2 pediatric infectious disease specialists, and 1 pediatric critical care physician. Preliminary statements addressing clinical questions related to MIS-C and hyperinflammation in COVID-19 were developed based on evidence reports. Consensus was built through a modified Delphi process that involved anonymous voting and webinar discussion. A 9-point scale was used to determine the appropriateness of each statement (median scores of 1-3 for inappropriate, 4-6 for uncertain, and 7-9 for appropriate). Consensus was rated as low, moderate, or high based on dispersion of the votes. Approved guidance statements were those that were classified as appropriate with moderate or high levels of consensus, which were prespecified before voting. RESULTS The guidance was approved in June 2020 and updated in November 2020 and October 2021, and consists of 41 final guidance statements accompanied by flow diagrams depicting the diagnostic pathway for MIS-C and recommendations for initial immunomodulatory treatment of MIS-C. CONCLUSION Our understanding of SARS-CoV-2-related syndromes in the pediatric population continues to evolve. This guidance document reflects currently available evidence coupled with expert opinion, and will be revised as further evidence becomes available.
Collapse
Affiliation(s)
| | - Scott W. Canna
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine
| | - Kevin G. Friedman
- Boston Children's Hospital and Harvard Medical SchoolBostonMassachusetts
| | - Mark Gorelik
- Morgan Stanley Children’s Hospital and Columbia UniversityNew YorkNew York
| | - Sivia K. Lapidus
- Joseph M. Sanzari Children’s Hospital at Hackensack University Medical Center and Hackensack Meridian School of MedicineHackensackNew Jersey
| | - Hamid Bassiri
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine
| | - Edward M. Behrens
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine
| | - Kate F. Kernan
- University of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Grant S. Schulert
- Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of MedicineCincinnatiOhio
| | - Philip Seo
- Johns Hopkins University School of MedicineBaltimoreMaryland
| | - Mary Beth F. Son
- Boston Children's Hospital and Harvard Medical SchoolBostonMassachusetts
| | - Adriana H. Tremoulet
- University of California San Diego and Rady Children’s Hospital San DiegoCalifornia
| | | | - Rae S. M. Yeung
- The Hospital for Sick Children and University of TorontoTorontoOntarioCanada
| | | | | | - David R. Karp
- University of Texas Southwestern Medical CenterDallas
| | - Jay J. Mehta
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine
| |
Collapse
|
2
|
Jones LM, Khatri P. Multisystem inflammatory syndrome in children: a microcosm of challenges and opportunities for translational bioinformatics in pediatric research. Curr Opin Pediatr 2021; 33:325-330. [PMID: 33871421 PMCID: PMC8096697 DOI: 10.1097/mop.0000000000001012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Despite significant progress in our understanding and clinical management of multisystem inflammatory syndrome in children (MIS-C), significant challenges remain. Here, we review recently published studies on the clinical diagnosis, risk stratification, and treatment of MIS-C, highlighting key gaps in research progress that are a microcosm for challenges in translational pediatric research. We then discuss potential solutions in the realm of translational bioinformatics. RECENT FINDINGS Current case definitions are inconsistent and do not capture the underlying pathophysiology of MIS-C, which remains poorly understood. Although overall mortality is low, some patients rapidly decompensate, and a test to identify those at risk for severe outcomes remains an unmet need. Treatment consists of various combinations of immunoglobulins, corticosteroids, and biologics, based on extrapolated data and expert opinion, while the benefits remain unclear as we await the completion of clinical trials. SUMMARY The small size and heterogeneity of the pediatric population contribute to unmet needs because of financial and logistical constraints of the current research infrastructure focused on eliminating most sources of heterogeneity, leading to ungeneralizable results. Data sharing and meta-analysis of gene expression shows promise to accelerate progress in the field of MIS-C as well as other childhood diseases beyond the current pandemic.
Collapse
Affiliation(s)
- Lara Murphy Jones
- Institute for Immunity, Transplantation and Infection, School of Medicine, Stanford University, CA 94305
- Center for Biomedical Informatics Research, Department of Medicine, School of Medicine, Stanford University, CA 94305
- Division of Critical Care Medicine, Department of Pediatrics, School of Medicine, Stanford University, CA 94305
| | - Purvesh Khatri
- Institute for Immunity, Transplantation and Infection, School of Medicine, Stanford University, CA 94305
- Center for Biomedical Informatics Research, Department of Medicine, School of Medicine, Stanford University, CA 94305
| |
Collapse
|
3
|
Henderson LA, Canna SW, Friedman KG, Gorelik M, Lapidus SK, Bassiri H, Behrens EM, Ferris A, Kernan KF, Schulert GS, Seo P, Son MBF, Tremoulet AH, Yeung RSM, Mudano AS, Turner AS, Karp DR, Mehta JJ. American College of Rheumatology Clinical Guidance for Multisystem Inflammatory Syndrome in Children Associated With SARS-CoV-2 and Hyperinflammation in Pediatric COVID-19: Version 2. Arthritis Rheumatol 2021; 73:e13-e29. [PMID: 33277976 PMCID: PMC8559788 DOI: 10.1002/art.41616] [Citation(s) in RCA: 256] [Impact Index Per Article: 85.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 12/03/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To provide guidance on the management of Multisystem Inflammatory Syndrome in Children (MIS-C), a condition characterized by fever, inflammation, and multiorgan dysfunction that manifests late in the course of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Recommendations are also provided for children with hyperinflammation during coronavirus disease 2019 (COVID-19), the acute, infectious phase of SARS-CoV-2 infection. METHODS The Task Force was composed of 9 pediatric rheumatologists and 2 adult rheumatologists, 2 pediatric cardiologists, 2 pediatric infectious disease specialists, and 1 pediatric critical care physician. Preliminary statements addressing clinical questions related to MIS-C and hyperinflammation in COVID-19 were developed based on evidence reports. Consensus was built through a modified Delphi process that involved anonymous voting and webinar discussion. A 9-point scale was used to determine the appropriateness of each statement (median scores of 1-3 for inappropriate, 4-6 for uncertain, and 7-9 for appropriate). Consensus was rated as low, moderate, or high based on dispersion of the votes. Approved guidance statements were those that were classified as appropriate with moderate or high levels of consensus, which were prespecified before voting. RESULTS The first version of the guidance was approved in June 2020, and consisted of 40 final guidance statements accompanied by a flow diagram depicting the diagnostic pathway for MIS-C. The document was revised in November 2020, and a new flow diagram with recommendations for initial immunomodulatory treatment of MIS-C was added. CONCLUSION Our understanding of SARS-CoV-2-related syndromes in the pediatric population continues to evolve. This guidance document reflects currently available evidence coupled with expert opinion, and will be revised as further evidence becomes available.
Collapse
Affiliation(s)
- Lauren A. Henderson
- Lauren A. Henderson, MD, MMSc, Kevin G. Friedman, MD, Mary Beth F. Son, MD: Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Scott W. Canna
- Scott W. Canna, MD: UPMC Children’s Hospital of Pittsburgh and University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kevin G. Friedman
- Lauren A. Henderson, MD, MMSc, Kevin G. Friedman, MD, Mary Beth F. Son, MD: Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Mark Gorelik
- Mark Gorelik, MD: Morgan Stanley Children’s Hospital and Columbia University, New York, New York
| | - Sivia K. Lapidus
- Sivia K. Lapidus, MD: Joseph M. Sanzari Children’s Hospital at Hackensack University Medical Center and Hackensack Meridian School of Medicine, Hackensack, New Jersey
| | - Hamid Bassiri
- Hamid Bassiri, MD, PhD, Edward M. Behrens, MD, Jay J. Mehta, MD: Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine
| | - Edward M. Behrens
- Hamid Bassiri, MD, PhD, Edward M. Behrens, MD, Jay J. Mehta, MD: Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine
| | - Anne Ferris
- Anne Ferris, MBBS: Columbia University Irving Medical Center, New York, New York
| | - Kate F. Kernan
- Kate F. Kernan, MD: University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Grant S. Schulert
- Grant S. Schulert, MD: Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Philip Seo
- Philip Seo, MD, MHS: Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mary Beth F. Son
- Lauren A. Henderson, MD, MMSc, Kevin G. Friedman, MD, Mary Beth F. Son, MD: Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Adriana H. Tremoulet
- Adriana H. Tremoulet, MD, MAS: University of California San Diego and Rady Children’s Hospital, San Diego, California
| | - Rae S. M. Yeung
- Rae S. M. Yeung, MD, PhD: The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Amy S. Mudano
- Amy S. Mudano, MPH: University of Alabama at Birmingham
| | - Amy S. Turner
- Amy S. Turner: American College of Rheumatology, Atlanta, Georgia
| | - David R. Karp
- David R. Karp, MD, PhD: University of Texas Southwestern Medical Center, Dallas
| | - Jay J. Mehta
- Hamid Bassiri, MD, PhD, Edward M. Behrens, MD, Jay J. Mehta, MD: Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine
| |
Collapse
|
4
|
Henderson LA, Canna SW, Friedman KG, Gorelik M, Lapidus SK, Bassiri H, Behrens EM, Ferris A, Kernan KF, Schulert GS, Seo P, F. Son MB, Tremoulet AH, Yeung RSM, Mudano AS, Turner AS, Karp DR, Mehta JJ. 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. Arthritis Rheumatol 2020; 72:1791-1805. [PMID: 32705809 PMCID: PMC7405113 DOI: 10.1002/art.41454] [Citation(s) in RCA: 270] [Impact Index Per Article: 67.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/21/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To provide guidance on the management of multisystem inflammatory syndrome in children (MIS-C), a condition characterized by fever, inflammation, and multiorgan dysfunction that manifests late in the course of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, and to provide recommendations for children with hyperinflammation during coronavirus disease 2019 (COVID-19), the acute, infectious phase of SARS-CoV-2 infection. METHODS A multidisciplinary task force was convened by the American College of Rheumatology (ACR) to provide guidance on the management of MIS-C associated with SARS-CoV-2 and hyperinflammation in COVID-19. The task force was composed of 9 pediatric rheumatologists, 2 adult rheumatologists, 2 pediatric cardiologists, 2 pediatric infectious disease specialists, and 1 pediatric critical care physician. Preliminary statements addressing clinical questions related to MIS-C and hyperinflammation in COVID-19 were developed based on evidence reports. Consensus was built through a modified Delphi process that involved 2 rounds of anonymous voting and 2 webinars. A 9-point scale was used to determine the appropriateness of each statement (median scores of 1-3 for inappropriate, 4-6 for uncertain, and 7-9 for appropriate), and consensus was rated as low, moderate, or high based on dispersion of the votes along the numeric scale. Approved guidance statements were those that were classified as appropriate with moderate or high levels of consensus, as prespecified prior to voting. RESULTS The ACR task force approved a total of 128 guidance statements addressing the management of MIS-C and hyperinflammation in pediatric COVID-19. These statements were refined into 40 final clinical guidance statements, accompanied by a flow diagram depicting the diagnostic pathway for MIS-C. CONCLUSION Our understanding of SARS-CoV-2-related syndromes in the pediatric population continues to evolve. The guidance provided in this "living document" reflects currently available evidence, coupled with expert opinion, and will be revised as further evidence becomes available.
Collapse
Affiliation(s)
| | - Scott W. Canna
- UPMC Children’s Hospital of Pittsburgh and University of PittsburghPittsburghPennsylvania
| | - Kevin G. Friedman
- Boston Children’s Hospital and Harvard Medical SchoolBostonMassachusetts
| | - Mark Gorelik
- Morgan Stanley Children’s Hospital and Columbia UniversityNew YorkNew York
| | - Sivia K. Lapidus
- Joseph M. Sanzari Children’s Hospital at Hackensack University Medical Center and Hackensack Meridian School of MedicineHackensackNew Jersey
| | - Hamid Bassiri
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine
| | - Edward M. Behrens
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine
| | - Anne Ferris
- Columbia University Irving Medical CenterNew YorkNew York
| | - Kate F. Kernan
- University of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Grant S. Schulert
- Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of MedicineCincinnatiOhio
| | - Philip Seo
- Johns Hopkins University School of MedicineBaltimoreMaryland
| | - Mary Beth F. Son
- Boston Children’s Hospital and Harvard Medical SchoolBostonMassachusetts
| | | | - Rae S. M. Yeung
- Hospital for Sick Children and University of TorontoTorontoOntarioCanada
| | | | | | - David R. Karp
- University of Texas Southwestern Medical CenterDallas
| | - Jay J. Mehta
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine
| |
Collapse
|