Clinical characteristics and outcomes of the multisystem inflammatory syndrome in children (MIS-C) following COVID-19 infection in Iran: A multicenter study

Post-discharge follow-up of pediatric COVID-19 patients: insights into serological dynamics

Introduction

Limited data are available regarding SARS-CoV-2 serological response dynamics in pediatric patients with COVID-19, contributing to gaps in our understanding of the immune response in this population. This study aimed to investigate SARS-CoV-2 IgG seropositivity in patients diagnosed with COVID-19 during hospitalization and 2-4 weeks after discharge.

Methods

A cohort of patients, consisting of 31 individuals with confirmed acute COVID-19 infection and 27 diagnosed with Multisystem Inflammatory Syndrome in Children (MIS-C), was enrolled in the study. Follow-up clinic appointments were scheduled for 2-4 weeks post-discharge. During admission and follow-up, blood samples were collected from each patient for laboratory analysis. Anti-nucleoprotein SARS-CoV-2 IgG levels were determined using the Enzyme-Linked Immunosorbent Assay (ELISA) method.

Results

In this study, a cohort of 58 patients was examined. At admission, 52% (n = 14) of MIS-C patients and 10% (n = 3) of acute COVID-19 patients had positive SARS-CoV-2 IgG test. Only 48 cases were referred to the hospital, and follow-up data was available for 20 cases with MIS-C and 28 cases with acute COVID-19. All patients (n = 15) who initially tested positive for SARS-CoV-2 IgG at admission remained positive serology during follow-up (100%). Among the 33 patients who initially tested negative, 12 (37.5%) showed a positive serology result during follow-up, while 21 (62.5%) remained negative. Within this subgroup, 11 cases (44%) were diagnosed with acute COVID-19, and one patient (12.5%) presented with MIS-C. Fourteen cases with acute COVID-19 infection (56%) and seven cases with MIS-C (87.5%) consistently showed negative serology results throughout the study. During follow-up, the median lymphocyte count demonstrated a significant difference, with 0.96 × 109 cells per L (IQR: 0.75-3.0 × 109 cells per L) in the SARS-CoV-2 IgG-negative group and 2.9 × 109 cells per L (IQR = 1.33-7.22 × 109 cells per L) in the SARS-CoV-2 IgG-positive group (p-value = 0.03). Patients who demonstrated seropositivity during the follow-up were associated with a notably severe disease (p-value = 0.028).

Conclusion

Our study highlights the dynamic nature of SARS-CoV-2 IgG antibody responses in pediatric patients with COVID-19 infection. We observed a notable increase in seropositivity rates during follow-up. Furthermore, patients who were seropositive at follow-up demonstrated a severe disease course and lower lymphocyte counts compared to those with persistently negative serology. Our findings underscore the importance of longitudinal serological monitoring in understanding disease progression and immune response dynamics in pediatric COVID-19 cases.

Clinical presentation, diagnosis and management of multisystem inflammatory syndrome in children (MIS-C): a systematic review

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.

Multisystem Inflammatory Syndrome in Children (MIS-C) Post COVID-19 Infection: Diagnosis and Treatment from the Paediatric Intensive Care Unit (PICU) at a Tertiary Hospital in the Kingdom of Bahrain

BACKGROUND

Post coronavirus disease 2019 (COVID-19) infections, children presented with varying clinical manifestations of a Multisystem Inflammatory Syndrome in Children (MIS-C). The aim of our study is to identify the clinical manifestations upon admission to paediatric intensive care unit (PICU) and to identify how different treatments affected post-treatment outcomes.  Methods: A retrospective cross-sectional study included 11 patients diagnosed with multisystem inflammatory syndrome based on the World Health Organization (WHO) classification and treated by intravenous immunoglobulin (IVIG) with/without corticosteroids.  Results: There were six female and five male patients with an average age of 5.08±4.7 years. Ten had a confirmed positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) serological antibody test or polymerase chain reaction (PCR) test, with one having only contact history. The most common systems affected by MIS-C were gastrointestinal and ophthalmological presentations. All presented with fever and raised inflammatory markers (erythrocyte sedimentation rate, C-reactive protein, procalcitonin, ferritin, d-dimer, and lactate dehydrogenase). There was no statistical difference between both treatment groups. Clinical and inflammatory markers significantly improved in both groups.

CONCLUSION

This study highlights an improved outcome associated with combination therapy, although there is no statistical significance between both groups.

SARS-CoV-2 infections and MIS-C among children: A narrative review

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has less of an impact among the babies and teenagers, than it does on adults as a whole. Children turned out to be less symptomatic during the coronavirus disease (COVID-19) surge worldwide. Researchers discovered the ways of protection by preemptive care, like, treatment, variants, vaccination, social distancing, and cohorting among children as soon as their medical and epidemiological factors were assessed while being exposed to SARS-CoV-2 transmission. The actual pervasiveness of asymptomatic SARS-CoV-2 contagion is possibly undervalued because of less examination of the asymptomatic children. A half of young-aged people who tested SARS-CoV-2 positive don't show any symptoms as per the study of serology. Nevertheless, there is wide circulation of information reporting a post-infectious acute illness known as multisystem inflammatory syndrome in children (MIS-C) or multisystem hyperinflammatory syndrome. Therefore, we undertook this narrative review to synthesize the evidence from existing studies to assess the relationship between SARS-CoV-2 infections and MIS-C among Children. We reviewed PubMed, Science Direct, and Google Scholar to find the pertinent scientific papers published in English that were available for such analysis. The main purpose of this article is to present, on this limited topic, a better-comprehended review covering pertinent material and data to be informed on SARS-CoV-2 infections and MIS-C among Children.

Coronavirus disease 2019 and gastrointestinal disorders in children

During the past 3 years, the coronavirus disease 2019 (COVID-19) pandemic has had a great impact on people all over the world. However, it has become evident that disease manifestations and severity differ across age groups. Most children have a milder disease course than adults but possibly more pronounced gastrointestinal (GI) symptoms. Given the child's developing immune system, the impact of COVID-19 on disease development may differ compared to adults. This study reviews the potential bi-directional relationship between COVID-19 and GI diseases in children, focusing on common pediatric conditions such as functional GI disorders (FGID), celiac disease (CeD), and inflammatory bowel disease (IBD). Children with GI diseases, in general, and CeD and IBD, in particular, do not seem to have an increased risk of severe COVID-19, including risks of hospitalization, critical care need, and death. While infections are considered candidate environmental factors in both CeD and IBD pathogenesis, and specific infectious agents are known triggers for FGID, there is still not sufficient evidence to implicate COVID-19 in the development of either of these diseases. However, given the scarcity of data and the possible latency period between environmental triggers and disease development, future investigations in this field are warranted.

Role of Lung Ultrasonography (LUS) as a Tool for Evaluating Children with Pediatric Inflammatory Multisystem Syndrome Temporally Associated with SARS-CoV-2 (PIMS-TS)

BACKGROUND

Pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) is a novel entity. The inflammatory process involves the circulatory, digestive, respiratory, and central nervous systems, as well as the skin. Making a diagnosis requires extensive differential diagnoses, including lung imaging. The aim of our study was to retrospectively assess the pathologies found in lung ultrasound (LUS) in children diagnosed with PIMS-TS and to evaluate the usefulness of the examination in diagnostics and monitoring.

METHODS

The study group consisted of 43 children diagnosed with PIMS-TS, in whom LUS was performed at least three times, including on admission to hospital, on discharge, and 3 months after disease onset.

RESULTS

Pneumonia (mild to severe) was diagnosed in 91% of the patients based on the ultrasound image; the same number had at least one pathology, including consolidations, atelectasis, pleural effusion, and interstitial or interstitial-alveolar syndrome. By the time of discharge, the inflammatory changes had completely regressed in 19% of the children and partially in 81%. After 3 months, no pathologies were detected in the entire study group.

CONCLUSION

LUS is a useful tool for diagnosing and monitoring children with PIMS-TS. Inflammatory lesions of the lungs resolve completely when the generalized inflammatory process subsides.

Epidemiology, clinical characteristics and outcomes of multisystem inflammatory syndrome in children

BACKGROUND

We describe the epidemiology, clinical characteristics, and outcomes of multisystem inflammatory syndrome in children (MIS-C) among children from Negeri Sembilan, Malaysia.

METHODS

A retrospective, multicentre, observational study was performed among children ≤15 years old who were hospitalized for MIS-C between January 18, 2021 and June 30, 2023. The incidence of MIS-C was estimated using reported SARS-CoV-2 cases and census population data. Descriptive analyses were used to summarize the clinical presentation and outcomes.

RESULTS

The study included 53 patients with a median age of 5.7 years (IQR 1.8-8.7 years); 75.5% were males. The overall incidence of MIS-C was approximately 5.9 cases per 1,000,000 person-months. Pediatric intensive care unit (PICU) admission was required for 22 (41.5%) patients. No mortalities were recorded. Children aged 6-12 years were more likely to present with cardiac dysfunction/shock (odds ratio [OR] 5.43, 95% confidence interval [CI] 1.67-17.66), whereas children below 6 years were more likely to present with a Kawasaki disease phenotype (OR 5.50, 95% CI 1.33-22.75). Twenty patients (37.7%) presented with involvement of at least four organ systems, but four patients (7.5%) demonstrated single-organ system involvement.

CONCLUSION

An age-based variation in the clinical presentation of MIS-C was demonstrated. Our findings suggest MIS-C could manifest in a spectrum, including single-organ involvement. Despite the high requirement for PICU admission, the prognosis of MIS-C was favorable, with no recorded mortalities.

Clinical and laboratory characteristics of multisystem inflammatory syndrome in children associated with COVID-19 in Egypt: A tertiary care hospital experience

AIM

We aimed to evaluate MIS-C patients' clinical manifestations, laboratory test results and mortality outcomes in an Egyptian tertiary care university hospital.

METHODS

We conducted a 12 month cross-sectional study in a tertiary-care university children's hospital. All paediatric patients (1 month to 16 years old) who met the CDC criteria for MIS-C were enrolled in the study. We assessed patients' clinical presentations, complications, treatments, imaging studies, laboratory test results and outcomes. The baseline clinical and laboratory findings of survivors and non-survivors were compared.

RESULTS

Of 45 MIS-C patients, 24 (53.3%) were males, and the median (interquartile range) age was 4 (1.25-10) years. All patients had fever, 64.4% had respiratory manifestations, 48.9% presented with coma, 44.4% presented with shock, 33.3% presented with seizures, 31.1% had abdominal pain, 28.9% had vomiting and 22.2% presented with cerebrovascular stroke. A total of 15 (33.3%) patients died, and the non-survivors had a significantly higher incidence of respiratory manifestations (P = 0.028), shock (P = 0.034), cerebrovascular stroke (P = 0.043) and seizures (P = 0.044) as compared to the survivors. In addition, the serum levels of ferritin (P = 0.047), alanine aminotransferase (P = 0.047) and aspartate aminotransferase (P = 0.05) were significantly higher in the non-survivors as compared to the survivors.

CONCLUSIONS

Based on our findings, MIS-C associated with COVID-19 is a potentially fatal illness. Hospitalised patients with MIS-C often have multi-organ injuries affecting the respiratory, cardiovascular, gastrointestinal and neurological systems. The deceased are more likely to exhibit respiratory manifestations, shock, cerebrovascular stroke, seizures and elevated serum levels of ferritin and liver enzymes.