ORIGINAL ARTICLE |
https://doi.org/10.5005/jp-journals-10081-1389 |
Multisystem Inflammatory Syndrome in Children with COVID-19: Clinical Profile and Comparison in Two Age Groups
1-4Department of Paediatrics & Neonatology, Aster MIMS Hospital, Kannur, Kerala, India
Corresponding Author: Veena K Mavila, Department of Paediatrics & Neonatology, Aster MIMS Hospital, Kannur, Kerala, India, Phone: +91 9447795590, e-mail: veenamavila@gmail.com
Received on: 31 December 2021; Accepted on: 17 December 2022; Published on: 15 April 2023
ABSTRACT
Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may result in multisystem inflammatory syndrome in children (MIS-C). It manifests later in the course of SARS-CoV-2 infection and presents with higher severity.
Aim: To describe the clinical spectrum of illness and to compare the clinical profile, management and outcome in two age groups; upto 5 years and >5 years.
Materials and methods: Observational study. Children satisfying World Health Organization (WHO) MIS-C criteria admitted in the hospital during the study period were included in the study.
Results: A total of 44 children were included in the study. The median age was 6.5 years, interquartile range (IQR) was 3.92 to 10 years. Gastrointestinal symptoms were the commonest presentation, 70.45%. Gastrointestinal symptoms and shock were seen in children of >5 years and the difference was statistically significant. Hyperferritinemia and lymphopenia were statistically significant in the older age group. Intravenous immunoglobulin (IVIG) was used in 88.24% of children up to 5 years of age group. Around 55.56% of children of >5 years were managed with steroids alone.
Conclusion: The course and short-term outcome of MIS-C are generally favorable.
How to cite this article: Mavila VK, Kuppadakath NM, Chandroth MC, et al. Multisystem Inflammatory Syndrome in Children with COVID-19: Clinical Profile and Comparison in Two Age Groups. Pediatr Inf Dis 2023;5(1):10-16.
Source of support: Nil
Conflict of interest: None
Keywords: Intravenous immunoglobulin, Methylprednisolone, Multisystem inflammatory syndrome in children, Observational study, Shock.
INTRODUCTION
In late 2019, SARS-CoV-2 was first identified in China, and it quickly spread to become a pandemic. Earlier reports1 suggested that children with coronavirus infection only develop a slight upper respiratory infection. As COVID-19 evolved, In March 2020, pediatricians in the United Kingdom (UK) noticed an unusual illness. It was a severe illness, most requiring pediatric intensive care. The case definition of this new childhood inflammatory disorder was published in late April 2020 in the UK; It was termed pediatric inflammatory multisystem syndrome-temporarily associated with COVID-19 (PIMS-TS).2 Centers for Disease Control and Prevention and WHO published their own differing definition,3,4 which they named MIS-C.
Multisystem inflammatory syndrome in children (MIS-C) manifests later in the course of SARS-CoV-2 infection and presents with higher severity. It shares the clinical picture of Kawasaki disease (KD), toxic shock syndrome, and secondary hemophagocytic lymphohistiocytosis/macrophage activation syndrome.5 This study aims to outline the clinical spectrum of illness in children with MIS-C and to compare the clinical profile, management, and outcome in two age groups, up to 5 years and >5 years. The study was conducted at Aster MIMS Hospital, Kannur, Kerala, India. Kannur is a Northern District in Kerala state, with a population of 25.23 lakhs, as per the 2011 census. Kannur has had around 2.7 lahks COVID-19 cases as of October 2021, with around 1,900 deaths.6
MATERIALS AND METHODS
An observational study was conducted at Aster MIMS Hospital, Kannur, Kerala, India, from November 2020 to July 2021. The Institutional Ethical Committee accepted the study protocol. The study comprised individuals aged 1–16 years with a diagnosis that satisfied the MIS-C WHO diagnostic criteria.
Signed informed consent was taken from the parents. Data from admission to discharge were collected from clinical records. They comprised—(1) demographic characteristics, age, and gender (2) comorbidities’ medical history (3) clinical history, symptoms, and signs at admission, including past history of COVID-19, fever duration, cough, fast breathing, chest pain, abdominal pain, vomiting, diarrhea, headache, myalgia, conjunctivitis, mucositis, cervical adenopathy, myocarditis, pericarditis, shock, and renal failure, (4) laboratory parameters—complete blood counts, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), serum ferritin, procalcitonin, D-dimer, troponin I, prohormone B-type natriuretic peptide (ProBNP), lactate dehydrogenase (LDH), transaminases, prothrombin time and international normalized ratio (PT-INR), serum albumin, serum sodium, serum creatinine, (5) viral tests—COVID-19 TrueNat test was done in all patients. COVID-19 IgG and IgM antibody tests were done to detect past infection, (6) imaging—included chest X-ray/ultrasound (USG) abdomen and echocardiography (ECHO). ECHO was done on admission, repeated if necessary. Follow-up ECHO was done in the 2nd and 6th week following discharge, (7) Treatment—use of steroids intravenous or oral, IVIG gamma, acetylsalicylic acid, anticoagulants, and (8) outcome measures—length of hospitalization, discharge, mortality, ECHO findings on follow-up at 2nd and 6th week. The treating unit managed cases in accordance with Kerala state guidelines for the care of children with MIS-C.7 Immunomodulatory drugs were decided by the treating team on an individual case basis.
We further compared demography, clinical signs and symptoms, laboratory parameters, treatment, and outcome in two age groups of up to 5 years and >5 years.
STATISTICAL METHODS
As primary outcome variables, demographic factors, symptoms, clinical findings, and laboratory investigation parameters were taken into consideration. Age distribution was regarded as a primary exploratory variable. For quantitative data, mean, and standard deviation were used in the descriptive analysis, while frequency and proportion were used for categorical variables.
Quantitative variables with nonnormal distribution were summarized using the median and IQR. Using an independent sample t-test, the mean values for normally distributed quantitative parameters were compared between study groups (two groups). Using the Mann–Whitney U test, medians, and the IQR for quantitative parameters with nonnormal distribution were compared between research groups. Categorical outcomes were compared between study groups using the Chi-squared test/Fisher’s exact test (If the overall sample size was <20 or if the expected number in any of the cells was <6, Fisher’s exact test was used). A p-value < 0.05 were deemed statistically significant. For the statistical analysis, Statistical Package for the Social Sciences was employed.8
RESULTS
The final analysis comprised a total of 44 patients. The median age was 6.5 years and IQR was 3.92–10 years. Around 56.82% of the study group were males. There was no comorbidity in any of the subjects studied.
Evidence of SARS-CoV-2 infection was identified in all patients in the form of positive serology, positive SARS-CoV-2 TrueNat, and contact with an individual with COVID-19. Nearly 90.91% of enrolled were COVID-19 serology positive and 9.09% had acute infection with COVID-19 TrueNat positive. Two patients were negative for TrueNat and antibody, but they had a recent history of contact with COVID-19-positive cases. In the study group, only 11.36% of patients had a past history of COVID-19. Around 31.82% had a history of fever a few weeks back but were not tested for COVID-19. A total of 57.8%were completely asymptomatic.
Fever was present in all patients, with a median (IQR) duration of 5 (4–7) days.
Symptoms and signs noted at the presentation are shown in Figure 1.
Fig. 1: Clinical symptoms and signs
Symptoms of gastrointestinal involvement were most common, like vomiting (70.45%), diarrhea (56.82%), and abdominal pain (54.55%). Conjunctivitis (88.64%) and oropharyngeal changes (63.64%) were the most common clinical findings.
Most children’s test results at admission were consistent with acute inflammation, with increased CRP (>50 mg/dL) in 93.18%, ferritin (>300 ng/mL) in 47.73%, procalcitonin (>2 ng/mL) in 75%, ESR (>40 mm in 1 hour) in 75%. D-dimer was (>0.5 mcg/mL) in 95.45% and fibrinogen (> 400 ng/dL) in 79.55%. Troponin I was high (>0.1 ng/mL) at 6.82%. On the contrary, N-terminal proBNP (NT-proBNP) (>125 pg/mL) was seen in 93.18%. The median (IQR) value of NT-proBNP was 951(31,83,797) in the study group. Median (IQR) was relatively high in patients who presented with shock 4688.5 (746,10691).
The Median (IQR) of the lab parameters is given in Table 1.
| Parameter | Median (IQR) |
|---|---|
| Hematology | |
| WBC count mcL | 10025 (6547.5,14010) |
| Absolute neutrophil count | 7326.65 (5013.9,10935.9) |
| Absolute lymphocyte count | 1364.5 (871,2263.75) |
| Hemoglobin % | 11.25 (10.05,12.275) |
| Platelet count mcL | 178500 (125250,330000) |
| Inflammatory markers | |
| CRP mg/L | 192.5 (84.65,280.375) |
| Procalcitonin ng/mL | 7.03 (1.96,12.1) |
| LDH IU/L | 295.5 (231.75–335.75) |
| Ferritin ng/mL | 279.5 (181.25,578) |
| ESR mm in 1 hour | 66.5 (36.75–88.25) |
| Coagulation and cardiac profile | |
| D-dimer mcg/mL | 3.245 (1.9175,5.595) |
| Fibrinogen mg/dL | 506.5 (415.75,575.75) |
| Troponin ng/mL | 0.012 (0.012,0.03225) |
| NT-proBNP pg/mL | 951 (318,3797) |
| Liver and Renal | |
| ALT (UL) | 24.5 (15,37.75) |
| AST (UL) | 34 (26,61.5) |
| Prothrombin time in seconds | 14.05 (13,15.575) |
| INR | 1.1 (1,1.1475) |
| Serum albumin gm/dL | 3.2 (2.7,3.475) |
| Serum creatinine mg/dL | 0.3 (0.2,0.5) |
| Electrolytes | |
| Serum sodium mEq/L | 135 (132,137) |
ALT, alanine transaminase; AST, aspartate aminotransferase; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; INR, international normalized ratio; IQR, interquartile range; LDH, lactate dehydrogenase; NT-proBNP, N-terminal pro-brain natriuretic peptide; WBC, white blood cells
Chest X-ray was normal in the majority, 90.70%. Pleural effusion was seen in 6.98% and cardiomegaly in 2.33%. USG showed mild ascites in 29.5%; other findings were edematous ileal loop (6.98%) and hepatomegaly (4.65%). ECHO was done in all patients. On admission, 29 cases (65.91%) had normal findings. Abnormal findings reported were pericardial effusion (20.5%), left ventricular dysfunction (9.09%), and coronary dilatation (Z score) in 6.8%.
Management and Outcome Data
Overall 40 (90.91%) patients were admitted to PICU. A total of 17 (38.64%) required inotropic support and 2 (4.54%) mechanical ventilation. Intravenous steroids were given to 40 (90.91%) and IVIG γ was administered to 27 (61.31%). Aspirin was started in all patients. In patients with thrombocytopenia, it was started once the platelet count was >80,000. Anticoagulation was prescribed to three (6.8%) patients. Infliximab was given to one infant <1-year-old; he had developed a coronary aneurysm (Z-score of >10) at the time of admission.
A total of 43 patients were discharged and one child died; mortality was 2.27%. The mean duration of hospitalization was 5.76 ± 1.57 (ranging from 3 to 10 days).
For all discharged patients, follow-up ECHO was done in the 2nd and 6th week. In the 2nd week, ECHO was normal in 39 (88.69%) and two (4.54%) had abnormal coronaries. Around three (6.8%) had mild dilated left ventricle and trace pericardial effusion. ECHO in the 6th week, following discharge, showed abnormality in only one child; he had a coronary aneurysm (Z-score of >10).
These results were further compared in two age groups.
The number of children up to 5 years was 17 (38.6%) and >5 were 27 (61.4%). The age group and symptoms like vomiting and diarrhea had a statistically significant difference (p-value < 0.05). Gastrointestinal symptoms were more common in the older age group. Similarly, there was a statistically significant difference between the age group and children who presented with shock. It was seen more in older children (Table 2).
| Symptoms | Age distribution | p-value | |
|---|---|---|---|
| Up to 5 years (N = 17) | >5 years (N = 27) | ||
| Fever in no of days | |||
| Up to 5 years | 10 (58.82%) | 17 (62.96%) | 0.784b |
| >5 years | 7 (41.18%) | 10 (37.04%) | |
| Vomiting | |||
| Yes | 8 (47.06%) | 23 (85.19%) | 0.007b |
| No | 9 (52.94%) | 4 (14.81%) | |
| Diarrhea | |||
| Yes | 6 (35.29%) | 19 (70.37%) | 0.022b |
| No | 11 (64.71%) | 8 (29.63%) | |
| Abdominal pain | |||
| Yes | 7 (41.18%) | 17 (62.96%) | 0.158b |
| No | 10 (58.82%) | 10 (37.04%) | |
| Fast breathing | |||
| Yes | 0 (0%) | 8 (29.63%) | c |
| No | 17 (100%) | 19 (70.37%) | |
| Conjunctivitis | |||
| Yes | 17 (100%) | 22 (81.48%) | c |
| No | 0 (0%) | 5 (18.52%) | |
| Mucocutaneous lesions | |||
| Yes | 13 (76.47%) | 15 (55.56%) | 0.160b |
| No | 4 (23.53%) | 12 (44.44%) | |
| Rash | |||
| Yes | 6 (35.29%) | 12 (44.44%) | 0.548b |
| No | 11 (64.71%) | 15 (55.56%) | |
| Shock | |||
| Yes | 3 (17.65%) | 14 (51.85%) | 0.023b |
| No | 14 (82.35%) | 13 (48.15%) | |
| Periorbital puffiness | |||
| Yes | 2 (11.76%) | 6 (22.22%) | 0.455a |
| No | 15 (88.24%) | 21 (77.78%) | |
| Cervical lymphadenopathy | |||
| Yes | 1 (5.88%) | 7 (25.93%) | 0.125a |
| No | 16 (94.12%) | 20 (74.07%) | |
| Pericarditis | |||
| No | 15 (88.24%) | 22 (81.48%) | 0.689a |
| Yes | 2 (11.76%) | 5 (18.52%) | |
| Myocarditis | |||
| Yes | 0 (0%) | 3 (11.11%) | c |
| No | 17 (100%) | 24 (88.89%) | |
aFisher exact p-value; bChi-square p-value; cno statistical test was applied due to 0 subjects in the cells
Comparing age group and lab parameters—ferritin and absolute lymphocyte count showed statistically significant differences. Ferritin was high (>300 ng/mL) in older children. Lymphopenia was significantly seen in the older age group (Table 3).
| Age distribution | |||
|---|---|---|---|
| Laboratory parameters | Up to 5 years (N = 17) | >5 years (N = 27) | p-value |
| Hematology | |||
| WBC count mcL | |||
| High (≥16000) | 5 (29.41%) | 5 (18.52%) | 0.473a |
| Low (<16000) | 12 (70.59%) | 22 (81.48%) | |
| Absolute neutrophil count | |||
| Neutrophilia ≥7700) | 9 (52.94%) | 12 (44.44%) | 0.583b |
| <7700 | 8 (47.06%) | 15 (55.56%) | |
| Absolute lymphocyte count | |||
| ≥1000 | 16 (94.12%) | 15 (55.56%) | 0.006b |
| <1000 | 1 (5.88%) | 12 (44.44%) | |
| Hemoglobin% | |||
| Anemia (N = 17) | 8 (47.06%) | 9 (52.94%) | 0.363b |
| Normal (N = 27) | 9 (33.33%) | 18 (66.67%) | |
| Inflammatory markers | |||
| Ferritin (ng/mL) | |||
| High (≥300) | 4 (23.53%) | 17 (62.96%) | 0.011b |
| Low (<300) | 13 (76.47%) | 10 (37.04%) | |
| CRP (mg/L) | |||
| High (≥50) | 15 (88.24%) | 26 (96.3%) | 0.549a |
| Low (<50) | 2 (11.76%) | 1 (3.7%) | |
| Procalcitonin (ng/mL) | |||
| High (>2) (N = 33) | 11 (33.33%) | 22 (66.67%) | 0.289a |
| Low (≤2) (N = 11) | 6 (54.55%) | 5 (45.45%) | |
| LDH (IU/L) | |||
| High (>250) (N = 29) | 14 (48.28%) | 15 (51.72%) | 0.068b |
| Low (≤250) (N = 15) | 3 (20%) | 12 (80%) | |
| ESR | |||
| High (>40 mm in 1 hour) (N = 33) | 11 (33.33%) | 22 (66.67%) | 0.289a |
| Low (≤40 mm in 1 hour) (N = 11) | 6 (54.55%) | 5 (45.45%) | |
| Coagulation and cardiac profile | |||
| Fibrinogen (mg/dL) | |||
| ≥400 | 13 (76.47%) | 22 (81.48%) | 0.716a |
| <400 | 4 (23.53%) | 5 (18.52%) | |
| D-Dimer (mcg/mL) | |||
| High (≥0.5) | 15 (88.24%) | 27 (100%) | c |
| Low (<0.5) | 2 (11.76%) | 0 (0%) | |
| Troponin (ng/mL) | |||
| High (≥0.1) | 1 (5.88%) | 2 (7.41%) | 1.000a |
| Low (<0.1) | 16 (94.12%) | 25 (92.59%) | |
| ProBNP (pg/mL) | |||
| High (≥125) | 14 (87.5%) | 26 (96.3%) | 0.545a |
| Low (<125) | 2 (12.5%) | 1 (3.7%) | |
| Liver and renal | |||
| Total bilirubin (in mg/dL) | |||
| Abnormal (>1) | 1 (5.88%) | 5 (18.52%) | 0.380a |
| High (≤1) | 16 (94.12%) | 22 (81.48%) | |
| ALT (U/L) | |||
| ≤40 | 16 (94.12%) | 19 (70.37%) | 0.121a |
| >40 | 1 (5.88%) | 8 (29.63%) | |
| AST (U/L) | |||
| ≤60 | 14 (82.35%) | 19 (70.37%) | 0.486a |
| >60 | 3 (17.65%) | 8 (29.63%) | |
| Prothrombin time (in second) | |||
| Abnormal (>15.90) | 2 (11.76%) | 7 (25.93%) | 0.445a |
| Normal (<15.90) | 15 (88.24%) | 20 (74.07%) | |
| Albumin gm/dL | |||
| Hypoalbuminemia (<3.5) (N = 35) | 11 (31.43%) | 24 (68.57%) | 0.068a |
| Normal (≥3.51) (N = 9) | 6 (66.67%) | 3 (33.33%) | |
| Serum creatinine (mg/dL) | |||
| High (>1) (N = 1) | 0 (0%) | 1 (100%) | c |
| Low (≤1) (N = 43) | 17 (39.53%) | 26 (60.47%) | |
| International normalized ratio | |||
| Abnormal (≥1.20) | 2 (11.76%) | 8 (29.63%) | 0.271a |
| Normal (<1.20) | 15 (88.24%) | 19 (70.37%) | |
| Triglycerides (mg/dL) | |||
| High (>200) (N = 17) | 6 (35.29%) | 11 (64.71%) | 0.718b |
| Low (≤200) (N = 27) | 11 (40.74%) | 16 (59.26%) | |
| Sodium mEq/L | |||
| Hyponatremia (<135) (N = 20) | 5 (25%) | 15 (75%) | 0.090b |
| Normal (≥135) (N = 24) | 12 (50%) | 12 (50%) | |
*aFisher exact p-value; bChi-square p-value; cno statistical test was applied due to 0 subjects in the cells. ALT, alanine transaminase; AST, aspartate aminotransferase; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; INR, international normalized ratio; LDH, lactate dehydrogenase; NT-proBNP, N-terminal pro-brain natriuretic peptide; WBC, white blood cells
The median (IQR) value of inflammatory markers like procalcitonin and CRP was high in older children, though not statistically significant (Table 4).
| Lab parameters | Up to 5 years (N = 17) median (IQR) | >5 years (N = 25) median (IQR) | Mann Whitney U test p-value |
|---|---|---|---|
| CRP | 179.8 (70.3, 225.65) | 224.6 (88, 296) | 0.181 |
| Serum ferritin | 199 (131.5, 334) | 394 (240, 783) | 0.006 |
| Procalcitonin | 4.35 (0.77, 9.27) | 8 (4.23, 14.2) | 0.044 |
| ESR | 65 (32.5, 75) | 70 (53, 93) | 0.262 |
CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; IQR, interquartile range
Coming to the treatment, there was a statistically significant difference between the age group and the use of IVIG (p-value < 0.05). IVIG was used in 88.24% of the up to 5 years age group. In the older age group, 44.44% received IVIG, remaining were treated with pulse methylprednisolone.
There was no statistically significant difference between the age group and outcome parameters like duration of hospital stay, ECHO at 2nd and 6th week follow-up (p-value > 0.05). But it was noticed that in the 2nd week, 23.5% and 6th week, 5.9% of children had abnormal findings on ECHO in <5-year age group.
DISCUSSION
Pediatric patients experience less severe clinical symptoms of SARS-CoV-2 infection than adults.9 In Kannur, the Northern District of Kerala, where this study was done similar trend was noted. Children requiring intensive care due to acute COVID-19 in our center were <0.5%. Warning of a novel postinfectious hyperinflammatory syndrome associated with SARS-CoV-2 came from the UK in April 2020.10 Around late April 2020, a case of a 5-year-old child with the MIS-C was first reported from our state, Kerala, India.11 The first case of MIS-C came to our hospital in October 2020. Since then, till the end of July, we had around 44 cases, most requiring PICU.
A total of 90.91% of enrolled patients were COVID-19 serology positive and 9% were COVID-19 TrueNat positive. Only 11.36% had a past history of COVID-19 and 31.82% had a history of fever a few weeks back but were not tested.57.8% were asymptomatic. This shows that acute COVID-19 infection was mild and asymptomatic in most of the patients admitted with MIS-C, and the immune-mediated inflammatory response has a greater role in the pathogenesis of MIS-C.
The median age of the study group was 6.5 years (IQR 3.92 10). Earlier studies have shown that MIS-C affects older children and adolescents.12 In our study, 17 (38.6%) were <5 years. Pediatricians have identified some clinical parallels between MIS-C and KD. For the past 50 years or more, the epidemiology of KD has been consistent throughout the world. Around 80% of KD cases occur in children <5 years of age.13 In this study, we have compared the clinical profile, lab parameters, treatment, and outcome in children up to 5 years and >5 years as our secondary objective.
The most common symptom of MIS-C patients is fever. All children in the study group had a fever. Gastrointestinal symptoms are more frequent in patients with MIS-C. In the study group, the majority had abdominal symptoms, vomiting, and diarrhea. There was a statistically significant difference between the age group and abdominal symptoms; it was more in older children. This fits with the MIS-C case series that has already been reported.13,14
For clinical signs, the majority had conjunctival congestion (88.64%) and there was no difference in age group. Around 40.9% had shock. Children with shock had hypotension with poor peripheral perfusion requiring inotropic support and/or fluid resuscitation. The shock was more common in the older age group and the difference was statistically significant. In a multicentric study from Spain, almost the totality of patients presented with arterial hypotension.15 A study from Mumbai by Jain et al.16 showed 65% of patients presenting with shock and in a study from Thiruvananthapuram, 52.6% had hypotension.17 Early diagnosis of MIS-C, as awareness of this syndrome, increased among physicians, would be one reason why a lower percentage had shock in this study.
White blood cell count, CRP, procalcitonin, D-dimer, and ferritin levels were higher in MIS-C patients. When comparing age groups and laboratory parameters—ferritin and absolute lymphocyte count were statistically significant ferritin was high, and lymphopenia was seen in children >5 years. The median value of inflammatory markers like CRP and procalcitonin was high in older children. Zhao et al.,18 in their meta-analysis of inflammatory markers of MIS-C, showed that young children had lower ferritin, indicating less inflammatory response in young children. These variations were explained by variations in the exposure likelihood of SARS-CoV-2 infection or with the variations in the nasal expression of angiotensin-converting enzyme 2, which is the receptor of SARS-CoV-2 infection, in different age groups.
Cardiac involvement is frequent in MIS-C. Cardiac markers, including troponin I, NT-proBNP, aspartate aminotransferase (AST), and ECHO, were done in all patients. Troponin was high in only 6.82% of patients. On the contrary, NT-proBNP was high in 93.18% of patients. The mean value of NT-proBNP was high in patients with shock. Zhao et al.,19 in another study on cardiac markers of MIS-C, showed similar results. The high levels of BNP are suggested to be a mechanism of myocardial edema or stunning.20 ECHO abnormalities were noted in 34.09% of cases. Abnormalities detected were pericardial effusion, left ventricular dysfunction, and coronary dilatation. Follow-up ECHO in 2nd week following discharge, 11.31% had abnormal findings, like coronary dilatation, mild dilated left ventricle, and trace pericardial effusion. In 6th week only one 9-month-old infant had a coronary aneurysm (Z-score >10). Myocarditis, vasculitis, pericardial effusion, and coronary dilatation are described as cardiac abnormalities seen in MIS-C. Given that the long-term prognosis of children with MIS-C is unknown, it has been suggested that even children who have improved cardiac function or whose coronary dilatation has resolved call for ongoing monitoring in the future.21
Intravenous immunoglobulin (IVIG) γ was administered to 61.31% of children in the study group; of this, 88.24% were <5 years. In older children (>5 years), 55.56% were managed with pulse methylprednisolone. There was a statistically significant difference between the age group and the use of IVIG. Sugunan et al.,17 suggested a favorable role for pulse methylprednisolone in the treatment of MIS-C in older children.
Only one child needed infliximab; this 9-month-old infant presented with 10 days history of fever. Had coronary dilatation on admission, and at the 6th week follow-up ECHO he had developed a giant coronary aneurysm. One child died; he had myocarditis and shock on admission.
Limitations of our study are sample size was small and the study was observational in nature.
CONCLUSION
Patients with MIS-C most commonly present with gastrointestinal symptoms. Conjunctivitis and oropharyngeal findings were the most common clinical findings. Children in the >5 years age group presented with gastrointestinal symptoms and shock. Hyperferritinemia and leucopenia were significantly seen in this group. Older children could be managed with only pulse methylprednisone. The course of this syndrome is generally favorable. The short-term outcome is good and long-term follow-up is suggested.
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