Citation Information :
Gupta P, Sarkar SD, Bhelo M, Mondal A, Pal P. Analysis of Clinicopathological Characteristics and Treatment Modalities in Multisystem Inflammatory Syndrome in Children: An Eastern Indian Cohort. Pediatr Inf Dis 2023; 5 (3):79-83.
Aim: Document and analyze our experiences from eastern India pertaining to multisystem inflammatory syndrome in children (MISC), which is a novel disease entity with variable presentations and varying treatment guidelines.
Materials and methods: Observational cohort study on children diagnosed with MISC by the World Health Organization (WHO) criteria at the Institute of Child Health (ICH) Kolkata from July to December 2020. History, clinical findings, laboratory investigations, including imaging, and response to different therapeutic modalities were noted, and postdischarge follow-up data for 6 months were recorded and subsequently analyzed.
Results: A total of 75 children with a median age of 11 years [interquartile range (IQR): 3 years] were included. All presented with fever. 86% had erythematous maculopapular rashes. Gastrointestinal complaints were present in about 30%. Central nervous system (CNS) affection varied from extreme irritability in 63% to drowsiness in 18%. Around 42.67% needed intensive care, and 28% required inotropic support. Cardiac affection was detected in 57.74%, mostly as myocarditis, and 27% had coronary artery dilatations (CAAs). About 20% required respiratory support, and four had to be ventilated. Significant laboratory investigations included neutrophilia, very high C-reactive protein (CRP) (mean 186.8 mg/L), and pro B-type natriuretic peptide (NT-proBNP) (mean 10370 pg/mL). Coronavirus disease 2019 (COVID-19) immunoglobulin (IgG) was positive in 91%. A total of 90.6% received intravenous Ig (IVIg), and 57.3 received methylprednisolone (MP) + IVIg. The dosage of MP varied from 2 to 30 mg/kg; doses were individualized depending on the clinical severity. All of the patients survived and had normalization of cardiac lesions on follow-up.
Conclusion: Multisystem inflammatory syndrome in children (MISC) is a hyperinflammatory disease with variable presentations, often requiring intensive care management. Early identification and immediate administration of steroids/IVIg revert the stormy progression, usually without significant residual morbidity.
CDC COVID-19 Response Team. Coronavirus disease 2019 in children - United States, February 12-April 2, 2020. MMWR Morb Mortal Wkly Rep 2020;69(14):422–426. DOI: 10.15585/mmwr.mm6914e4
Diorio C, Henrickson SE, Vella LA, et al. Multisystem inflammatory syndrome in children and COVID-19 are distinct presentations of SARS-CoV-2. J Clin Invest 2020;130(11):5967–5975. DOI: 10.1172/JCI140970
Malviya A, Mishra A. Childhood multisystem inflammatory syndrome: an emerging disease with prominent cardiovascular involvement-a scoping review. SN Compr Clin Med 2021;3(1):48–59. DOI: 10.1007/s42399-020-00650-0
Pal P, Jagwani H, Mandal A, et al. Acute encephalitis beyond the usual in the COVID era. Indian J Pediatr 2021;88(9):948. DOI: 10.1007/s12098-021-03873-8
Gupta P, Giri PP, Das D, et al. Pediatric inflammatory multisystem syndrome (PIMS) presenting with retropharyngeal phlegmon mimicking Kawasaki disease. Clin Rheumatol 2021;40(5):2097–2098. DOI: 10.1007/s10067-020-05538-x
Nakra NA, Blumberg DA, Herrera-Guerra A, et al. Multi-system inflammatory syndrome in children (MIS-C) following sars-cov-2 infection: review of clinical presentation, hypothetical pathogenesis, and proposed management. Children (Basel) 2020;7(7): DOI: 10.3390/children7070069
Abrams JY, Godfred-Cato SE, Oster ME, et al. Multisystem inflammatory syndrome in children associated with severe acute respiratory syndrome coronavirus 2: a systematic review. J Pediatr 2020;226:45–54.e1. DOI: 10.1016/j.jpeds.2020.08.003
Lee PY, Day-Lewis M, Henderson LA, et al. Distinct clinical and immunological features of SARS-CoV-2-induced multisystem inflammatory syndrome in children. J Clin Invest 2020;130(11):5942–5950. DOI: 10.1172/JCI141113
Feldstein LR, Rose EB, Horwitz SM, et al. Multisystem inflammatory syndrome in U.S. children and adolescents. N Engl J Med 2020;383(4):334–346. DOI: 10.1056/NEJMoa2021680
Belhadjer Z, Méot M, Bajolle F, et al. Acute heart failure in multisystem inflammatory syndrome in children in the context of global SARS-CoV-2 pandemic. Circulation 2020;142(5):429–436. DOI: 10.1161/CIRCULATIONAHA.120.048360
Clark BC, Sanchez-de-Toledo J, Bautista-Rodriguez C, et al. Cardiac Abnormalities Seen in Pediatric Patients During the SARS-CoV2 Pandemic: An International Experience. J Am Heart Assoc 2020;9(21):e018007. DOI: 10.1161/jaha.120.018007
Matsubara D, Kauffman HL, Wang Y, et al. Echocardiographic findings in pediatric multisystem inflammatory syndrome associated with COVID-19 in the United States. J Am Coll Cardiol 2020;76(17):1947–1961. DOI: 10.1016/j.jacc.2020.08.056
Valverde I, Singh Y, Sanchez-de-Toledo J, et al. Acute cardiovascular manifestations in 286 children with multisystem inflammatory syndrome associated with COVID-19 infection in Europe. Circulation 2021;143(1):21–32. DOI: 10.1161/CIRCULATIONAHA.120.050065
Ganguly M, Nandi A, Banerjee P, et al. A comparative study of IL-6, CRP and NT-proBNP levels in post-COVID multisystem inflammatory syndrome in children (MISC) and Kawasaki disease patients. Int J Rheum Dis 2022;25(1):27–31. DOI: 10.1111/1756-185X.14236
Sperotto F, Friedman KG, Son MBF, et al. Cardiac manifestations in SARS-CoV-2-associated multisystem inflammatory syndrome in children: a comprehensive review and proposed clinical approach. Eur J Pediatr 2021;180(2):307–322. DOI: 10.1007/s00431-020-03766-6
Henderson LA, Canna SW, Friedman KG, et al. 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(4):e13–e29. DOI: 10.1002/art.41616
Pal P, Bathia JN, De H, et al. A retrospective analysis of the need for methylprednisolone in addition to IVIG for treating multisystem inflammatory syndrome in children. Rheumatology (Oxford) 2022;61(6):e141–e142. DOI: 10.1093/rheumatology/keac086