SUMMARY:

While most children will be asymptomatic or exhibit mild symptoms, SARS-CoV-2 infection has been temporally associated with a syndrome called Pediatric Multi-System Inflammatory Syndrome. It was first identified in the UK and cases have now been reported in New York City, a US ‘hot spot’ for COVID-19.  The underlying mechanism for this severe inflammatory syndrome is not yet understood, but some speculate that the antibody following illness may be generating an overly vigorous immune response in these children and teens.

Key Features

• Presentation is that of an inflammatory syndrome and appears to overlap with Kawasaki Disease, Toxic Shock Syndrome, bacterial sepsis and macrophage activation syndromes
• Kawasaki Disease
  • Inflammation of blood vessels in children (including coronary arteries)
  • Findings include rash, conjunctivitis, and swollen hands or feet which can also be seen in Pediatric Multi-System Inflammatory Syndrome | However cardiac inflammation is greater in Pediatric Multi-System Inflammatory Syndrome and can affect teens, while Kawasaki disease is usually seen in younger children
• Findings in Pediatric Multi-System Inflammatory Syndrome include
  • Inflammatory markers: Abnormal Fibrinogen | High CRP | High D-Dimers | High ferritin | Hypoalbuminaemia | Lymphopenia | Neutrophilia in most – normal neutrophils in some
  • Fever:  Persistent >38.5°C
• Additional presenting signs and symptoms may include
  • Abdominal symptoms
  • Rash
  • Myocarditis (and other cardiovascular changes)
• Some children will develop cardiogenic or vasogenic shock with evidence of single or multi-organ failure
  • Cardiac, respiratory, renal, gastrointestinal or neurological system failure

Note: Royal College of Paediatrics and Child Health (RCPCH) Guidelines (see ‘Learn More – Primary Sources’) provide a comprehensive list of symptoms as well as clinical, laboratory and imaging findings

Management

• Obtain history of any past COVID-19 like symptoms or close contact with someone who may have COVID-19
• Rule out microbial cause, including
  • Bacterial sepsis | Staphylococcal or streptococcal shock syndromes | Infections associated with myocarditis such as enterovirus
  • Note: Do “not delay seeking expert advice while waiting for results of these investigations”
• Requires quick recognition and referral to in-patient specialist as patient may require further intensive/critical care
  • Additional specialists may include those with expertise in pediatric infectious diseases, cardiology, and rheumatology
• Testing
  • According to NYS DOH “The majority of patients who have presented with this syndrome have tested positive for SARS-CoV-2 or corresponding antibodies. Some tested positive on diagnostic, molecular testing for SARS-COV-2, others were positive on serological testing for corresponding antibodies” | However, some patients will test negative
  • Hospitals must perform a diagnostic and serological test to detect the presence of SARS-COV2
  • In NYS, hospitals must immediately report these cases in patients <21 years of age to NYS department of health

KEY POINTS:

Treatment

• The RCPCH guidelines provide detailed management protocols (see ‘Learn More – Primary Sources’ below)
• Treat all children with this presentation as suspected COVID-19
• Blood cultures and empiric antibiotics should be started as per local sepsis protocols
• Mild illness
  • Supportive therapy
• If clinically deteriorating or severe disease
  • Discuss transfer with pediatric ICU teams
  • IVIG, aspirin and immunomodulator therapy may be used on a case by case basis
  • Antivirals: Should only be given in the context of a clinical trial if available

Prognosis

The RCPCH expert panel add that

• Most of the children were very ill but recovered
• It is a syndrome where there is a pattern to the features that leads physicians to suspect the diagnosis
• Dr Sanjay Patel, consultant in pediatric infectious diseases at Southampton Children’s Hospital, states

It’s very important to keep this in perspective. It’s a very rare condition and because of that parents shouldn’t be alarmed. We’re talking about a really small number of cases, each of which was picked up and treated by experts in our health system. It remains extremely unlikely that a child will become unwell with COVID-19, and it’s even more unlikely that a child will become unwell with this condition. I want to reassure parents that our advice to them has not changed. If you have an unwell child, it probably isn’t anything to do with COVID and is more likely to be something else. If you’re concerned, do what you’d normally do. Call your GP, use NHS 111, or for emergencies – go to hospital

Learn More – Primary Sources:

NYSDOH: Health Advisory: Pediatric Multi-System Inflammatory Syndrome Potentially Associated with Coronavirus Disease (Covid-19) In Children

Royal College of Paediatrics and Child Health Guidance: Paediatric multisystem inflammatory syndrome temporally associated with COVID-19

Royal College of Paediatrics and Child Health: Leading paediatricians publish case definition for illness affecting children during COVID-19

NYC 2020 Health Alert #13: Pediatric Multi-System Inflammatory Syndrome Potentially Associated with COVID-19

GHR: Kawasaki Disease

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