Multisystem inflammatory syndrome associated with SARS-CoV-2 infection in 45 children: a first report from Iran

Abstract

During the coronavirus disease 2019 (COVID-19) pandemic, a new phenomenon manifesting as a multisystem inflammatory syndrome in children (MIS-C) which has a similar clinical presentation to Kawasaki disease, toxic shock syndrome and severe sepsis has emerged. Although the number of MIS-C reports is increasing, rare reports in Asia is still available. To our knowledge, this study is the largest series of published MIS-C cases in Iran. We performed a retrospective study of all patients with case definition for MIS-C admitted to the three paediatric hospitals in Iran. All of these hospitals are located within the most active COVID-19 pandemic areas (Tehran, Qom and Mazandaran) in Iran. Demographic characteristics, clinical data, laboratory findings, imaging and echocardiographic findings, treatment and outcomes were collected. Between 7 March and 23 June 2020, 45 children were included in the study. The median age of children was 7 years (range between 10 months and 17 years). Common presenting symptoms include fever (91%), abdominal pain (58%), nausea/vomiting (51%), mucocutaneous rash (53%), conjunctivitis (51%) and hands and feet oedema (40%) with median duration of symptoms prior to presentation of 5 (interquartile range (IQR) 3, 7) days. Fifty-three percent of children showed lymphopaenia. Overall, the majority of cases at admission had markedly elevated inflammatory markers erythrocyte sedimentation rate (ESR) (95.5%) and C-reactive protein (CRP) (97%). Ferritin was abnormal in 11 out of 14 tested patients (73%), and it was highly elevated (>500 ng/ml) in 47% of cases. Median fibrinogen level was 210 (IQR 165, 291) mg/dl, D-dimer was 3909 (IQR 848, 4528) ng/ml and troponin was 0.6 (IQR 0.1, 26) ng/ml, respectively. Twenty out of 31 patients (64.5%) had hypoalbuminaemia. In addition, hyponatraemia was found in 64% of cases. Twenty-five patients (56%) presented with cardiac involvement and acute renal failure was observed in 13 cases (29%). Pleural, ascitic, ileitis and pericardial effusions were found in 18%, 11%, 4% and 2% of cases, respectively. In conclusion, this is a first large case series of hospitalised children who met criteria for MIS-C in Iran. There was a wide spectrum of presenting signs and symptoms; evidence of inflammation with abnormal values of CRP, ESR, D-dimer, ferritin and albumin; and multi-organ involvement.

Multisystem inflammatory syndrome in children and SARS-CoV-2: A scoping review

“…Only three studies, Dufort et al [40], Capone et al [39], and Mamishi et al [57] reported WBC count within reference range (4500-11,000 µL −1 ) [71]. The highest median WBC was reported at 32.35 µL −1 by Chiotos et al [33].…”

Emerging Evidence on Multisystem Inflammatory Syndrome in Children Associated with SARS-CoV-2 Infection: a Systematic Review with Meta-analysis

“…Twenty-three percent had both RT-PCR and Serology positive [ 6 , 7 , 12 – 14 , 16 , 21 ]. Out of 743 cases, 76 (10%) patients had contact history with COVID patients [ 6 , 9 , 11 , 12 , 15 – 18 , 21 , 22 ]. Fever was the most common reported symptom in 95%, followed by gastrointestinal (78%), cardiovascular (75.5%), respiratory system (55.3%), and CNS (30.6%) involvement, while 19.6% patients had acute kidney injury.…”

Clinical features, diagnosis, and outcomes of multisystem inflammatory syndrome in children associated with coronavirus disease 2019

“…13,14) In contrast, most patients with MIS-C have been reported in Europe and the US, [4][5][6][7]15) while some MIS-C cases have been reported in Korea, India, Pakistan, and Iran among Asian countries ( Table 2). [16][17][18][19] It is not yet known why the incidence of MIC-S is low in Asian countries. This may be due to the role of racial factors in the development of MIS-C, changes in the pathogenicity of SARS-CoV-2, or differences in population sizes affected by SARS-CoV-2 infection in Asia, Europe, and the US.…”

“…An individual aged <21 years presenting with fever (1) , laboratory evidence of inflammation (2) , Table 2. Epidemiology of multisystem inflammatory syndrome in children (MIS-C) in various countries [15][16][17][18][19][20][21]…”