Short-term Outcomes of Corticosteroid Monotherapy in Multisystem Inflammatory Syndrome in Children

Villacis-Nunez, D Sofia; Jones, Kaitlin; Jabbar, Aysha; Fan, Lucie; Moore, Whitney; Peter, Andrew; Henderson, Michaela; Xiang, Yijin; Kelleman, Michael; Sherry, Whitney; Chandrakasan, Shanmuganathan; Oster, Matthew E.; Jaggi, Preeti; Prahalad, Sampath

doi:10.1001/jamapediatrics.2022.0292

Cited by 38 publications

(44 citation statements)

References 26 publications

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“…Through the application of inverse probability of treatment-weighting methodology, we balanced these characteristics between the groups, as demonstrated in Table 1 in the article. 1 As a result, we report similar rates of treatment failure after adjustment for disease severity markers. Our article also calls for caution at interpreting the increased likelihood of cardiac parameters as the reason for initial treatment failure in the corticosteroid group, as this relied on clinician assessment, while other objective echocardiographic outcomes did not differ between groups.…”

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confidence: 52%

Short-term Outcomes of Corticosteroid Monotherapy in COVID-19–Associated Multisystem Inflammatory Syndrome in Children—Handle With Caution—Reply

2022

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COMMENT & RESPONSEIn Reply We appreciate Song's interest in our article 1 and would like to address the concerns about potential study limitations as detailed in Song's Letter to the Editor. First, we emphasize that all patients in our study met the US Centers for Disease Control and Prevention (CDC) case definition for multisystem inflammatory syndrome in children (MIS-C), 2 described in our Methods; as such, all had at least 2 organ systems involved. While lymphopenia, neutrophilia, and interleukin 6 elevation are markers of inflammation in the CDC case definition, those are not required for diagnosis, as other laboratory parameters can be sufficient to satisfy this criterion. As per eTable 3 in the Supplement to our article, 1 the median lymphocyte and neutrophil count values did not significantly differ between groups. Notably, lymphopenia is not universal in MIS-C, being reported in only 30% of cases. 3 In addition, levels of interleukin 6 were not routinely obtained, as the long turnaround times limit their use in our practice. For these reasons, we favored the inclusion of other relevant and widely used laboratory markers of inflammation in our multivariate model.Similarly, though MIS-C has been associated with a wide array of manifestations, including articular involvement as referenced by Song, visceral, hematologic, and dermatologic manifestations are more common, usually more severe, and listed in the CDC case definition. 2 Therefore, we focused on these features to enhance the potential significance and generalizability of our findings.To address Song's point about vaccination status, we highlight that most of the patients were ineligible for SARS-CoV-2 immunization based on their age (median [IQR], 8 [5-12] years), as vaccines became available in the US for children aged 12 to 15 years in May 2021, after our study completion. 4 While vaccination for individuals 16 years and older was authorized in the US in December 2020, among the patients in our cohort diagnosed after this date, only 14 (6.5%) were 16 years and older. None of these vaccine-eligible patients had documented SARS-CoV-2 immunization prior to their MIS-C diagnosis. This renders vaccination status irrelevant to our study. Similarly, only 7 patients within our cohort (3.2%) received remdesivir. Furthermore, antivirals are not routinely used in the management of MIS-C, a postinfectious phenomenon. Hence, antiviral use is not pertinent to our findings.Lastly, as pointed out by Song, the patients in the intravenous immunoglobulin therapy plus corticosteroids group in our study had higher frequencies of several markers indica-

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confidence: 52%

Short-term Outcomes of Corticosteroid Monotherapy in COVID-19–Associated Multisystem Inflammatory Syndrome in Children—Handle With Caution—Reply

2022

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“…During the varying treatment period, many guidelines recommended corticosteroid treatment with IVIG for MIS-C, but recently, comparative publications in terms of their use with IVIG alone or with corticosteroid use have begun to emerge. In one of the recent research, corticosteroid implementations without IVIG have been seen to be effective in the treatment of MIS-C, except for severe cases and those with cardiac involvement [43]. Although more research is needed, considering the clinical conditions, it is thought that single corticosteroid therapy may be an alternative, according to studies.…”

Section: Discussionmentioning

confidence: 99%

“…Coronary dilatation rate in echocardiography was statistically higher in Group I compared to Group II (11 (29.7%),4 (4.1%), respectively; p < 0.001). The rate of mitral regurgitation was 43.9% (43) in Group II versus 29.7% (11) in Group I, the rate of myocarditis was 10.2% (10) in Group II versus 0% (0) in Group I, and the rate of perimyocarditis was 2% (2) in Group II versus 0% (0) in Group I and it was statistically higher (p = 0.001, p < 0.001, and p < 0.001, respectively). There was no statistically significant difference between ejection fractions in both patient groups (p > 0.05).…”

Section: Comparison Of Echocardiographic Findings Of Kawasaki Disease...mentioning

confidence: 93%

Which Findings Make multisystem Inflammatory Syndrome in Children Different from the Pre-Pandemic Kawasaki Disease?

et al. 2022

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Multisystem Inflammatory Syndrome in Children associated with COVID-19 infection attracted attention because some features overlapped with Kawasaki disease. And due to these overlapping features with Kawasaki disease, it has become difficult to diagnose both disorders. Therefore, this study focused on the differences between the patients diagnosed with MIS-C after COVID-19 and Kawasaki patients analyzed, particularly during the pre-pandemic period. In this way, it is aimed to reduce the dilemmas experienced in Diagnosis. In this descriptive study, 98 patients diagnosed with MIS-C throughout the pandemic were compared to 37 patients diagnosed with Kawasaki Disease during the pre-pandemic period. The patients in the MIS-C group were older children and clinically suffered from more headaches, vomiting, diarrhea, abdominal pain, and chest pain than Kawasaki patients. Signs of shock such as hypotension and tachycardia were more remarkable. Also, myocarditis and mitral regurgitation were detected at a higher rate in the MIS-C group. Besides, in the laboratory, lymphopenia, hypoalbuminemia, and creatinine elevation were more apparent. In conclusion, our present study findings support that although the MIS-C and Kawasaki share common features, they present with different clinical and laboratory features. And these differences are thought to be supportive in treatment and patient management. KeywordsMultisystem inflammatory syndrome in children • MIS-C • Kawasaki disease • Children * Ela Cem

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“…The conservative approach for mild cases of MIS-C is now being discussed more. However, a few clinical studies have compared treatments with and without IVIG [ 26 , 27 , 28 ]. Evaluating different treatment approaches is not the subject of this study.…”

Section: Discussionmentioning

confidence: 99%

Evaluation of Baseline Characteristics and Prognostic Factors in Multisystemic Inflammatory Syndrome in Children: Is It Possible to Foresee the Prognosis in the First Step?

Çetin

Kısaarslan

Tekin

et al. 2022

JCM

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Background: Two years after the first cases, critical gaps remain in identifying prognostic factors in multisystem inflammatory syndrome in children (MIS-C). Methods: This retrospective study included 99 patients with MIS-C hospitalized between August 2020 and March 2022 in a pediatric tertiary center. The patients were divided into two groups according to clinical severity (low- and high-risk). Prognostic values of baseline clinical and laboratory characteristics were evaluated with advanced statistical analysis, including machine learning. Results: Sixty-three patients were male, and the median age was 83 (3–205) months. Fifty-nine patients (59.6%) were low-risk cases. Patients aged six years and over tended to be at higher risk. Involvement of aortic or tricuspid valve or >1 valve was more frequent in the high-risk group. Mortality in previously healthy children was 3.2%. Intensive care unit admission and mortality rate in the high-risk group were 37.5% and 7.5%, respectively. At admission, high-risk patients were more likely to have reduced lymphocyte count and total protein level and increased brain natriuretic peptide (BNP), ferritin, D-dimer, and troponin concentrations. The multiple logistic regression model showed that BNP, total protein, and troponin were associated with higher risk. When the laboratory parameters were used together, BNP, total protein, ferritin, and D-dimer provided the highest contribution to the discrimination of the risk groups (100%, 89.6%, 85.6%, and 55.8%, respectively). Conclusions: Our study widely evaluates and points to some clinical and laboratory parameters that, at admission, may indicate a more severe course. Modeling studies with larger sample groups are strongly needed.

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Short-term Outcomes of Corticosteroid Monotherapy in Multisystem Inflammatory Syndrome in Children

Abstract: This cohort study compares initial treatments for multisystem inflammatory syndrome in children to assess short-term patient outcomes associated with corticosteroids, intravenous immunoglobulin, and both.

Cited by 38 publications

References 26 publications

Short-term Outcomes of Corticosteroid Monotherapy in COVID-19–Associated Multisystem Inflammatory Syndrome in Children—Handle With Caution—Reply

Short-term Outcomes of Corticosteroid Monotherapy in COVID-19–Associated Multisystem Inflammatory Syndrome in Children—Handle With Caution—Reply

Which Findings Make multisystem Inflammatory Syndrome in Children Different from the Pre-Pandemic Kawasaki Disease?

Evaluation of Baseline Characteristics and Prognostic Factors in Multisystemic Inflammatory Syndrome in Children: Is It Possible to Foresee the Prognosis in the First Step?

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