Toxic shock-like syndrome and COVID-19: Multisystem inflammatory syndrome in children (MIS-C)

Abstract

Early reports of COVID-19 in pediatric populations emphasized a mild course of disease with severe cases disproportionately affecting infant and comorbid pediatric patients. After the peak of the epidemic in New York City, in late April to early May, cases of severe illness associated with COVID-19 were reported among mostly previously healthy children ages 5-19. Many of these cases feature a toxic shock-like syndrome or Kawasaki-like syndrome in the setting of SARS-CoV-2 positive diagnostic testing and the CDC has termed this presentation Multisystem Inflammatory Syndrome (MIS-C). It is essential to disseminate information among the medical community regarding severe and atypical presentations of COVID-19 as prior knowledge can help communities with increasing caseloads prepare to quickly identify and treat these patients as they present in the emergency department. We describe a case of MIS-C in a child who presented to our Emergency Department (ED) twice and on the second visit was found to have signs of distributive shock, multi-organ injury and systemic inflammation associated with COVID-19. The case describes two ED visits by an 11-year-old SARS-CoV-2-positive female who initially presented with fever, rash and pharyngitis and returned within 48 hours with evidence of cardiac and renal dysfunction and fluid-refractory hypotension requiring vasopressors and PICU admission.

Extrapulmonary manifestations of COVID-19 in children: a comprehensive review and pathophysiological considerations

“…The main extrapulmonary manifestations found were gastrointestinal (GI), with high prevalence of diarrhea, abdominal pain, and vomiting. 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 Other GI symptoms found were related to inflammatory process, such as pharyngeal erythema, 19 swollen tongue, and pronounced lingual papillae. 31 Reduced feeding, 21 , 32 odynophagia, 15 , 26 and feeding intolerance 33 were also reported and are important signs for pediatric cases.…”

“…Acute kidney injury was identified in 38 patients, 16 , 20 representing a frequent complication. Cardiac manifestations were often described as alterations in myocardial enzymes, 18 , 24 , 34 tachycardia, 26 , 27 , 34 , 36 , 37 , 38 and shock, 16 with eight and 25 presentations, respectively. Vascular manifestations included aneurysms 26 and ischaemic infarctions 15 were identified and associated with obesity.…”

“…3 ). 13 , 27 Dermatologic presentations were defined as skin rashes, 13 , 15 , 26 , 27 , 31 perineal or facial desquamation, 13 erythemas 22 and exanthems. 19 Complete Kawasaki disease and KD shock syndrome was confirmed in 21 and 28 patients, respectively.…”

“… 12 However, due to the outrageous number of infected children, some fatal cases are being reported, associated with extrapulmonary complications, pointing to a need of medical and scientific attention. 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 …”

Rapid Antibody-Based COVID-19 Mass Surveillance: Relevance, Challenges, and Prospects in a Pandemic and Post-Pandemic World

“…Contextually, as one of the later developments in the COVID-19-related complications, MIS-C or multisystem inflammatory syndrome in children needs a special mention [ 167 , 168 , 169 , 170 , 171 , 172 , 173 , 174 , 175 , 176 ]. On 2 May 2020, a Pediatric Intensive Care-COVID-19 international collaborative conference call was held, where panelists recognized MIS-C as an emerging effect of COVID-19 infections in children [ 177 ].…”