Updated Management Protocol for Multisystem Inflammatory Syndrome in Children (MIS-C)

Abstract

The multisystem inflammatory syndrome in children (MIS-C) is a post-viral immunological or hyper-inflammatory complication of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection commonly seen in older children, who commonly present with fever, multi-systemic involvement including myocardial dysfunction and shock, and hyper-inflammation. The treatment of MIS-C is adapted from the treatment of other immunological or hyper-inflammatory conditions and these treatment protocols are not uniform across the globe, and more so, in India. We propose a uniform management protocol for MIS-C based on our experience of treating MIS-C cases, available evidence till now, and recent guidelines. The aims are to identify children with MIS-C with high sensitivity, recognize other infections or inflammatory processes, stratify treatment based on severity, and manage hyper-inflammatory syndrome.

Multisystem Inflammatory Syndrome in Children: Follow-Up of a Cohort from North India

“…Discharge criteria included clinically stable child with no fever, decreasing inflammatory markers, and stable cardiac function without vasoactive drugs for more than 48 hours. 17 In this study, the children with MIS-C were followed up with at 1-2 weeks and 4-6 weeks after discharge by the treating team and pediatric cardiologist. At each follow-up visit, a detailed clinical evaluation and echocardiography were performed.…”

“…The diagnosis of current or recent SARS-CoV-2 infection was confirmed by nasopharyngeal swab SARS-CoV-2 RT-PCR, or serology, or contact with a case with SARS-CoV-2 infection in recent past (2–6 weeks prior). The management protocol we followed is published elsewhere 17 and was based on the recent guidelines for managing MIS-C. 9 , 18 , 19 Along with supportive and intensive care, mild cases were treated with IVIG (2 gm/kg over 12–24 hours, maximum dose 100 gm) alone or in combination with low-dose steroids (methylprednisolone, 1–2 mg/kg/day, max 60 mg/day). Cases with moderate to severe disease were treated with IVIG and high-dose methylprednisolone (10–30 mg/kg/day, maximum dose 1,000 mg/day, for 1–3 days) followed by low-dose steroids (methylprednisolone or prednisolone, 1–2 mg/kg/day, maximum dose 60 mg/day, continued and tapered slowly over 2–3 weeks or even longer for severe disease).…”

Progress in the Diagnosis and Treatment of COVID-19 in Children: A Review

“…MIS-C may be explained by an abnormal immune or inflammatory response triggered by SARS-CoV-2 infection. 55 The ratio of neutrophils to lymphocytes can be used as an inflammatory marker to assess the condition of COVID-19 patients with MIS-C. 52 When the immune system is activated to a certain degree or even out of control, there is an extreme immune attack on the host. When SARS-CoV-2 further invades children, it prompts the human body to secrete cytokines such as interleukin-8, IL-6, IL-10, and tumor necrosis factor-α and produce a cytokine storm, which leads to an excessive inflammatory response and destroys blood vessels, causing MIS-C. 56 Vascular endothelial injury and vasculitis are important lesions in MIS-C and may also be induced by immune complexes.…”

“…Supportive intensive care, immune modulation (steroids and intravenous immunoglobulins), and organ support therapy (including hemodynamic support) are effective in children with MIS-C. 55 In the pediatric MIS-C treatment consensus, intravenous immunoglobulin is recommended as the first-line treatment, corticosteroids as the second-line drugs, and anticoagulants according to the child’s condition. 105 At present, the most widely recommended is intravenous immunoglobulin drugs, 106 the drug helps restore the systolic function of the left ventricle.…”

Clinical practice guidelines in multisystem inflammatory syndrome (MIS-C) related to COVID-19: a critical review and recommendations

“…Currently, there are no MIS-C-specific clinical practice guidelines established by the Saudi Ministry of Health. According to the latest statistical update by the Centers for Disease Control and Prevention in the USA in early 2021, the total number of MIS-C cases increased to 1659 cases and 26 MIS-C deaths [ 9 – 11 ]. The median age of the patients ranged from seven to ten years, and more than 59% of all patients were male [ 8 ].…”