Multisystem Inflammatory Syndrome Associated with COVID-19

“MIS-C”

On May 14, 2020 CDC issued a Health Advisory Alert for MIS-C associated with COVID-19. The CDC case definition is outlined below. CDC recommends reporting suspected/confirmed cases of MIS-C to local health departments (even if patient is meeting Kawasaki criteria).

  • Similar to Kawasaki Disease in presentation of symptoms.
  • Children under 21 years old presenting with the following:
    1. Fever*, laboratory evidence of inflammation**, and evidence of clinically severe illness requiring hospitalization, with multi system ≥2 organ involvement (cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic, or neurological); AND
    2. No alternative plausible diagnosis; AND
    3. Positive for current or recent SARS-CoV-2 infection by RT-PCR, serology, or antigen test; or COVID-19 exposure within the 4 weeks prior to the onset of symptoms.

*Fever ≥38.0°C for ≥24 hours
**Including, but not limited to, ≥1 of the following: an elevated CRP, ESR, fibrinogen, procalcitonin, d-dimer, ferritin, lactic acid, IL-6, neutrophilia, lymphopenia, hypoalbuminemia.

Treatment considerations:

  • In cases of concern for shock, be cautious with fluids as patients may have myocardial dysfunction component and could decompensated with aggressive fluid resuscitation.
    • Start with 10 mL/kg and reassess (as your would for myocarditis)
  • Vasopressor of choice is currently EPINEPHRINE if patient decompensates.
    • OK to start NOREPINEPHRINE if clear cut warm shock.

ED “MIS-C” Pathway

LINK to CDC Health Advisory Report
LINK Royal College of Pediatrics and Child Health Guidance
LINK to Lancet: Hyperinflammatory shock in children during COVID-19 pandemic
LINK to Lancet: An outbreak of severe Kawasaki-like disease at the Italian epicentre of the SARS-CoV-2 epidemic: an observational cohort study
VIDEO ACEP MIS-C Webinar & Panel Discussion 6/1/2020

Disclaimer: These clinical pathways are intended to be a guide specifically for residents, fellows, CRNPs, and physicians (“practitioners”) at Children’s of Alabama (“COA”). These clinical pathways may be adapted for each patient depending on clinical scenarios based on the practitioner’s judgment, consideration of unique circumstances, needs of the patient and their respective family, and availability of resources of where the patient is located. These clinical pathways are not to be construed as medical advice or treatment. COA does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one of more of them apply to a particular patient or medical condition. COA is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.