Title: Multisystem inflammatory syndrome in children (MIS-C): A rare manifestation of COVID-19 in

young population.

Author: Dr. Farhan Ismael Sami, Demonstrator Department of Pathology, Shaheed Mohtarma Benazir
Bhutto Medical College Lyari Campus.

Abstract:

Towards the end of 2019, a novel coronavirus named severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2) was identified and designated as the leading cause of pneumonia outbreak in the region of
Wuhan, a city in Hubei province of China. The disease that was initially localized to the region of Wuhan
spread rapidly throughout Mainland China followed by an exponential increase in numbers of cases
globally. The WHO declared COVID-19 a pandemic on March 11, 2020[1].

The natural course of COVID-19 in children is usually mild. However, in rare instances children can
present with the serious manifestation of the disease. One unique attribute associated with Covid-19
among children and teenagers is Multisystem inflammatory syndrome in children (MIS-C), sometimes
referred to as a pediatric inflammatory multisystem syndrome (PIMS). MIS-C was first reported by the
doctors in the US and the UK in April 2020[2]. Since then, similar cases have been reported in Europe,
Canada, and a few countries in Africa. What unique is that no cases have been reported from China and
Asia during the early pandemic.

The clinical spectrum of symptoms associated with MIS-C varies between Kawasaki disease, an illness
that causes inflammation of blood vessels throughout the body, and Toxic shock syndrome. The risk of
acquiring Covid-19 and its severity of symptoms varies with race and ethnicity. While MIS-C severely
affects children of the Black and Hispanic races, Kawasaki disease on the other hand has a predilection
for children of Asian ethnicity.

The syndrome of MIS-C usually develops within four weeks of exposure. WHO has defines MIS-C as
Children and adolescents 0–19 years of age with fever > 3 days and

AND  two of the following:                                                  

1. Rash or bilateral non-purulent conjunctivitis or muco-cutaneous inflammation signs (oral, hands

or feet).

2. Hypotension or shock.

3. Features of myocardial dysfunction, pericarditis, valvulitis, or coronary abnormalities (including

ECHO findings or elevated Troponin/NT-proBNP),

4. Evidence of coagulopathy (by PT, PTT, elevated d-Dimers).

5. Acute gastrointestinal problems (diarrhoea, vomiting, or abdominal pain).

AND
Elevated markers of inflammation such as ESR, C-reactive protein, or procalcitonin. 

AND

No other obvious microbial cause of inflammation, including bacterial sepsis, staphylococcal or

streptococcal shock syndromes.

AND

Evidence of COVID-19 (RT-PCR, antigen test or serology positive), or likely contact with patients with
COVID-19 [3].

The pathophysiology associated with MIS-C is not well defined. A proposed immunological mechanism
triggered in response to virus is suggested. The mechanism by which virus triggers an aberrant response
is unknown.

The treatment options involve Intravenous Immunoglobulins, steroids and other anti-inflammatory
drugs. The use of anti-inflammatory drugs is associated with reduce inflammation and reduction in
damage to Heart, Kidney and other critical organs.

References:

1. World Health Organization (WHO). WHO Director-General's opening remarks at the media
briefing on COVID-19 -- 11 March 2020. Available at:
https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-
media-briefing-on-covid-19---11-march-2020 (Accessed on May 01, 2020).
2. Paediatric Intensive Care Society (PICS) Statement: Increased number of reported cases of novel
presentation of multi system inflammatory disease. Available at https://picsociety.uk/wp-
content/uploads/2020/04/PICS-statement-re-novel-KD-C19-presentation-v2-27042020.pdf
(Accessed on May 15, 2020).
3. WHO/2019-nCoV/Sci_Brief/Multisystem_Syndrome_Children/2020.