COVID-19: WHAT EVERY HEALTH CARE PROVIDER MUST KNOW

Multi-system inflammatory syndrome in

children (MIS-C)
Dr. Monalisa Muchatuta, MD

LEARNING OBJECTIVES
At the end of this lecture, the learner will be able to:
1. Define Multi inflammatory System in Children (MIS-C)
2. Identify risk factors for MIS-C
3. Diagnose MIS-C in pediatric patients
4. Manage patients with MIS-C

LECTURE OVERVIEW
I. Overview of MIS-C
II. WHO MIS-C Criteria for Diagnosis
III. Clinical Management of MIS-C patients
IV. Summary

I. OVERVIEW OF MIS-C

● MIS-C is Multi-system inflammatory syndrome that causes children to develop serious

systemic symptoms requiring hospitalization. MIS-C is related to previous COVID-19
infection and symptoms typical develop about 2-4 weeks after an acute COVID
infection.

● MIS-C is Multi-system inflammatory syndrome that causes children to develop serious

systemic symptoms requiring hospitalization. MIS-C is related to previous COVID-19
infection and symptoms typical develop about 2-4 weeks after an acute COVID
infection.
 II. WORLD HEALTH ORGANIZATION (WHO) MIS-C CRITERIA

According to WHO diagnosis MIS-C must meet all of the following criteria:

● Age 0–19 years old with fever greater 3 days

● Laboratory evidence of COVID 19 or contact with COVID positive person
● Elevated markers of inflammation ex. ESR, CRP, D-dimer
● No other obvious bacterial co-infection
● And any 2 of the following systemic abnormalities:
○ Rash or bilateral non-purulent conjunctivitis or muco-cutaneous
inflammation 
○ Hypotension or shock
○ Features of myocardial dysfunction
○ ECHO findings or elevated cardiac markers
○ Evidence of coagulopathy (elevated PT/PTT)
○ Acute gastrointestinal symptoms

III. CLINICAL MANAGEMENT OF MIS-C PATIENTS

The mainstay of clinical management of MIS-C is hospitalization for observation and supportive
management of specific systemic symptoms as they occur. Because MIS-C can have multiple varying
systems involved, symptoms may be different and treatment modalities should be tailored to specific
clinical symptoms:

● Fever
o Administer weight based anti-pyretics ex. acetaminophen, ibuprofen,
naproxen for fever control.
● Dehydration
o Children presenting with signs of dehydration will benefit from IV or Oral
fluid hydration. If the source of dehydration is vomiting then anti-emetics
may be administered to support re-hydration. and Fever with anti-pyretics
for symptomatic relief. 
● Sepsis
o IV fluid hydration at 20-30ml/kg of crystalloid infusion
 o MIS-C may mimic symptoms of other non-COVID related common
infections in children.
o If the clinical picture is unclear or unable to rule out bacterial infections
then a provider may treat sepsis empirically by initiating IV antibiotics.
● Shock
o Management of shock should include all modalities used in sepsis
management and if hemodynamics are refractory to fluid management
should be escalated to include vasopressors.
o Vasopressors ex. epinephrine, norepinephrine, dopamine, dobutamine
may be used at weight-based dosages. Choice of pressor is dependent
upon availability and factor in patient co-morbidities ex heart disease vs
chronic lung disease.
● Respiratory Distress
o Supplemental Oxygen via nasal cannula, high flow oxygen, CPAP or BIPAP
depending on clinical status.
o Intubation should be avoided if other modalities are available and clinical
status allows.
o Additionally, IV steroids such as solumedrol 2-30 mg/kg/day may also be
initiated in MISC.

● Other
o MISC patients are at risk of developing thrombotic complications such as
MI and hypercoagulable states such as PE, hence Anti-coagulation such as
Lovenox or low dose aspirin should be administered. For more severe
cases of MISC IVIG infusions at 2 g/kg have shown some promise to be
useful and are considered standard of care dependent on availability.

IV. SUMMARY
 ● Providers should maintain a high index of suspicion for MISC when seeing patients
presenting with severe systemic symptoms during or after COVID-19 illness, especially
in children with co-morbidities.

● Providers should be able to identify MIS-C diagnosis criteria in patients.

● MISC treatment is tailored to be specific systemic symptoms that the patient presents
with.

●  Empirically treat for common infections if clinical picture is unclear or unable to test
for COVID-19

V. REFERENCES

● WHO Multisystem inflammatory syndrome in children and adolescents temporally related

to COVID-19.
https://www.who.int/news-room/commentaries/detail/multisystem-inflammatory-syndro
me-in-children-and-adolescents-with-covid-19

● CDC. COVID-19 in Children and Teens.

https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/children/symptoms.html

● Feldstein, L. R. et al. Multisystem inflammatory syndrome in U.S. children and adolescents.

N. Engl. J. Med. 383, 334–346 (2020).

● Riphagen S, Gomez X, Gonzalez-Martinez C, Wilkinson N, Theocharis P. Hyperinflammatory

shock in children during COVID-19 pandemic. Lancet. 2020. Epub 2020/05/11.

● Jones VG, Mills M, Suarez D, Hogan CA, Yeh D, Bradley Segal J, et al. COVID-19 and
Kawasaki Disease: Novel Virus and Novel Case. Hosp Pediatr. 2020. Epub 2020/04/09