The latest twist in the COVID-19 pandemic is a multi-system disorder that is occurring in the pediatric population and has been labeled the Multisystem Inflammatory Syndrome (MIS). It shares many similarities to the Kawasaki Syndrome that is believed to be an autoimmune response to a virus. Kawasaki Syndrome is commonly seen in children under five years of age. In the cases of MIS diagnosed thus far ages have ranged from 2 to 21. MIS is felt to be a delayed effect of the coronavirus. Originally it was thought that children were somewhat resistant to the COVID-19 virus. The number of children infected with the virus appears to be smaller than that seen in adults, but some of those children who are infected are experiencing life-altering complications. Children with MIS share many common characteristics of adults with COVID-19 infections such as an overactive immune response, a vasculitis that causes the toes to appear red & swollen similar to chilblains. Dermatologists are referring to this as “COVID toes.” The most serious complication of MIS is cardiac involvement that can include myocarditis, pericarditis, valvulitis and coronary artery aneurysms. Like the sickest of adult patients these children tend to run a high fever for several days, have swollen, painful joints and intestinal symptoms (usually diarrhea). They may also have oral signs & symptoms characterized by red, swollen lips, red eyes (conjunctivitis), a red (strawberry) tongue and swollen lymph nodes in the neck. One of the most striking signs of the infection is often a diffuse, erythematous (red) rash of the extremities. Unlike adult COVID-19 infections, MIS patients have shown few (if any) respiratory symptoms. In recent days Health Department officials reported a total of 15 cases of the syndrome in NYC and 64 cases statewide. Two children in NYC have died from the syndrome. This Kawasaki-like syndrome has also been reported in Italy, Spain, and the U.K. Laboratory findings in these patients suggest an inflammatory process with elevated levels of C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) and ferritin levels. Most (if not all) also had decreased levels of albumin and total lymphocyte counts. Most of those admitted to the hospital with MIS are either positive for the virus or had antibodies to the virus in their serum.
Diagnosis may be difficult because the inflammatory syndrome can occur several days or weeks after an apparent COVID-19 infection. Symptoms of fever and rash are so common in children that it is easy to overlook or misdiagnose MIS initially. Early intervention is critical to prevent complications particularly cardiac and renal involvement. MIS should be considered in the differential diagnosis for anyone under age 21 with a fever and rash. Treatment of Kawasaki Disease has traditionally included aspirin, intravenous immunoglobulin and corticosteroids. Hospitalized patients were often found to be hypotensive and most of the inpatient care was supportive in nature. Pediatricians are fearful that parents may delay bringing their child to the hospital because they have been cautioned against going to the ER unless there was a serious emergency. Parents may also fear that if they go to the hospital they risk exposure to COVID-infected patients. No test exists for the diagnosis of MIS but high fever, rash and joint pain should not be considered normal. Any parent should feel justified in having your child thoroughly evaluated under such circumstances. That may be more important now than it has ever been.