Multi-System Inflammatory Syndrome in Children (MIS-C) Potentially Associated with COVID-19: Call for Cases

Bureau of Communicable Diseases, May 19, 2020

Summary

• The Wisconsin Department of Health Services (DHS) now prioritizes prompt reporting of suspected cases of Multi-System Inflammatory Syndrome in Children (MIS-C), a newly described illness that is potentially associated with COVID-19.
• Cases are characterized by persistent fever and features of Kawasaki disease and/or toxic shock syndrome, and were first identified in the United Kingdom. Cases have recently been identified in multiple regions of the United States.
• These patients may require intensive care unit admission for cardiac and/or respiratory support and testing for SARS-CoV-2 virus may be positive or negative.
• Wisconsin providers should report suspected cases of MIS-C to DHS via WEDSS or by calling the Epidemiology Section at (608) 267-9003.

Dear Colleagues,

Below please find new information about this recently identified complication of COVID-19 infection, Multi-System Inflammatory Syndrome in Children.

This syndrome has features which overlap with Kawasaki Disease and Toxic Shock Syndrome. Inflammatory markers may be elevated, and fever and abdominal symptoms may be prominent. Rash may also be present. Myocarditis and other cardiovascular changes may be seen. Additionally, some patients have developed cardiogenic or vasogenic shock and required intensive care. This inflammatory syndrome may occur days to weeks after acute COVID-19 illness.

The syndrome may include:

• A child presenting with persistent fever, inflammation (e.g. neutrophilia, elevated C-reactive protein and lymphopenia) and evidence of single or multi-organ dysfunction (shock, cardiac, respiratory, renal, gastrointestinal or neurological disorder). This may include children meeting full or partial criteria for Kawasaki disease.
• Exclusion of any other microbial cause, including bacterial sepsis, staphylococcal or streptococcal shock syndromes, and infections associated with myocarditis such as enterovirus. Clinicians should not delay seeking expert advice while waiting for results of these investigations.

Early recognition by pediatricians and prompt referral to an in-patient specialist, including to critical care, is essential.

This syndrome should be considered by pediatricians and specialists, particularly when other microbial etiologies have not been identified.

Pediatricians and specialists should elicit any recent history of illness with COVID-19 or close contact with individuals who are known to have COVID-19 in children presenting with symptoms that are compatible with MIS-C.

Most patients who have presented with this syndrome have tested positive for the SARS-CoV-2 virus with a diagnostic molecular test, or were positive on a serologic test.

Testing and Treatment:

• Diagnostic testing to detect the presence of SARS-CoV-2, the virus that causes COVID-19, or corresponding antibody testing should be performed in patients who are under 21 years of age and present with symptoms compatible with MIS-C.
•  Patients should receive supportive treatment. Healthcare providers should provide disease-specific treatments as appropriate.

Case Reporting:

• COVID-19-Associated Multi-System Inflammatory Syndrome in Children should be reported to DHS for any patient who meets the following the CDC case definition for MIS-C.

CDC Case Definition for Multisystem Inflammatory Syndrome in Children (MIS-C)

An individual aged <21 years presenting with feverⁱ, laboratory evidence of inflammationⁱⁱ, and evidence of clinically severe illness requiring hospitalization, with multisystem (>2) organ involvement (cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic or neurological); AND

No alternative plausible diagnoses; AND

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

ⁱFever >38.0°C for ≥24 hours, or report of subjective fever lasting ≥24 hours

ⁱⁱIncluding, but not limited to, one or more of the following: an elevated C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), fibrinogen, procalcitonin, d-dimer, ferritin, lactic acid dehydrogenase (LDH), or interleukin 6 (IL-6), elevated neutrophils, reduced lymphocytes and low albumin

Additional comments

• Some individuals may fulfill full or partial criteria for Kawasaki disease but should be reported if they meet the case definition for MIS-C
• Consider MIS-C in any pediatric death with evidence of SARS-CoV-2 infection

Wisconsin providers should report suspected cases of MIS-C to DHS via WEDSS, or by calling the Epidemiology Section at (608) 267-9003. We anticipate a standard national MIS-C case report form will be available soon, and will share this with partners when it is available.  In the meantime, the DHS epidemiology team will review any case reports and coordinate securing medical records and chart abstraction as necessary.

Sincerely,

Ryan Westergaard, MD, PhD, MPH
Chief Medical Officer and State Epidemiologist for Communicable Diseases
Wisconsin Department of Health Services