One bright spot in the novel coronavirus pandemic is that children, in general, have fared well with most only having mild symptoms or no symptoms at all.
That narrative began to change in early May with news reports of 15 children in New York, the epicenter of the U.S. COVID-19 pandemic, being hospitalized with a scary new illness that seemed to be connected to COVID-19. At least two children have died, and the New York State Department of Health has identified 102 patients with similar presentations.
A post-viral syndrome
The Centers for Disease Control and Prevention (CDC) is calling the condition multisystem inflammatory syndrome in children (MIS-C) and is urging clinicians to report suspected cases so officials can learn more.
The CDC provided a case definition for MIS-C in a health advisory:
- An individual under 21 years presenting with fever, laboratory evidence of inflammation and evidence of clinically severe illness requiring hospitalization with the involvement of two or more organ systems (cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic or neurological); and
- No alternative plausible diagnoses; and
- Has tested positive for current or recent coronavirus (SARS-CoV-2) infection or COVID-19 exposure within the four weeks prior to the onset of symptoms.
The CDC noted the fever should be at least 100.4 (F) for at least 24 hours.
Akron Children’s establishes a multi-disciplinary team
Akron Children’s Hospital has a multi-disciplinary clinical team in place to keep abreast of the latest information, to share information with colleagues and to have best practices in place should we see suspected cases in our service area. Specialists from infectious disease, cardiology, emergency medicine, critical care, and hospital medicine are represented, said Dr. Ira Taub, a pediatric cardiologist who is serving on the committee.
Based on the first reports, the cases seem to show a delayed immune response in children who have had exposure to the virus, said Dr. Taub. The working theory is that, in these cases, the child’s white blood cells mounted a good immune defense and fought off the coronavirus (maybe so successfully that parents did not even know the child was ill) but weeks later the child’s own immune response has accelerated, causing the fever and inflammation.
“This is different than the most well-known symptoms being reported in adults with COVID-19, such as the dry cough, the loss of taste and smell, and the low oxygen levels and declining respiratory function,” said Dr. Taub. “In these children, parents, may notice rash, vomiting, or pain or fullness in the abdomen, in addition to fever. A small subset of these children may progress to requiring hospitalization and a smaller subset of these require an intensive care unit. It’s important to emphasize how rare these cases remain, as of now.”
First observed in Europe
Published accounts in the medical journal, The Lancet, indicate doctors in the Bergamo province of Italy and later in the United Kingdom, both hit hard by the COVID-19 pandemic, had been seeing children with a “hyperinflammatory toxic shock” syndrome similar to Kawaski disease” weeks before the first New York cases.
Kawaski disease is a condition that causes inflammation in the walls of blood vessels. Its symptoms include fever, abdominal pain, GI distress, rashes or peeling skin, pink eye, enlarged lymph nodes, a swollen or bumpy tongue and swollen feet. It is most commonly seen in children ages 2 to 5. The new syndrome has been reported in both children and teens.
“There’s definitely overlap in the symptoms [between Kawaski and MIS-C],” said Dr. Taub.
There are many questions surrounding this syndrome. Is it more likely to occur in areas hit hard by COVID-19? Were children affected in the Wuhan area of China, where the pandemic began? And, closer to home, are several cases under investigation in Cuyahoga County related?
A diagnosis would begin with a thorough medical history and exam, and several blood tests to rule out other conditions in consultation with Akron Children’s infectious disease team.
Based on their experience with Kawaski disease, doctors have a variety of established therapies to treat inflammation and clotting, with more being investigated.
“We are rapidly learning more about this syndrome and there is a great deal of information sharing internationally,” said Dr. Taub.
Advice for parents
Despite the widespread media coverage in recent weeks, Dr. Taub again stressed how rare these cases are as of now. But parents, doctors and pediatric hospitals should definitely be aware of MIS-C symptoms since the coronavirus will be with us for months to come, with outbreaks possible in every community.
“Parents know their children better than anyone else,” said Dr. Taub. “While this new syndrome can look differently from one child to the next, the one constant is fever. If parents see a fever and it’s unrelenting over several days and they see their child is not behaving as typical, it’s time to call the pediatrician.”