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Multisystem Inflammatory Syndrome
Aka: Multisystem Inflammatory Syndrome, MIS-C
- See Also
- Covid19
- Kawasaki Disease
- Epidemiology
- First identified during Spring 2020 with onset of Covid19 pandemic
- Age
- Initially identified in children and unlike Kawasaki (age <11 years) extended to age 21
- Has since been reported in adults
- Morris (2020) MMWR Morb Mortal Wkly Rep 69:1450-56 [PubMed]
- https://www.cdc.gov/mmwr/volumes/69/wr/mm6940e1.htm
- Pathophysiology
- Systemic inflammatory condition as a complication of COVID-19, and similar to Kawasaki Disease
- Indications: Evaluation for MIS-C
- Suspected or confirmed COVID-19 within prior 4 weeks AND
- Fever >3 days AND
- No other apparent explanation AND
- Two or more of the following systems involved (or unexplained Fever >5 days)
- Neurologic findings
- Headache or irritability
- Neurologic deficits
- Conjunctivitis
- Oral Lesions or other oral changes
- Lymphadenopathy
- Swelling of hands or feet
- Gastrointestinal findings
- Abdominal Pain or Diarrhea
- Nausea or Vomiting
- Urethritis
- Arthralgias or Arthritis
- Dermatologic findings
- Polymorphic rash
- Scaling or peeling of skin (Exfoliative Dermatitis)
- Labs
- First-Line - Tier 1 Screening
- Complete Blood Count with platelets and differential
- Comprehensive metabolic panel (Electrolytes, Renal Function tests, Liver Function Tests, albumin)
- Erythrocyte Sedimentation Rate
- C-Reactive Protein
- Covid19 Test (typically nasopharyngeal PCR)
- First-Line - Tier 2 Screening
- Indications for Tier 2 tests (from Tier 1 Screening)
- C-Reactive Protein or CRP >5 mg/L or Erythrocyte Sedimentation Rate or ESR >40 mm/h AND
- At least one of the following
- Absolute Lymphocyte Count <1000/ul
- Platelet Count <150,000/ul
- Serum Sodium <135 mmol/L
- Neutrophilia
- Hypoalbuminemia (e.g. Serum Albumin <3 g/dl)
- Tier 2 Tests
- INR and PTT
- D-Dimer
- Serum Troponin
- NT-BNP
- Urinalysis (and consider Urine Culture)
- Blood Culture
- Additional Testing to consider based on Consultation
- Fibrinogen
- Factor VIII and Von-Willebrand profile
- Antithrombin III
- Procalcitonin
- Serum Ferritin
- Serum Triglycerides
- Total IgG
- Mycoplasma PCR
- Tick-Borne Illness Serology (e.g. Lyme Disease, Babesiosis, Anaplasmosis, Rickettsia - depending on region)
- Antiphospholipid Antibody profile and Lupus Anticoagulant Profile
- Cytokine Panel (e.g. IL1, IL6, IL8, TNFa)
- Lactate Dehydrogenase
- Uric Acid
- Peripheral Smear
- Diagnostics
- First-Line
- Electrocardiogram
- Imaging
- First-Line
- Chest XRay
- Second-Line (suspected MIS-C)
- Echocardiogram
- Differential Diagnosis
- Multisystem Infammatory Syndromes
- Covid19
- Kawasaki Disease
- Other Infections
- Toxic Shock Syndrome
- Septic Shock
- Mycoplasma pneumonia
- Viral Infections (e.g. Adenovirus, other Enteroviruses)
- Measles
- Tick-Borne Illness
- Leptospirosis
- Rheumatic Fever
- Rheumatologic Conditions
- Vasculitis
- Systemic Lupus Erythematosus (SLE)
- Juvenile Idiopathic Arthritis
- Macrophage Activation Syndrome
- Hemophagocytic lymphohistiocytosis
- Adverse Drug Reaction
- See Serious Cutaneous Adverse Reaction
- Stevens-Johnson Syndrome
- Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS Syndrome)
- Miscellaneous
- Malignancy
- Management: Indications for Inpatient Evaluation and Management
- Cardiac involvement
- Hypoxia
- Dehydration
- Lymphocytes <1000/ul
- Platelets <150k or >450k
- C-Reactive Protein or CRP >30 mg/L
- Erythrocyte Sedimentation Rate or ESR >40 mm/h
- Serum Albumin <3 g/dl
- Significant Anemia for age
- Coagulopathy
- Management: General
- See Covid19 for respiratory management
- Multispecialty Consultation (Infectious disease, hematology and oncology, cardiology, rheumatology)
- Immunomodulatory agents, antiplatelet agents and Anticoagulation per Consultation
- Consider empiric antibiotics
- Ceftriaxone (or if immunocompromised, Cefepime) AND
- Consider Vancomycin (if Septic Shock, Meningitis, Central Line) AND
- Consider Metronidazole (if suspected abdominal source of infection) AND
- Consider Doxycycline (if suspected Tick Borne Illness)
- Resources
- Children's Hospital of Philadelphia MIS-C Evaluation Protocol
- https://www.chop.edu/clinical-pathway/multisystem-inflammatory-syndrome-mis-c-clinical-pathway
- American College of Rheumatology
- https://www.rheumatology.org/Portals/0/Files/ACR-COVID-19-Clinical-Guidance-Summary-MIS-C-Hyperinflammation.pdf
- References
- (2020) University of Minnesota Masonic Guidance on Emergency Management MIS-C in Children
- Jiang (2020) Lancet Infect Dis [PubMed]
- https://www.thelancet.com/action/showPdf?pii=S1473-3099%2820%2930651-4