TOMADO DE:
THE NEW ENGLAND JOURNAL OF MEDICINE
Multisystem Inflammatory Syndrome in Children in New York State
List of authors.
· Elizabeth M. Dufort, M.D.,
· Emilia H. Koumans, M.D., M.P.H.,
· Eric J. Chow, M.D., M.P.H.,
· Elizabeth M. Rosenthal, M.P.H.,
· For the New York State and Centers for Disease Control and Prevention Multisystem Inflammatory Syndrome in Children Investigation Team *
June 29, 2020
·
Abstract
BACKGROUND
A multisystem inflammatory syndrome in children (MIS-C) is associated with coronavirus disease 2019. The New York State Department of Health (NYSDOH) established active, statewide surveillance to describe hospitalized patients with the syndrome.
METHODS
Hospitals in New York State reported cases of Kawasaki’s disease, toxic shock syndrome, myocarditis, and potential MIS-C in hospitalized patients younger than 21 years of age and sent medical records to the NYSDOH. We carried out descriptive analyses that summarized the clinical presentation, complications, and outcomes of patients who met the NYSDOH case definition for MIS-C between March 1 and May 10, 2020.
RESULTS
As of May 10, 2020, a total of 191 potential cases were reported to the NYSDOH. Of 95 patients with confirmed MIS-C (laboratory-confirmed acute or recent severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] infection) and 4 with suspected MIS-C (met clinical and epidemiologic criteria), 53 (54%) were male; 31 of 78 (40%) were black, and 31 of 85 (36%) were Hispanic. A total of 31 patients (31%) were 0 to 5 years of age, 42 (42%) were 6 to 12 years of age, and 26 (26%) were 13 to 20 years of age. All presented with subjective fever or chills; 97% had tachycardia, 80% had gastrointestinal symptoms, 60% had rash, 56% had conjunctival injection, and 27% had mucosal changes. Elevated levels of C-reactive protein, d -dimer, and troponin were found in 100%, 91%, and 71% of the patients, respectively; 62% received vasopressor support, 53% had evidence of myocarditis, 80% were admitted to an intensive care unit, and 2 died. The median length of hospital stay was 6 days.
CONCLUSIONS
The emergence of multisystem inflammatory syndrome in children in New York State coincided with widespread SARS-CoV-2 transmission; this hyperinflammatory syndrome with dermatologic, mucocutaneous, and gastrointestinal manifestations was associated with cardiac dysfunction.
Discussion
Our study involving hospitalized pediatric patients with MIS-C in New York State describes a febrile hyperinflammatory syndrome with dermatologic, mucocutaneous, and gastrointestinal manifestations associated with cardiac dysfunction; this syndrome is currently being seen worldwide. Although 32% of the patients had hypotension at admission, 62% (48% of those 0 to 5 years of age) received vasopressor support and 80% were admitted to an ICU. Notable findings were the high prevalence of cardiac dysfunction or depression, coagulopathy, and gastrointestinal symptoms, accompanied by mild respiratory symptoms and occasional indications for supplemental oxygen, in contrast with most cases of acute Covid-19 among hospitalized children. 4,19 Patients were commonly treated with IVIG, glucocorticoids, and vasopressors. This constellation suggests an inflammatory vasculopathy, with some similarities to Kawasaki’s disease and toxic shock syndrome. Our findings are consistent with those of other studies to date, which have been limited to case reports, short reports, and small case series. 10,11,20-24
As in a study from Italy, MIS-C cases in New York State followed the peak of the Covid-19 epidemic in the state, which supports a temporal and geographic association between Covid-19 and MIS-C. 10 Of the patients tested with a serologic assay, nearly all had reactivity, and of the 76 who were tested with both RT-PCR and serologic assays for SARS-CoV-2, 44 (58%) had only serologic evidence of current or recent SARS-CoV-2 infection, which supports a laboratory-based association. Of the 4 patients with suspected cases, none of whom had laboratory evidence of SARS-CoV-2 infection on admission, 2 (50%) had had a Covid-19–like illness in the 6 weeks before MIS-C symptom onset. These findings support that MIS-C is probably a postinfectious, inflammatory process related to Covid-19.
We found variations in presenting symptoms and manifestations according to age. The prevalence of dermatologic symptoms was highest among children 0 to 5 years of age, and the prevalence of myocarditis (diagnoses and clinical) was highest among the adolescents. The prevalence of gastrointestinal symptoms was high in all age groups. Nearly half of children 0 to 5 years of age with MIS-C but only 12% of the adolescents 13 to 20 years of age had a discharge diagnosis of Kawasaki’s disease or atypical Kawasaki’s disease. Children 0 to 12 years of age with MIS-C were more likely to present with Kawasaki’s disease–like symptoms such as conjunctival injection, rash, and oral mucosal changes than adolescents with MIS-C; however, children 0 to 12 years of age in our study presenting with Kawasaki’s disease–like symptoms were older, were more likely to present with hypotension, and were more commonly admitted to the ICU than children with Kawasaki’s disease described in previous reports. 25 Although Kawasaki’s disease–like symptoms were less common among adolescents than among younger children with MIS-C, they did still occur, and rare cases of Kawasaki’s disease among adults have been reported. 26 Further research could explore whether a post–SARS-CoV-2 inflammatory syndrome exists in adults.
Although classic Kawasaki’s disease disproportionately affects Asian children, MIS-C that is associated with Covid-19 appears to occur among children of all racial and ethnic backgrounds. 24 Among our patients, predominantly from the New York Metropolitan Region, 40% were black and 36% were Hispanic. This may be a reflection of the well-documented elevated incidence of SARS CoV-2 infection among black and Hispanic communities. 6,27 In comparison, among persons younger than 21 years of age, an estimated 25% and 32% of people living in the New York Metropolitan Region in 2018 were black and Hispanic, respectively. 28
Limitations of our study include presumed underestimation, possibly due to mild cases of MIS-C that did not involve hospitalization, and possible underreporting due to lack of recognition of an emerging syndrome. Furthermore, clinicians may not have ordered a full panel of inflammatory markers, possibly excluding some patients. Children with severe acute Covid-19 who had a concurrent inflammatory syndrome 29 complicating their hospitalization may have met the case definition, which would dilute our understanding of MIS-C. In addition, the lack of serologic tests early in the outbreak, limited availability of molecular or serologic testing, and clinician testing practices in children may have led to underrecognition. This may have been particularly true for those excluded because they did not meet the virologic or epidemiologic criteria; the clinical and laboratory characteristics of these patients were more similar to the characteristics of patients with MIS-C than they were to the characteristics of patients excluded for other reasons. However, others not meeting the virologic or epidemiologic criteria may represent patients with baseline Kawasaki’s disease, particularly in geographic areas without ongoing community-based transmission of SARS-CoV-2. The sensitivity or specificity of the case definition for confirmed MIS-C may be further affected by the varying performance of both PCR and serologic tests according to manufacturer and setting. We could not independently verify the diagnosis of Kawasaki’s disease, atypical Kawasaki’s disease, or toxic shock syndrome.
Although most children have mild or no illness from SARS-CoV-2 infection, MIS-C may follow Covid-19 or asymptomatic SARS-CoV-2 infection. Recognition of the syndrome and early identification of children with MIS-C, including early monitoring of blood pressure and electrocardiographic and echocardiographic evaluation, could inform appropriate supportive care and other potential therapeutic options. 10,11
Because children often present with mild symptoms of Covid-19 and are less frequently tested than adults, 4,7 the incidence of MIS-C among children infected with SARS-CoV-2 is unclear. It is crucial to establish surveillance for MIS-C cases, 14 particularly in communities with higher levels of SARS-CoV-2 transmission.
NOTA: Sin duda la presencia de este sindròme en pacientes con diabetes tipo I pueden deteriorar severamente el control metabòlico, generando cetoacidosis y aumentando la morbimortalidad
