Novel conundrum of mis-c in childhood Covid-19

by Dr B. J. C. Perera 

MBBS(Cey), DCH(Cey), DCH(Eng), MD(Paed), MRCP(UK), FRCP(Edin), FRCP(Lon), FRCPCH(UK), FSLCPaed, FCCP, Hony FRCPCH(UK), Hony. FCGP(SL) 

Specialist Consultant Paediatrician and Honorary Senior Fellow, Postgraduate Institute of Medicine, University of Colombo, Sri Lanka.

It is now common knowledge that no unvaccinated age group is immune to the vagaries of the microbe SARS-CoV-2 that causes the disease COVID-19. Quite contrary to popular belief, children and adolescents are as vulnerable as adults and the elderly to catch the disease. The difference perhaps is that in children it is largely without even symptoms and even when there are symptomatic effects on their bodies, the features are quite mild in children. There is a tendency amongst many people to take childhood COVID-19 rather lightly and nonchalantly because of these documented facts.

However, in a very small proportion of affected children, the disease can cause some real problems. In some of them, albeit in a very small minority, there could be severe disease, such as COVID Pneumonia, especially in those with a variety of different coexistent diseases which make them vulnerable to develop more severe disease.

Yet for all that, over the last few months, another enigmatic presentation of COVID-19 in children and adolescents, presenting as a severe and novel complication, has aroused intense interest worldwide. It is the Multi-system Inflammatory Syndrome in Children, abbreviated as MIS-C. As its name implies it shows clinical effects in many organ systems in the body and it is temporal or time-based association with COVID-19. It was first described in the United Kingdom in April 2020, that is over a year ago, and subsequently in other parts of Europe, USA and many other countries. In one research report, nearly 4000 cases of MIS-C and 35 deaths have been reported in the United States. There may be even a larger number of unreported cases worldwide.

A steep learning curve for the identification, diagnosis, and treatment of this condition has been effective through rapid communication globally among multidisciplinary specialists at pediatric centres who faced the challenge of caring for the affected children. In a triumph of collaboration, experts achieved consensus about diagnostic criteria and the need to induce rapid management strategies aimed at limiting the course of the illness. However, in the absence of randomized, controlled clinical trials, consensus around specific therapies has been more elusive, given the speed with which centres have had to establish cohorts and deliver treatment. This complication seems to be an abnormal immune response to the virus which, if left untreated or sub-optimally managed, tends to damage many organs and systems of the body.

It is now known that MIS-C tends to affect one in five thousand COVID-19 positive patients with a median age of between 8 to 11 years. At the Intensive Care Unit of the Lady Ridgeway Hospital for Children in Colombo, they have managed around 20 patients of age ranging from 1 to 14 years in the recent past. All of them have had high swinging fever and around 87% have had involvement of the gastrointestinal system of the abdomen while 70% have had the heart and the cardiovascular system being affected. It is imperative to note that almost any organ or system could be affected by MIS-C. Many have had sore eyes, skin rashes and involvement of mucous membranes of the mouth and tongue as well. Quite a few have had the heart being affected with low blood pressures and circulatory failure; a potentially fatal complication if not adequately and promptly treated. This complication of MIS-C appears to occur a little later than the severe COVID-19 effects such as pneumonia and as such when a definitive diagnosis could be made, the vast majority of the affected children are non-infective from the point of view of their ability to spread the disease. So far, in those cases where a definitive diagnosis of MIS-C could be made, there has not been any deaths. That speaks volumes for the dedication and expertise of those who are called upon to care for these cases of MIS-C, particularly in the Intensive Care Units of our hospitals.

The biggest problem for those healthcare personnel who are called upon to manage these children and adolescents with MIS-C is that the condition is a great mimicker. In its presentation it resembles a wide variety of other conditions that present with similar features, particularly the toxic shock syndromes following bacterial infections, which are a bit more commonly seen than this particular problem. In that sense, MIS-C is a sort of a diagnosis made by exclusion of other similar presentations and a variety of tests and investigations may be necessary before a definitive diagnosis can be made. A very high degree of suspicion is necessary to be able to sort out this condition from other similar disorders.

To make matters further complicated, a similar syndrome to MIS-C has also been noticed in adults over 21 years of age. It is known as MIS-A. There are some differences in the adult version but the basic symptoms are very similar. There is very little scientific studies on MIS-A and more definitive medical information is awaited.

It is imperative not to miss the diagnosis of MIS-C as a lot could be done if these patients are detected early. Specific treatment modalities have now been sorted out according to the scientific evidence available. If a child has sustained high fever with abdominal symptoms, lethargy, changes in the sensorium, skin rashes, redness of the whites of the eyes and soreness of the lining of the mouth and tongue, the diagnosis has to be strongly suspected. All these symptoms may not be there in each and every case and it is essential that the parents stay watchful if their child has any of these and looks ill.

Parents are the people who know their children best and if there is any reason to be concerned, then the child must, I repeat MUST, be taken to a qualified doctor for assessment. Immediate response on the part of parents, care-givers and healthcare personnel is of absolute essence as so much can be done for this condition if treated early, so as to prevent unfortunate outcomes.

Although clinical trials are in progress on the efficacy and safety of available vaccines in children, we do not know whether immunisation against COVID-19 could prevent or mitigate against the disease complications like MIS-C as yet. Then there are the more recent ‘COVID variants of concern’, now being labelled using the letters of the Greek alphabet such as α (alpha), β (beta), γ (gamma), δ (delta), ε (epsilon) etc. As to whether some of these more potent mutant variants are liable to cause MIS-C in higher numbers of children and adolescents is also not all that well established. These variants have been around only for a relatively shorter time than the original index strains of SARS-CoV-2 and our knowledge on all these aspects is constantly evolving. It is important to remember that as the virus undergoes changes to its genetic code, so does its capability to surpass antibodies and immune defences of the human body as well.

The healthcare personnel need to remember that common things occur commonly and that over-diagnosis of MIS-C needs to be avoided. However, it is also crucial that we need to avoid missing the diagnosis of MIS-C as well. Sometimes, the doctors are caught between the devil and the deep blue sea and they need to respond swiftly and appropriately. All medicines and equipment that are needed to care for even the most severely affected children with MIS-C are available in all government hospitals in our country. I am quite sure that the healthcare staff who look after sick children in our hospitals will not let a child suffer unnecessarily or let him or her succumb to MIS-C without a determined and dedicated fight.

The writer is well aware of the fact that many parents are intensely worried about all the information and even misinformation, that is flying around, about MIS-C, especially in the social media. The parents, for their part, have to studiously employ cat-like vigilance and make sure that they take their children who are sick and who do not look quite right, to a suitable hospital, without any delay whatsoever. Undeterred and ever so very prompt action is absolutely vital and will certainly save the day.

(This article is based on the available research literature up to 30th June 2021 and a scientific webinar for doctors, transmitted on-line by the Paediatric Intensive Care Chapter of the Sri Lanka College of Paediatricians on 28th June 2021)