COMMENTARY

Treating Kids With MIS-C: It's 'Humbling'

Justin L. Berk, MD, MPH, MBA; Christopher J. Chiu, MD

Disclosures

August 14, 2020

Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

This transcript has been edited for clarity.

Christopher J. Chiu, MD: Welcome. We are The Cribsiders. I'm Christopher Chiu and I'm here with my colleague, Dr Justin Berk.

Justin L. Berk, MD, MPH, MBA: We are very excited to provide the first in a Medscape series of video recaps of our previous Cribsiders podcast episodes. Cribsiders is the pediatric medicine podcast that takes practice-changing knowledge and clinical pearls and brings them to listeners — students, residents, attendings, and faculty members who graduated years ago. We're all here to learn about pediatric medicine.

Chiu: Today we're recapping our episode on multisystem inflammatory syndrome in children (MIS-C) with our guest, Dr Adriana Tremoulet, associate director of the Kawasaki Disease Research Center at UC San Diego. Justin, during this episode, we clarified exactly what MIS-C is. Can you explain that?

Berk: Absolutely. I'm not going to lie; this was something that was a little confusing to me at first. The original syndrome was called PIMS, or pediatric inflammatory multisystem syndrome. This is how it was first characterized in Italy, in the United Kingdom, and in many European countries. In the United States, we've come to call it MIS-C.

Chiu: It is a postinflammatory syndrome that appears about a month after COVID-19 infection. It has several different phenotypes, including one that involves the GI system; another, the neuro system; and then there's a Kawasaki-like syndrome.

Berk: That's right. Our guest said that while there are those three major phenotypes, the diagnostic criteria essentially just require involvement of more than two systems.

Chiu: Because it's an inflammatory syndrome, one thing that is an important part of the diagnostic workup is the C-reactive protein (CRP).

Berk: That was one thing I thought was interesting. We talked about a broad workup, looking for hemolytic anemia, thrombocytopenia, elevated ferritin, D-dimer, fibrinogen, and even inflammatory markers, though it's unclear if those are helpful. But the big takeaway is that the CRP would be quite elevated in these children. The erythrocyte sedimentation rate (ESR) might not be. The patient may not be able to mount an elevated ESR if the thrombocytopenia is causing such a coagulopathy that the sediment is not there to elevate the ESR.

Chiu: I thought the discussion about treatment for MIS-C was interesting also. We talked about intravenous immunoglobulin (IVIG), which seems to be the mainstay of therapy at least in some way, although we're not quite sure how well it works or even how it works. But this is extrapolated from what we know about Kawasaki's. She did talk about some other anti-inflammatory agents too.

Berk: That's right. As you said, the treatment is kind of extrapolated from data from other inflammatory conditions, which is humbling. We talked about IVIG, steroids, anakinra, tocilizumab, and infliximab. There are not many trials, but the idea is to stick with whatever works.

Chiu: One of the last pearls I took away from this was that MIS-C really doesn't have much lung involvement. This probably goes back to the fact that this is a postinflammatory response that is apart from an acute infection. While an acute infection probably has some respiratory component, MIS-C doesn't.

Berk: I was surprised by that as well. It seems that the main organ that requires major critical care is the heart. So you can sometimes have coronary artery aneurysms, as in Kawasaki's, but you also have some myocardial stunning. This is not so much a myocarditis with a wildly elevated troponin, though you can have some, but an elevated BNP just as in a true myocardial strain that can lead to cardiogenic shock.

Chiu: I encourage everyone to check out our full episode with guest Dr Adriana Tremoulet. I hope you enjoy it.

Berk: Thanks so much. You can find this episode and subscribe to all of our shows on The Cribsiders website or send us an email at thecribsiders@gmail.com. Thanks so much for tuning in.

Justin Berk, MD, MPH, MBA, is assistant professor of medicine and pediatrics at the Warren Alpert School of Medicine at Brown University. He is a clinical educator active in ambulatory and inpatient patient care on medicine and pediatrics. He enjoys coffee, thinking about hiking, and being a generalist. Follow him on Twitter

Chris Chiu, MD, is assistant professor at The Ohio State University, where he is also the physician lead at OSU's Outpatient Care East Clinic and serves as the assistant clinical director for the internal medicine residency. He is an Air Force veteran and a self-proclaimed gadget geek. Follow him on Twitter

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