A Young Adolescent With a Multisystem Inflammatory Syndrome in Children (MIS-C)-Like Illness During the COVID-19 Pandemic

A Case Report

Jomol Rajesh, BSc; Poonam Joshi, PhD, MSc; Suman Dabas, MSc; Vanita Kumari, MSc; Rakesh Lodha, MD


Pediatr Nurs. 2022;48(1):47-48. 

In This Article

What do you Suspect?

The young adolescent is being evaluated for a prolonged history of fever and rash. There was no history of child having an exposure to anyone with COVID-19.

Differential Diagnoses

Acute Viral Illness. Acute viral illness is one of the most common illnesses seen in children, causing several symptoms, such as fever, lethargy, and maculopapular rash on the body. Acute viral illness is self-limiting in children, requiring administration of antipyretics, such as acetaminophen. One may or may not observe any change in serum blood chemistry.

Kawasaki Disease. Kawasaki disease is an autoimmune disease characterized by high-grade fever and rash on the body, followed by joint pain. Sometimes there can be an episode of diarrhea or vomiting as well. Most children recover from the disease without any serious problem. One can observe rise in inflammatory markers, such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP).

Rheumatic Fever. Rheumatic fever is a complex disease primarily seen in children between 5 to 15 years of age, affecting the skin, heart, blood vessels, and joints. The health care provider should look for fever, rash, and pain in one or more joints. Investigations, such as inflammatory markers and echocardiography, are done to establish the diagnosis. In the case of this child, the echocardiography showed a normal ejection fraction (60%), with no valvular abnormalities.

Acute Septic Arthritis. Acute septic arthritis is an acute hematogenous spread characterized by fever, limited movement, and acutely swollen painful joints. Serum CRP, white blood cell count, and ESR are used to rule out the diagnosis. In view of the COVID-19 pandemic, the provisional diagnosis of the child was MIS-C, but the child was also investigated for other possible disease conditions.

Management Plan and Recommendations

The child was shifted to the pediatric intensive care unit (PICU) for further management and put on respiratory support via a heated humidified high-frequency cannula (HHHNC) at 20 L/min, FiO2 of 54%. Antimicrobial therapy, namely ceftriaxone 2 g/20mL NS, IV every 12 hours, and vancomycin 500 mg/50 mL every 6 hours, were started. The child was transitioned from IV fluid therapy to restricted fluid orally (500 mL) on day three of her intensive care unit stay. Considering probable MIS-C, the child was started on methylprednisolone at 1 mg/kg/day20 mg once a day. Other drugs in her treatment were paracetamol tablets 500 mg, pantoprazole 40 mg before breakfast, clobazam 6 mL, risperidone 0.5 mg, and potassium chloride 10 mL.

The total duration of the child's stay in the PICU was 13 days. The child was weaned off successfully from H3FNC to nasal cannula (2 L/minute) to room air. Injectable drugs were changed to oral ones and full feeds were started. The child had HR varying between 50 to 70 beats/minute with infrequent atrial premature contractions (APC) with varying PR intervals (180 to 210 msec) at the time of writing of this article. The child is being under evaluation for possible acute rheumatic fever, and septic arthritis, and continuously being hemo-dynamically monitored.