key: cord-0898165-o9p0kv9k
authors: Kannikeswaran, Nirupama; Merolla, David M.; Bond, Kersten; Philip, Livia; Sethuraman, Usha
title: MIS-C among return visits for fever in a pediatric emergency department during the COVID-19 pandemic
date: 2021-12-15
journal: Am J Emerg Med
DOI: 10.1016/j.ajem.2021.12.022
sha: 689aa2c03d7e456dc3da9c66d96fcd3d174cd441
doc_id: 898165
cord_uid: o9p0kv9k

Return visits (RV) to a pediatric emergency department (PED) can be secondary to illness progression, parental concerns, call backs or rarely due to a diagnostic error during the first visit. Fever accounts for nearly half of these RVs and is also one of the most common presenting complaints of Corona Virus Disease 2019 (COVID- 19) due to severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) infection in children. Although majority of children with COVID 19 have a mild illness, severe complications such as Multisystem inflammatory syndrome in children (MIS-C) can occur. These children are often critically ill with a mortality rate of 2–4%. Initial symptoms of MIS- C are non- specific and mimic other viral illness making early diagnosis challenging. We report five patients who were evaluated for fever and discharged from our PED and were subsequently diagnosed with MIS-C (n = 3) or Kawasaki Disease (n = 2) during their RV within 7 days. All patients presented with fever during the initial visit and three of the five children had gastrointestinal symptoms. They were all noted have persistent tachycardia during the index visit. Three patients presented in cardiogenic shock and echocardiographic abnormalities were noted in four patients during the RV. Significant interventions were required in majority of these children (PICU admission: 4, inotropes: 3, mechanical ventilation:2). Clinicians need to maintain a high index of suspicion for diagnosis of MIS-C especially in those who present with persistent fever and have abnormal vital signs during the COVID-19 pandemic.

Fever is the most common symptom associated with severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) infections in children. Although majority of cases in children have been mild, severe diseases such as Multisystem Inflammatory Syndrome in Children (MIS-C) have occurred. The return visits(RV) of children who were evaluated for fever and discharged home during the pandemic is unknown. We performed a retrospective chart review of seven RV of children ≤18 years of age who were evaluated for fever and discharged from our pediatric emergency department (PED) during the first six months (4/1/2020 -12/31/2020) of the Corona Virus Disease 2019 (COVID 19) pandemic to identify those children who were diagnosed with Multisystem Inflammatory Syndrome in children (MIS-C) or Kawasaki Disease during the RV.

Our PED is an inner city, level 1 trauma center attached to a free standing children's hospital with approximately 85,000 visits/year. Among the seventy seven children who had a seven day RV after an index visit for fever, five children (5/77; 0.6%) were diagnosed with MIS-C (n=3) and Kawasaki disease (n=2). (Table 1a) These children ranged in age from 1-15 years. Sixty percent were male and African American.

Three children had gastrointestinal symptoms and one child had a rash. All children had persistent tachycardia during the index visit. One of these children had a screening evaluation for MIS-C during the index visit which was only abnormal during the RV (Table 1b) . All children were noted to be tachycardic and shock (defined as presence of hypotension with vasopressor support requirement) was noted in three children during the RV. The laboratory results are noted in (table 1a) . There were no deaths in our cohort.

The The major morbidity noted in children with MIS-C results from cardiac abnormalities which include ventricular dysfunction, coronary artery dilation and aneurysms, arrhythmia, and conduction abnormalities. 8 Patients with severe illness often present in cardiogenic shock requiring inotropic support, mechanical ventilation and extracorporeal membrane oxygenation.

Given the frequent association with cardiac abnormalities, all patients with suspected MIS-C should undergo evaluation with an electrocardiogram, echocardiogram as well serial monitoring of troponin and BNP. Prompt recognition and admission to a pediatric intensive care unit of children with cardiac involvement at risk for hemodynamic compromise is essential to improve mortality and morbidity.

1. Children and COVID-19: State level data report -American Academy of Pediatrics.

https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/children-and-covid-19-state-level-data-report. Accessed December 6 th 2021. 

Multisystem Inflammatory Syndrome in Children in New York State. New York State and Centers for Disease Control and Prevention Multisystem Inflammatory Syndrome in Children Investigation Team

Childhood Multisystem Inflammatory Syndrome -A New Challenge in the Pandemic N

Multisystem Inflammatory Syndrome in U.S. Children and Adolescents. Overcoming COVID-19 Investigators, CDC COVID-19 Response Team

Intensive care admissions of children with paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) in the UK: a multicenter observational study

Review of Cardiac Involvement in Multisystem Inflammatory Syndrome in Children

Fever accounts for nearly half of these RVs and is also one of the most common presenting complaints of Corona Virus Disease 2019 (COVID-19) due to severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) infection in children. Although majority of children with COVID 19 have a mild illness, severe complications such as Multisystem inflammatory syndrome in children (MIS-C) can occur. These children are often critically ill with a mortality rate of 2-4%. Initial symptoms of MIS-C are non-specific and mimic other viral illness making early diagnosis challenging. We report five patients who were evaluated for fever and discharged from our PED and were subsequently diagnosed with MIS-C (n=3) or Kawasaki Disease (n=2) during their RV within 7 days. All patients presented with fever during the initial visit and three of the five children had gastrointestinal symptoms. They were all noted have persistent tachycardia during the index visit. Three patients presented in cardiogenic shock and echocardiographic abnormalities were noted in four patients during the RV

Clinicians need to maintain a high index of suspicion for diagnosis of MIS-C especially in those