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In April 2020, doctors in England reported a cluster of children with hyperinflammatory shock resembling Kawasaki disease and toxic shock syndrome. The illness appeared to develop 2–4 weeks after COVID-19, and every child had antibodies to SARS-CoV-2. Symptoms included fever, rash, red eyes, swelling of the hands and feet, gastrointestinal symptoms, shock, and high markers of inflammation and heart damage. On May 14, 2020, CDC issued a Health Advisory describing this multisystem inflammatory syndrome in children (MIS-C), set out a case definition and asked clinicians to report cases.
The first 570 U.S. cases
By July 29, 2020, 570 patients meeting the definition, with illness beginning March 2–July 18, had been reported from 40 states, the District of Columbia and New York City.
Geographic distribution of reported MIS-C cases, March–July 2020. From CDC's MMWR.
| Finding | Share of patients |
|---|---|
| Median age | 8 years |
| Hispanic / Black (of those with known race) | 40.5% / 33.1% |
| No underlying condition | about two thirds |
| Obesity | 25.6% |
| Four or more organ systems involved | 86.0% |
| Admitted to intensive care | 63.9% (median ICU stay 5 days) |
| Median hospital stay | 6 days |
| Died | 10 (1.8%) |
Most common symptoms: abdominal pain (61.9%), vomiting (61.8%), rash (55.3%), diarrhea (53.2%), low blood pressure (49.5%) and red eyes (48.4%). Most had gastrointestinal (90.9%), cardiovascular (86.5%) or skin and mucous membrane (70.9%) involvement.
Serious complications: heart dysfunction (40.6%), shock (35.4%), myocarditis (22.8%), coronary artery dilation or aneurysm (18.6%) and acute kidney injury (18.4%).
Testing: all 565 children who were tested had evidence of SARS-CoV-2 — 46.1% by antibody test only and 25.8% by PCR only. The other five had a known link to a case.
Treatment: 92.5% were treated — most with intravenous immunoglobulin (IVIG) (80.5% of those treated), steroids (62.8%), antiplatelet drugs (58.6%), anticoagulants (44.2%) or drugs to support blood pressure (41.9%).
Three patterns
A statistical method called latent class analysis sorted the cases into three groups:
| Class 1 | Class 2 | Class 3 | |
|---|---|---|---|
| Patients | 203 (35.6%) | 169 (29.6%) | 198 (34.7%) |
| Picture | Classic MIS-C: most organ systems involved — every child had heart involvement; highest rates of abdominal pain, shock, myocarditis and inflammation markers | Mostly respiratory: cough, shortness of breath, pneumonia, ARDS — possibly acute COVID-19 or COVID-19 plus MIS-C | Milder, with rash and mucous membrane lesions; overlaps with Kawasaki disease |
| Median age | 9 | 10 | 6 |
| Six or more organ systems | 48.8% | 18.3% | 4.5% |
| Shock | 75.9% | 28.4% | 0% |
| ICU | 84.2% | 62.1% | 44.4% |
| PCR-positive without antibodies | 0.5% | 84.0% | 2.0% |
| Deaths | 1 (0.5%) | 9 (5.3%) | 0 |
Class 3 children most often met criteria for complete Kawasaki disease (6.6%), and as more children carry antibodies to SARS-CoV-2, true Kawasaki disease could be mistaken for MIS-C.
What it means
- MIS-C is rare but severe. With no confirmatory test and a broad case definition, it can be hard to tell apart from severe acute COVID-19 and Kawasaki disease.
- Hispanic and Black children made up 73.6% of cases, mirroring COVID-19's disproportionate toll on these groups — linked to long-standing inequities in housing, economic security, insurance and work.
- Because MIS-C appears weeks after infection, rising COVID-19 cases may bring more MIS-C later.
- Clinicians should watch for children with a hyperinflammatory syndrome and report suspected cases to state or local health departments.
Limits: reporting and diagnosis varied between jurisdictions; some forms were incomplete (race was missing for 18.9%); access to testing varied; and the broad definition may have captured some children with acute COVID-19 or Kawasaki disease.
Sources
Based on Godfred-Cato S, Bryant B, Leung J, et al., "COVID-19–Associated Multisystem Inflammatory Syndrome in Children — United States, March–July 2020," Morbidity and Mortality Weekly Report 69(32), CDC, as corrected; a work of the United States government in the public domain.
Licenza: CC0 1.0 (pubblico dominio) · Tratto da www.cdc.gov
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