Management of Multisystem Inflammatory Syndrome in Children with Combined Use of Corticosteroids and Intravenous Immunoglobulin—Report from Bursa, Turkey

Abstract

Objective In this article, we aimed to evaluate the clinical, laboratory, and radiological findings and outcomes of patients treated with corticosteroids and intravenous immunoglobulin (IVIG) with the multisystem inflammatory syndrome in children (MIS-C) in two centers in Bursa, Turkey.

Methods We retrospectively collected the clinical characteristics, laboratory results, and treatment outcomes of MIS-C cases treated in two centers from April 2020 to February 2021. Patients were compared both according to their clinical categorization and the place they were hospitalized in, as well as with studies published in the literature.

Results Fifty-six patients were included. Thirty-six (64.3%) were male with a mean age of 67.95 ± 50.87 months. Thirty patients (53.5%) were categorized as Kawasaki-like disease, 17 (30.3%) sepsis-like disease, and 9 (16%) were toxic shock syndrome (TSS). Admission symptoms were fever (100%), rash (71.4%), myalgia (69.6%), and abdominal pain (62.5%). Seventeen (30.3%) patients were hospitalized in pediatric intensive care unit. Elevated C-reactive protein levels, procalcitonin, erythrocyte sedimentation rate, D-dimer, and troponin were found in 100, 77, 84, 84, and 23.2% of the patients, respectively. Of all, 55 (98.2%) received IVIG, 54 (96.4%) corticosteroids, 56 (100%) antibiotic therapy, 22 (40%) albumin infusion, and 13 (23.2%) inotropic support. Fifty patients (89.3%) received low-molecular-weight heparin: enoxaparin, followed by acetylsalicylic acid treatment. Only one patient who was resistant to both IVIG and steroid treatment received Anakinra. One patient (1.7%) with TSS died within 1 hour of hospitalization.

Conclusion Combined use of IVIG and corticosteroids is an effective way of treatment in MIS-C patients resulting in low mortality.

Keywords

multisystem inflammatory syndrome - Kawasaki disease - toxic shock syndrome - sepsis - corticosteroids - intravenous immunoglobulin

Authors' Contributions

Concept: S.E.B.; E.T.; design: S.E.B., E.T.; supervision: E.T., H.A.; materials: S.E., B.A.; data collection and/or processing: S.E., B.A., E.K., E.Y., S.S.; analysis and/or interpretation: E.T.; literature review: S.E.B., E.T.; writing: S.E.B.; critical review: E.Y., E.K., S.S.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

Publikationsverlauf

Eingereicht: 09. Dezember 2021

Angenommen: 22. Februar 2022

Artikel online veröffentlicht:
17. Mai 2022

• References

• 1 Morand A, Fabre A, Minodier P. et al. COVID-19 virus and children: what do we know?. Arch Pediatr 2020; 27 (03) 117-118
• 2 Riphagen S, Gomez X, Gonzalez-Martinez C, Wilkinson N, Theocharis P. Hyperinflammatory shock in children during COVID-19 pandemic. Lancet 2020; 395 (10237): 1607-1608
• 3 Verdoni L, Mazza A, Gervasoni A. et al. An outbreak of severe Kawasaki-like disease at the Italian epicentre of the SARS-CoV-2 epidemic: an observational cohort study. Lancet 2020; 395 (10239): 1771-1778
• 4 Belhadjer Z, Méot M, Bajolle F. et al. Acute heart failure in multisystem inflammatory syndrome in children (MIS-C) in the context of global SARS-CoV-2 pandemic. Circulation 2020; 142 (05) 429-436
• 5 New York State Department of Health. Health advisory: pediatric multisystem inflammatory syndrome temporally associated with COVID-19- interim case definition in New York State. Accessed February 15, 2021 at: https://health.ny.gov/press/releases/2020/docs/2020-05-13_health_advisory.pdf
• 6 Centers for Disease Control and Prevention. Emergency preparedness and response. Accessed February 15, 2021 at: https://emergency.cdc.gov/han/2020/han00432.asp
• 7 Whittaker E, Bamford A, Kenny J. et al; PIMS-TS Study Group and EUCLIDS and PERFORM Consortia. Clinical characteristics of 58 children with a pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2. JAMA 2020; 324 (03) 259-269
• 8 Rafferty MS, Burrows H, Joseph JP, Leveille J, Nihtianova S, Amirian ES. Multisystem inflammatory syndrome in children (MIS-C) and the coronavirus pandemic: current knowledge and implications for public health. J Infect Public Health 2021; 14 (04) 484-494
• 9 Brodsky NN, Ramaswamy A, Lucas CL. The mystery of MIS-C post-SARS-CoV-2 infection. Trends Microbiol 2020; 28 (12) 956-958
• 10 Son MB, Gauvreau K, Ma L. et al. Treatment of Kawasaki disease: analysis of 27 US pediatric hospitals from 2001 to 2006. Pediatrics 2009; 124 (01) 1-8
• 11 Consiglio CR, Cotugno N, Sardh F. et al; CACTUS Study Team. The immunology of multisystem inflammatory syndrome in children with COVID-19. Cell 2020; 183 (04) 968.e7-981.e7
• 12 Rowley AH. Understanding SARS-CoV-2-related multisystem inflammatory syndrome in children. Nat Rev Immunol 2020; 20 (08) 453-454
• 13 Gruber CN, Patel RS, Trachtman R. et al. Mapping systemic inflammation and antibody responses in multisystem inflammatory syndrome in children (MIS-C). Cell 2020; 183 (04) 982.e14-995.e14
• 14 Diorio C, Henrickson SE, Vella LA. et al. Multisystem inflammatory syndrome in children and COVID-19 are distinct presentations of SARS-CoV-2. J Clin Invest 2020; 130 (11) 5967-5975
• 15 World Health Organization. Multisystem inflammatory syndrome in children and adolescents with COVID-19. Published May 15, 2020. Accessed February 22, 2021 at: https://www.who.int/publications/i/item/multisystem-inflammatory-syndrome-in-children-and-adolescents-with-covid-19
• 16 Weiss SL, Peters MJ, Alhazzani W. et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Pediatr Crit Care Med 2020; 21 (02) e52-e106
• 17 Kanegaye JT, Wilder MS, Molkara D. et al. Recognition of a Kawasaki disease shock syndrome. Pediatrics 2009; 123 (05) e783-e789
• 18 Odabasi Z, Cinel I. Consideration of severe coronavirus disease 2019 as viral sepsis and potential use of immune checkpoint inhibitors. Crit Care Explor 2020; 2 (06) e0141
• 19 Mamishi S, Movahedi Z, Mohammadi M. et al. Multisystem inflammatory syndrome associated with SARS-CoV-2 infection in 45 children: a first report from Iran. Epidemiol Infect 2020; 148: e196
• 20 Feldstein LR, Rose EB, Horwitz SM. et al; Overcoming COVID-19 Investigators, CDC COVID-19 Response Team. Multisystem inflammatory syndrome in U.S. children and adolescents. N Engl J Med 2020; 383 (04) 334-346
• 21 Antúnez-Montes OY, Escamilla MI, Figueroa-Uribe AF. et al. COVID-19 and multisystem inflammatory syndrome in Latin American children: a multinational study. Pediatr Infect Dis J 2021; 40 (01) e1-e6
• 22 Mahmoud S, Fouda EM, Kotby A. et al. The “Golden Hours” algorithm for the management of the Multisystem Inflammatory Syndrome in Children (MIS-C). Glob Pediatr Health 2021; 8: X21990339
• 23 Pouletty M, Borocco C, Ouldali N. et al. Paediatric multisystem inflammatory syndrome temporally associated with SARS-CoV-2 mimicking Kawasaki disease (Kawa-COVID-19): a multicentre cohort. Ann Rheum Dis 2020; 79 (08) 999-1006
• 24 Kaushik S, Aydin SI, Derespina KR. et al. Multisystem inflammatory syndrome in children associated with severe acute respiratory syndrome coronavirus 2 infection (MIS-C): a multi-institutional study from New York City. J Pediatr 2020; 224: 24-29
• 25 Cheung EW, Zachariah P, Gorelik M. et al. Multisystem inflammatory syndrome related to COVID-19 in previously healthy children and adolescents in New York City. JAMA 2020; 324 (03) 294-296
• 26 Bautista-Rodriguez C, Sanchez-de-Toledo J, Clark BC. et al. Multisystem inflammatory syndrome in children: an international survey. Pediatrics 2021; 147 (02) e2020024554
• 27 Radia T, Williams N, Agrawal P. et al. Multi-system inflammatory syndrome in children & adolescents (MIS-C): a systematic review of clinical features and presentation. Paediatr Respir Rev 2021; 38: 51-57
• 28 García-Salido A, de Carlos Vicente JC, Belda Hofheinz S. et al; Spanish Pediatric Intensive Care Society working group on SARS-CoV-2 infection. Severe manifestations of SARS-CoV-2 in children and adolescents: from COVID-19 pneumonia to multisystem inflammatory syndrome: a multicentre study in pediatric intensive care units in Spain. Crit Care 2020; 24 (01) 666
• 29 Dufort EM, Koumans EH, Chow EJ. et al; New York State and Centers for Disease Control and Prevention Multisystem Inflammatory Syndrome in Children Investigation Team. Multisystem inflammatory syndrome in children in New York State. N Engl J Med 2020; 383 (04) 347-358
• 30 Carlotti APCP, de Carvalho WB, Johnston C. et al. Update on the diagnosis and management of COVID-19 in pediatric patients. Clinics (São Paulo) 2020; 75: e2353
• 31 Lima-Setta F, Magalhães-Barbosa MC, Rodrigues-Santos G. et al; Brazilian Research Network in Pediatric Intensive Care (BRnet-PIC). Multisystem inflammatory syndrome in children (MIS-C) during SARS-CoV-2 pandemic in Brazil: a multicenter, prospective cohort study. J Pediatr (Rio J) 2021; 97 (03) 354-361
• 32 Henderson LA, Canna SW, Friedman KG. et al. American College of Rheumatology clinical guidance for multisystem inflammatory syndrome in children associated with SARS-CoV-2 and hyperinflammation in pediatric COVID-19: version 2. Arthritis Rheumatol 2021; 73 (04) e13-e29
• 33 Ouldali N, Toubiana J, Antona D. et al; French Covid-19 Paediatric Inflammation Consortium. Association of intravenous immunoglobulins plus methylprednisolone vs immunoglobulins alone with course of fever in multisystem inflammatory syndrome in children. JAMA 2021; 325 (09) 855-864
• 34 Son MBF, Murray N, Friedman K. et al; Overcoming COVID-19 Investigators. Multisystem inflammatory syndrome in children - initial therapy and outcomes. N Engl J Med 2021; 385 (01) 23-34