Children who become ill with COVID-19 sometimes develop a rare but serious reaction called multisystem inflammatory syndrome in children (MIS-C). This reaction causes various organs to become inflamed, including the heart, lungs, intestinal tract and brain. More than 600 cases of MIS-C were reported in the U.S. as of Aug. 20, 2020, most in minority populations.
On this Mayo Clinic Q&A podcast,
Emily R. Levy, M.D., a pediatric critical care and infectious disease expert at Mayo Clinic in Rochester, Minnesota, gives an overview of MIS-C ? including its similarities with Kawasaki disease.
This interview was recorded Aug. 31, 2020. Information in this podcast was accurate at the time of its posting. Due to the fluid nature of the COVID-19 pandemic, scientific understanding, guidelines and recommendations may have changed since the original publication date.
welcome everyone to Mayo Clinic Q and A. I'm Doctor Holly Nigga's Elka Multi system Inflammatory syndrome and Children, or Missy is a condition where different body parts can become inflamed. These can include the heart, the lungs, the brain and even the skin and the eyes. While we don't know the cause of Missy, there seems to be in association with Cove in 19 and here to discuss this with us today. This Mayo Clinic physician, Dr Emily Levy, a Dr Levy, is a pediatric critical care and a pediatric infectious disease specialist. Thanks for being here. Dr Levy, could you give us an overview of exactly what is Missy? I haven't heard of this, and I'm sure many of our listeners haven't and what's happening in the body when this occurs. Multi system inflammatory syndrome and Children, which I will call this see for the rest of the interview, is a pretty rare Onda. Serious condition. Um, it has to do with dis regulated inflammation Onda. What's happening in the body is that parts of the body, such as the heart, blood, vessels, kidneys or digestive system and even the brain can become inflamed. We first heard about missy in the pediatric world in April of 2020 when UK reports of previously healthy Children presenting with a severe inflammatory syndrome came out on. Initially, it was reported as having some Kawasaki disease like features, which I'll talk about a little bit more later in the interview on all of these Children had current or recent infection by stars Coronavirus two, otherwise known as Cove in 19. Um, as of August 20th, eso the most recent reporting date we have for this interview. There's been more than 600 cases of Misty in the United States. The CBC definition includes any individual under 21 years old with a fever laboratory. Evidence of inflammation two or more organ systems involved lab evidence of co vid 19 and importantly, no other plausible diagnosis. So here in the United States, most of the cases have been between one year old and 14 years old. The average age is eight years old that we're seeing more than 70% of our cases have been Hispanic Latino Children or non Hispanic black Children. So we're seeing this disease disproportionately affect minorities. Most Children developments see 2 to 4 weeks after their initial infection with Kobe 19 and again, the clinical presentation can vary quite a bit, but always includes fevers and then may have symptoms. Um, that indicates shock. So decreased heart function, poor blood pressure or profusion, different organs on multi organ or vascular disease. And that could be indicated by something like diarrhea or vomiting. Cough rash, red eyes, swollen hands, Onda on lab testing, elevated blood inflammatory markers. Actually, we do. We know why Cove in 19 is causing missy and patients, so we don't really know why this specific viruses triggering this immune or auto inflammatory reaction. And we also don't really know why Missy is more common in Children than in adults. Those air both, um, things that will really need to look into over the next couple of years or even decades as we're trying to learn more about this disease. What we do know is that it's been suspected for years that there's a viral trigger for Kawasaki disease, which again is somewhat similar to Miss C. Onda. That viral trigger has never been discovered, so it may be that Kobe, 19 is working as a similar viral trigger for this inflammatory condition. Well, you mentioned Kawasaki Disease. Could you tell us how this is different from Kawasaki disease? How do you know the difference? Initially, there were some major parallels between Misty and Kawasaki disease because some of the symptoms specifically, um conjuring title injection or read in the whites of your eyes. Rash and fever were very similar on DFA, those who are not as familiar with Kawasaki Disease. Kawasaki disease is also an inflammatory condition, which typically will present with multiple days of fever, red eyes rash and then may have swollen extremities a swollen tongue on DSA mother features that could indicate multi organ inflammation. However, as we've gathered more data about miss see, some major differences have emerged. And so it's no longer thought that this is, um, just another form of Kawasaki disease in these patients. So in comparison to Kawasaki disease, misty patients are older. They have more prominent gastrointestinal symptoms, so they're more likely tohave vomiting or diarrhea. They're more likely to present in shock, that is, with low blood pressure or cardiovascular symptoms, and then on lab testing, they're more likely to have a low lymphocyte count, So a low white blood count, specifically the lymphocyte what blood cells and more likely to have higher inflammatory markers. Unfortunately, like Children with Kawasaki disease, Children of Missy may develop coronary artery aneurysms on Beacon. Talk a bit more about the treatment for those later, um, but we would we would, uh, similarly follow those coronary artery aneurysms with echocardiograms. And they may need similar treatment to what we do right now with Children with Kawasaki disease. So you mentioned along the way multiple the signs and symptoms of Missy and I'm wondering, Is it safe to say that these people Children appear quite ill? Well, parents recognize this, and what should they dio? They suspect it always difficult within emerging disease or syndrome to capture exactly how Children are going to appear with the disease. Because there's some suspicion that what we're catching right now is the tip of the iceberg s O. That would be a way of saying what we're seeing the most of is the sickest group of these Children, which makes sense because those were the Children that are going to present to medical care. And perhaps there's many more Children out there who actually have some form of this syndrome but are not ill enough to either require hospitalization or critical care. Um, that being said, um, what we are seeing right now in terms of the signs and symptoms of Missy have mainly been characterized from inpatient Children or Children in I. C. E. O. S. And those Children are quite sick when they present so again they must have a fever. And right now, the CBC is defining that as a temperature greater than 38 0 for more than 24 hours. And then they must have to organ system involvement. And so, in a child that's going toe look, they're going toe look relatively ill to parents. They must have some sort of G I involvement. That's something like vomiting or diarrhea. They could have problems with their calculation or blood plotting system that could manifest is different skin rashes, swollen tongue or red mouth or red lips? Um, they may have neurologic symptoms that could manifest as a child, being too tired to awaken or otherwise confused, used and then a variety of other inflammatory related organ dysfunction. The signs that you mentioned earlier was a low loan for site count. I'm interested in that because obviously the inflammatory markers air high because we're talking about an inflammatory disorder. But why would some of the white blood cells below with their markers of inflammation? So it's not uncommon in viral illnesses or sepsis. So, for instance, ah, high inflammatory state in a child triggered by an infection for them to have this paradoxical immune response. And we actually see this across all sorts of infections or inflammatory conditions in Children, where they paradoxically actually have lower immune cells in terms of certain cells in the body. Some theories around that are that viruses can suppress the bone marrow or suppress the cells that make immune cells. Um, and other theories around it are that inflammation the inflammation cascade itself can suppress kind of mobilization of immune cells. But this isn't unique to Missy. Um, it's more that I mentioned it because it differentiates it from Kawasaki syndrome, where Children actually tend to have higher white blood cell counts or higher immune cell counts. And how do you treat Missy? And what happens if you don't? There is no specific evidence proven treatment from this. See, right now, that is, there's no medicine that cures Missy the Hallmark of Missy treatment is supportive care. Um, and so at this point, if you don't treat missy with any specific medication, it's expected to eventually resolved. But what's needed is often either inpatient hospitalization or even critical care. Hospitalization supportive care for Children who have missy to start to support them through the symptoms that are related to the disease. Eso in terms of the specifics about the types of supportive care that air typically required more than 50% of Children admitted to hospitals with Missy require. I see you level support and typically that involves cardiac or respiratory support interventions, even like a ventilator or medications that support the blood pressure. Typically, they should be managed by a multi disciplinary team of doctors, so that would include intensive ist and infectious disease doctors like myself, but also hematologist rheumatologist, immunologists and cardiologists are often involved. Um, if there's a lot of overlap with Kawasaki disease right now, we are sometimes trying some of the therapies that have been proven to help in Kawasaki disease. Most common, that would be immunoglobulin eso, antibodies from other patients in the community and aspirin to help with some of the clotting side effects you can have on Ben. In many cases, we are trying high dose steroids, which would suffer, trust me and information that's causing many of the problems in the symptoms. Um, some centers are using anti coagulation for these patients because they do seem more likely to clot just like we're seeing an adult patients with co vid. Um, there's no specific antiviral therapy indicated. Unfortunately, unlike an acute covert infection where you might try an antiviral medication, this isn't actually an infection with cove it It's a dis regulated inflammatory response after Cove it and so infections that treat the virus. Um, excuse me. Medications that treat the virus themselves don't work very well, but we sometimes do consider immuno modulator torrey agents. And these are a bit outside of the scope of this conversation, but their specific targeted biologics that can target certain areas of the inflammatory cascade. A little bit ago, you mentioned immuno globulin s, and I'm wondering, um, that may provoke some of our listeners. Toe Wonder is that the same is giving someone the convalescent plasma that we've heard so much about in the news that would be the right thing for them. toe Wonder about and something many physicians actually also asked me about. So in general, from Miss See, we're giving pool the I V I. G, which is a general immunoglobulin from the community. So it would be a normal person who probably has not had UM, CO vid 19 who was donating their pooled immunoglobulin, which is used in a variety of different conditions. And it's not clear how I v I G works in Kawasaki disease, but it does seem to decrease inflammation in many auto, inflammatory or autoimmune diseases. That's compared to convalescent plasma, which is targeted. Donation from people who have had co vid 19 often has tight Er's measured against Cove in 19. Andi, also at our center at least, has neutralizing tigers. Check against Cove in 19. Um, Interestingly, there's some theoretical concern about giving convalescent plasma in Children with Messi because people wonder if you gave them Covad 19 antibodies, would that kind of propagate this inflammatory response they're having? But the majority of the Children actually already have Kobe 19 antibodies, so the majority of them have had co vid 19 develop this inflammatory condition, and when you check, they actually have the Copa 19 antibody already. That's one of the ways we use to diagnose Smith to see. Is it anticipated that Children who develop Missy will recover fully? And is there any risk of permanent damage? Our long term illness? The vast majority of Children will eventually recover. There's overall been a very low death rate sorted. So less than 1% in the studies reported in both the United States and in Europe. Um, as you might guess, with a new disease that's only been around for three or four months now, we don't have very good long term data, but the long term data we have is optimistic. Um, and the other thing that we can speculate about is that typically, Kawasaki disease long term outcomes are quite good. Um, the biggest long term thing we see in our Kawasaki disease patients are coronary artery aneurysms, which kind of occasionally require long term monitoring with serial echocardiograms and sometimes even long term anti coagulation. What's a bit more difficult to speculate about in Missy Outcomes is many of the complications are going to be related to how sick the child would be while they were in the hospital. on what would be needed for supportive care on DSO. At this point, it's not really possible. The list percentages about long term outcomes. What we do know is that Children seem to be doing pretty well in the kind of medium term. Couple months of data we have last several months has been frightening. Andi, I think anxiety provoking for many and particularly when you consider your child or your grandchild becoming this ill, I'm sure that some of our listeners will wonder. Is there anything that I can do to prevent my child or my grandchild from developing Missy? Because Missy is thought to be a direct sick Well, I from co vid So an inflammatory reaction to having had covert 19 infection. The best way to prevent it is to prevent your child from being exposed or having Cove in 19 affection. And that would just be the simple kind of measures that have been recommended to most people in the population at this point to prevent exposure or contracting Cove in 19. And they include kind of simple infection control things like keeping your hands clean, avoiding people who are sick, whether or not they have a formal diagnosis of Cove in 19 practicing social distancing when possible, wearing of face mask when possible, even in a child. Cleaning and disinfecting high touch surfaces and washing clothing after being around people in public in a very close way where social distancing wasn't possible. Eso all of the kind of common sense things you do for your child normally, and particularly in the era of co bid night teen are things that would prevent them. Thio ever develop, Missy because they would hopefully prevent them toe ever developed Cove in 19? Well, I remember in the beginning watching the news and hearing. Essentially, the Children were developing Cove in 19 and clearly that was not the case. And I think this has been a really informative session for me and for our listeners, and I think a good reminder to use those universal precautions for Kogan 19 Prevention. Thanks so much for being here with us after leaving. Thank you so much for having me Our thanks to Mayo Clinic Pediatric Critical Care, an infectious disease specialist, Dr Emily Levy. I hope that you learned as much as I did today, and we wish you a wonderful day Mayo Clinic Q and A is a production of the Mayo Clinic News Network and is available wherever you get and subscribe to your favorite podcasts. To see a list of all male clinic podcasts, visit news network dot Mayo Clinic dot or GTA, then click on podcasts. Thanks for listening and be Well. We hope you'll offer a review of this and other episodes when the option is available. Comments and questions can also be sent to Mayo Clinic News Network at mayo dot e d u.