Understanding MIS-C: Everything You Need to Know

The general trends for coronavirus disease 2019 (COVID-19) started looking better for the past few days: infections, hospitalisations and deaths have been plummeting, as more vaccines are administered and—perhaps more important—the country’s major internal shortage seems to be diminishing at least slightly. But children’s hospitals are seeing something that has given medical experts pause: a surge in multisystem inflammatory syndrome (MIS-C), a newly recognised, potentially serious syndrome that happens to children who’ve gotten exposed to the Coronavirus. Dr Sivaranjani Santosh MBBS, MD (Paediatrics), a Pediatric consultant at Magna Centres and Rainbow Hospitals, with more than 14 years of experience in the field, tells You & I that this effect that COVID-19 has on children hasn’t been given much attention as far as raising awareness is concerned, but it’s a serious matter. According to Dr Sivaranjani, MIS-C “is a condition where different body parts can become inflamed, including the heart, lungs, kidneys, brain, skin, eyes, or stomach organs; and also lead to disturbances in the blood clotting system” She admits we don’t “yet know what exactly causes MIS-C. However, most children reported to be having MIS-C have tested positive for SARS CoV2 virus, or had been around someone with COVID-19.” Although doctors suspect a connection between the two conditions, there are many unanswered questions, and information is changing rapidly. In this in-depth interview, Dr Sivaranjani reveals some of the symptoms, treatments, and worries about the illness currently associated with MIS-C, also called pediatric multisystem inflammatory syndrome temporally Associated with SARS-COV-2 (PIMS-TS), “which can be fatal in kids.” 

Dr Sivaranjani Santosh - MBBS, MD (Paediatrics)

Many are understandably concerned about the life-threatening MIS-C. What do we know and don’t know about this condition?
Infection preventionists have been watching this since the beginning of COVID 19. It is called MIS-C, which is a multisystem inflammatory syndrome in children. Although not so common, it can either happen after kids got affected with COVID 19 and if they have not, it can also happen through someone else in the house who contracted the virus.

So why so much emphasis is being laid on it despite it being not so common? First thing first, we see it more nowadays since a large number of families got affected with Covid. Second, early diagnosis guarantees almost 100% cure. In contrast, delayed diagnosis can lead to severe complications like shock, multi-organ failure and death. They can also lead to complications, like aneurysms of the coronaries, which can cripple the child for life or predisposes the child to future risk of a heart attack. 

Essentially, the kids may show up usually with just fever alone. The second pattern is fever with Kawasaki syndrome features that are either redness of eyes and tongue or swelling in the neck on one side (lymph node swelling) or rash all over the body or peeling of the skin of the finger tips; and development of coronary aneurysms putting the child at future risk for heart attack and sudden death. The third type is fever, with at least two organ systems getting involved. It can be the heart (lowering of the function of the heart muscle and problems with the rhythm of the heart or coronary aneurysms) and the kidney (kidney failure); kidney and the brain (meningitis and seizure); and brain and the stomach (appendicitis and intussusception). So, it can lead to multiorgan failure, shock and death. So, parents must watch for symptoms suggestive of MIS-C  and get the kids to the hospital for proper treatment. 

And with COVID, we know we’re looking for the majority of the time the beginnings of respiratory tract infection. Just slight congestion, some people have. Other people go on to develop worse respiratory issues. With MIS-C, we don’t always see respiratory involvement. It’s more of the fever with rash and other symptoms resulting from  the involvement of atleast two organ systems,  but it can be fatal in kids. And I don’t think enough awareness is being raised about it. We’ve seen this MIS-C in infants and newborns, and it can happen up to age 21. It’s more common in kids around the nine and ten year age group and the adolescents.

What is the underlying mechanism behind MIS-C in children with COVID-19?
It is suggested that the Corona virus  stimulates our immune system in such a way that there is an exaggerated response and release of  a lot of cytokines (inflammation), which potentially can affect every organ of the body, including the inner lining of the blood vessels, kidney, intestine, heart, and brain.

Parents need to realise that the frequency of children getting admitted because of MIS-C has increased. What used to be one hospital admission in a week earlier is now every day. And that’s a reason why a high index of suspicion is necessary. So even if any of the family members got Coronavirus infection or if the children themselves contracted, usually within four weeks, MIS-C is likely to develop. Even if you do not have a definite history of contracting COVID, should we not suspect MIS-C? Given the pandemic, it is possible that the child has contacted somebody with COVID unknowingly; the person could be asymptomatic as well. So even if there is no history of coronavirus exposure, any fever above 100.4 degrees Fahrenheit (38 degrees Centigrade) lasting more than 24 to 72 hours, especially if associated with neck pain, stomach pain with vomiting and diarrhoea, neck pain, rash and other features of Kawasaki syndrome, chest discomfort, we need to keep MIS-C as one of the diagnoses. So in case, the parents suspect MIS-C, they need to consult the doctor immediately. They need to take the child to the emergency if troubled breathing, dullness, drowsiness,seizures,  low oxygen level (SpO2 less than 95 percent), cold and pale/blue hands and feet, severe stomach pain with vomiting and diarrhoea, are there.

To map out COVID exposure, the doctors will first take the Corona contact history and  to help determine if they had the infection antibody and a rRT PCR test would be recommended, and if they are positive, MIS-C will be strongly considered as the  diagnosis. Then, in addition to tests for ruling out other infections, doctors will order blood tests like CRP-ESR-LDH-FERRITIN D-dimer and fibrinogen tests to check the level of inflammation and also tests to check  how the blood is clotting. Echo heart and ECG will be done to look at the heart. Ultrasound of the abdomen may be done. Xray of the chest and CT scan of the chest may be done if needed.

It’s been compared to another rare disease in children, Kawasaki disease. How are they similar and what separates them?
We have known about Kawasaki disease for a long time. It too may be triggered by viruses among other triggers and is again due to an immunological response and inflammation mainly affecting blood vessels, and we know how to treat it effectively. On the other hand, MIS-C is a newly recognized syndrome and thought to be triggered by COVID-19 because of the temporal association. Although it has some similarities to Kawasaki, some details are different as well. Kawasaki disease is more common in children less than five years of age whereas MIS-C is more common with children around ten years of age and with adolescents. Both MIS-C and Kawasaki disease are equally  likely to cause coronary aneurysms, but  MIS-C is more likely to affect the heart muscle, rhythm, and valves compared to Kawasaki. MIS-C is more likely to affect other organs aswell and is more likely to result in shock and multi organ failure.

Adults with co-morbidities are likely to develop more complications with COVID-19. Is that also true for children with MIS-C?
As far as severity of Covid is concerned, any kid with comorbidities like kidney or congenital heart disease are likely to develop more severe complications than a healthy child. Developing MIS-C is not related to a child having underlying health issues, anybody can develop the syndrome. The risk of complications will definitely be more though, if the child is having comorbidities.

Do you worry about the impact that COVID-19 is having on vaccinations for kids?
There are many vaccinations like those protecting the children from  dangerous diseases like diphtheria, polio, tetanus, and measles, and diseases like the seasonal flu and the pneumonia, that  are supposed to be prioritized. Definitely the parents need to plan in such a way that they get the vaccinations done on time and at centres where COVID precautions are followed. So, get the vaccines, but take precautions.

Coming to the Covid vaccination, will the delay have any repercussion?
Definitely, the Corona vaccine will help slow down this pandemic, and we have already started the Covaxin trials for children. So when it gets approved, the parents should be proactive in getting the vaccination for their children. Once the risk of severe infection or symptomatic infection comes down, the spread comes down automatically. So naturally, if the infection rate comes down, indirectly MIS-C cases will come down. However, there is a risk of contracting the virus from asymptomatic people, hence we should keep MIS-C in mind irrespective of the vaccination status. Parents need to understand that vaccination only protects from severe infection, but not the asymptomatic infection. So an adult who is jabbed can still be a carrier and can infect a child, and that child can still be asymptomatic and later develop MIS-C.