Multisystem inflammatory syndrome in children (MIS-C) is linked to COVID-19, and, while rare, it is a serious syndrome. Fibi Attia, MD, MP, CIC, a member of Infection Control Today® (ICT®) Editorial Advisory Board, spoke with ICT about her research with George McSherry, MD, and Kathleen Julian, MD. This research is exclusive to ICT.
During the interview, Attia discussed the features, consequences, and results of MIS-C cases, with a specific emphasis on cardiac dysfunction. The focus was on the study's objectives and primary discoveries, emphasizing the significance of identifying MIS-C cases and the necessity for further research on COVID-19 vaccines.
ICT: Would you please explain what the multisystem inflammatory syndrome in children is, and how it relates to COVID-19 and pediatric patients?
Multisystem Inflammatory Syndrome in Children (MIS-C) at a tertiary level hospital, 2020-2022: Abstract
Fibi Attia, MD, MP, CIC; George McSherry, MD; Kathleen Julian, MD
Background: The Coronavirus Disease 2019 (COVID-19) pandemic has affected children as well as adults. While generally mild, COVID-19 can be severe in children, sometimes requiring hospitalization. Among the complications that can happen to individuals younger than 21 years old is the Multisystem Inflammatory Syndrome in Children (MIS-C); studies have estimated that MIS-C has occurred in 1 per 3,000 to 4,000 children and adolescents following COVID-19 infection.
Methods: ICD-10 codes were used to detect MIS-C cases through the discharge diagnosis. An alert would be sent to Infection Preventionists (IPs) through the surveillance software to detect those cases. Case report forms were completed by IPs for the identified patients who were admitted to our tertiary-level hospital during 2020-2022 and were sent to PA-DOH. We conducted descriptive statistics to characterize and estimate demographic differences and different body system involvement.
Results: Of the 35 identified MIS-C cases, 21 (60%) of the cases were White, 6 (17%) were Black and 8 (23%) were other, unknown, or Asian. Thirty of the patients (86%) were of non-Hispanic ethnicity, and 3 (9%) were of Hispanic ethnicity. Twenty of the patients (57%) were in the 10-18 age group, 12 (34%) were in the 5-9 age group, and 3 (9%) were in the 2-4 age group. Reviewing at the discharge summary, 32 (91%) patients had cardiac dysfunction, 29 (83%) had hematologic complications, 26 (74%) had GI involvement, 16 (46%) had dermatologic complications, 7 (20%) had respiratory manifestations, 5 (14%) had renal insufficiency, and 3 (8%) had neurologic symptoms. Twenty (57%) patients were admitted to the ICU of which 9 (45%) were females. After discharge, no readmissions related to MIS-C were reported for any of the patients.
Conclusion: Cardiac dysfunction is the most frequently identified complication among MIS-C patients. All of the identified cases survived; however, long-term outcomes are yet to be fully characterized.
Fibi Attia, MD, MP, CIC: We all know that the COVID-19 pandemic at the end of 2019 affected children as well as adults. While [COVID-19] was generally mild, when it affected the children, some of the children got severe syndromes, and they were hospitalized for that. Gladly, when we did our study in our tertiary level hospital from the year 2020 to 2022, we didn't have any after-discharge hospitalization for those kids. So those kids were good for the time being, and they didn't require any more hospitalization after discharge.
[MIS-C] is a syndrome that comes for some of the kids after they acquire COVID-19. We usually find the IgG positive for COVID-19. IgG means it's a chronic, not an acute. IgM is an acute one. Whenever we find COVID-19 IgG antibody in the children, the clinician will check for cardiovascular, neurology, [and gastrointestinal] GI system involvement.
MIS-C is well known, and the CDC would require us to inform them of those cases and then write down and fill out a paper form for that and send it back. That way, they get all the information needed, and they can deal with it whenever it happens. They can do more studies and see what's going on and how to deal with it. [Like,] what's the outcome of this syndrome? Those kinds of things that preventive medicine and clinicians [always] look.
ICT: What were the specific objectives of your study regarding MIS-C cases and children during those years?
FA: We wanted to know how many cases about [such as] racial [statistics]. Also, the age group that most affected children fell into. Also, the involvement of what system is the main thing. So we found out in our study that the cardiovascular is the most involved system, with a few changes in the heart and in the EKG echoes. After that, the kids would go on clinical appointments with physicians to follow up. By what we studied, there were no more hospitalizations, which meant it's a temporary change that happened, and when you deal with it the right way, then it goes away.
ICT: Please describe the methods that you employed to identify and collect data on these cases.
FA: Yes. What we did is that we used the ICD 10 codes to detect MIS-C cases whenever the kids are discharged. We have a software that surveillance software that detects if there is any positive lab results that happen in any of the patients that we have in the hospital. They send us notifications and alerts if there is a positive case, anything, any lab-positive thing. So we look at the IgG cases, the positive for COVID-19 cases, and I would keep them in a folder till the patient is discharged. Then when they are discharged, we'll go back and check if the ICD 10 would match the MIS-C. With the discharge diagnosis, if it matched, then this case should go further. And we should complete this form from the CDC and send it out to be investigated more.
ICT: How many were there?
FA: About 35 in the 2 years.
ICT: That's not too bad.
FA: I agree. It's not that many that happen to have MIS-C syndrome in children, but it is severe. That’s why it's irritating and disturbing.
ICT: What were the key demographic findings in your study, particularly in terms of age, ethnicity, and racial distribution?
FA: So, 60% were white. Age, most of them, like 40%, were in the 10 to 18 years of age. We are the age group of 2 to 4 [were] 10%. Most of them were white in their teens.
ICT: Is that what you expected?
FA: I'm not sure. I just went through the cases. So, I would know what kind of demographics are there? Because there are some studies that talk about demographics out there. But I wanted to check what our hospital had, just in case, to know what was going on.
ICT: Were there notable gender differences?
FA: Yes, 57 were male.
ICT: So, your study mentioned that no readmissions related to MIS-C were reported after discharge. Would you mind discussing the implications of this finding, and what it might suggest about the long-term outcomes of these MIS-C patients?
FA: This result is a more calming thing. You wonder if it's a permanent thing. You will see multiple admissions or at least deterioration for the patient. But luckily, we didn't find any of those 35 to be admitted again at the hospital. They all had clinic appointments as a follow-up for their syndromes for cardiac involvement, most likely. But looking at the charts, we didn't see any long-term [issue or] any disability related to this syndrome. So that made me think that it's a temporary thing that happened. Whenever you go in and intervene in the correct time, then it goes away.
ICT: In your conclusion, you mentioned that cardiac dysfunction is the most frequently identified complication among MIS-C patients. You have mentioned that here. Would you mind expanding on the significance of this finding and its implication for the clinical management of MIS-C patients?
FA: Yes, in most of the cases, they had changes in their Echo, or in their EKG studies. And this would make clinicians worried because whenever there is any change in the EKG or the Echo, then that means that the heart is not functioning right, especially in a previously healthy kid, with no issues at all, and then coming to the hospital requiring admission with a difference in the EKG readings. That is very disturbing. Whenever, even if it's an adult with some different EKG than the normal, like abnormal EKG, they would go into further studies. Till they find out what's the reason for those kids. There were found no reasons other than they had COVID-19 previously within like 28 days of this syndrome, and they found this involvement in the cardiovascular system, which made us [the investigators] link it to this COVID-19 because we don't have a lot of studies for that pandemic yet. It's so limited. We're trying to know what kind of infection is COVID-19? What does it do in your body? What does it do in the kid's body if they have this infection, some of the kids had nothing at all, maybe a little fever, maybe runny nose, and then they would develop this syndrome, which is terrifying. Because we have no idea what COVID-19 is doing in our bodies yet. So it is, it is a bad thing to find that it affects the heart. So that's why we tried to study more about kids especially. What effect does COVID-19 have on the heart specifically? Because it is the heart of everything, it's the core of everything.
ICT: That seems to be something that I've read, in many studies, that it affects the heart. Some people have discussed whether it comes from the vaccine. What do you think? What do you think [it matters] with whether they were vaccinated or not?
FA: Most of them are not, I would say; I don't want to say all of them, but most of them were not vaccinated because we studied that since 2020 when there was no vaccine yet. But we saw this syndrome in some of the kids. My belief is that it does something to the heart, but maybe it's doing something with the physiology of the heart for a little limited time, and then it may go back to normal. So that needs more studies to be done. But I don't think that the vaccine is the cause of that because we had cases before the vaccine development.
ICT: Speaking of future research, do you have any that you have planned to continue this study?
FA: For now, we didn't have more MIS-C cases that we know of. So that's a very good thing. Maybe a lot of kids have immunity already in developing their immune system, so they are fighting back. And they are not getting this syndrome, which is a very good thing, a very positive thing. Even if we are having an increase now in COVID-19 cases, but still, it's not as complicated as before. We're not seeing more admissions because of the COVID-19. I believe that most people already have their immunity built up.
ICT: What challenges did you encounter gathering this information and conducting the study? And how did you overcome them to make sure that you got the data that you needed?
FA: It is challenging to get the ICD 10 codes and to know what the discharge diagnosis is. You have to go into each chart of the patients and check, yes, this discharge diagnosis was MIS-C or maybe an alternative diagnosis. Sometimes, it's not the principal diagnosis, but it is an alternative one, which made it a little bit challenging overall. The surveillance software that we have is sending us alerts for IgG-positive patients, which made it easier for us to limit the number of cases that we have and the number of patient charts that we need. That was a little bit challenging, but it's a good thing to be challenged.
ICT: How do you feel that your study has contributed to the broader understanding of the impact of COVID-19 on the pediatric population? And what implications do you think that it will have? Or that it could have an impact on public health strategies in the future?
FA: I was trying to get as much data as I could in my study. So that it could help whoever is planning or doing research more depth that you would use my results in, some research to develop something that may help the kids in this period if they are having cardiac dysfunction for any reason, and [and the reason is] not known. Maybe we can think about COVID-19. And maybe we can think about MIS-C. It is one of the likely diagnoses of after COVID-19 infection. It may help in the resources that would come up one day.
Maybe I would worry about cardiac involvement, neurologic, or GI, I have to check all the systems because some kids have multisystem involvement, not just cardiac. So [our research] could be helpful, although it is a limited study. It's not a huge number of cases. But that's what we had in our hospital. Hopefully, it can help the researchers to prevent this kind of syndrome from happening from the beginning. Maybe they will develop something that would control COVID-19 cases, so the kids wouldn't develop [MIS-C] after infection.
ICT: Do you have anything else you'd like to add?
I would just like to thank you very much for this interview and for agreeing to talk about this study with me.