Six-month cardiac outcomes in children with multisystem inflammatory syndrome in children

An opportunity missed: Strengthening health system data on multisystem inflammatory syndrome in children from low- and middle-income countries in Asia

Background

Multisystem inflammatory syndrome in children (MIS-C) is a severe complication associated with SARS-CoV-2 infection. The clinical epidemiology of MIS-C is not completely understood in low- and middle-income countries (LMICs) due to limited reporting, including in Asia where there was a substantial burden of COVID-19. We aimed to discuss the challenges of diagnosing MIS-C and factors which may cause children from Asian LMICs to have an increased risk of MIS-C.

Methods

Not applicable.

Results

The burden of MIS-C in Asian LMICs may be disproportionately high due to underlying risk factors, resource-limited health systems, and the increased infectivity and transmissibility of recent SARS-CoV-2 variants. Complex clinical features of MIS-C contributed to missed or delayed diagnosis and treatment, while underlying risk factors including ethnicity, chronic health conditions, and socioeconomic factors may have predisposed children in Asian LMICs to MIS-C.

Conclusions

There was a lack of data on the clinical epidemiology of MIS-C in Asian LMICs during the COVID-19 pandemic, despite reports of higher paediatric mortality rates compared to high-income countries. This highlights the need for LMICs to have strong surveillance systems to collect high-quality and timely data on newly emerging complications associated with a pandemic, such as MIS-C. This will lead to rapid understanding of these emerging complications, and inform clinical management, disease prevention and health system planning.

Evolution of Cardiovascular Findings in Multisystem Inflammatory Syndrome in Children (MIS-C) Across COVID-19 Variants: Common Trends and Unusual Presentations

Multisystem inflammatory syndrome in children (MIS-C) is a rare condition following COVID-19 infection. Cardiac involvement is common and includes left ventricular systolic dysfunction, cardiac marker elevation, electrocardiogram (ECG) changes, and coronary artery dilation. This single-center retrospective cohort study compares cardiovascular disease between three major SARS-CoV-2 variants and describes the evolution of findings in medium-term follow-up. Of 69 total children (mean age 9.2 years, 58% male), 60 (87%) had cardiovascular involvement with the most common features being troponin elevation in 33 (47%) and left ventricular dysfunction in 22 (32%). Based on presumed infection timing, 61 patients were sorted into variant cohorts of Alpha, Delta, and Omicron. Hospitalization was longer for the Delta group (7.7 days) vs Alpha (5.1 days, p = 0.0065) and Omicron (4.9 days, p = 0.012). Troponin elevation was more common in Delta compared to Alpha (13/20 vs 7/25, p = 0.18), and cumulative evidence of cardiac injury (echocardiographic abnormality and/or troponin elevation) was more common in Delta (17/20) compared with Alpha (12/25, p = 0.013) or Omicron (8/16, p = 0.034). Forty-nine (77%) of the original cohort (n = 69) had no cardiac symptoms or findings beyond 3 months post-hospitalization. Cardiac MRI was performed in 28 patients (between 3 and 6 months post-hospitalization) and was normal in 25 patients (89%). The differences in the variant cohorts may be due to alteration of the immune landscape with higher severity of COVID-19 infection. Despite overall reassuring cardiac outcomes, it is important to note the variability of presentation and remain vigilant with future variants.

Overview of COVID-19 Infection, Treatment, and Prevention in Children

Coronavirus disease 2019 (COVID-19), caused by the novel respiratory virus-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-was declared a global pandemic by the World Health Organization on 11 March 2020. Since then, substantial gains have been made in our understanding of COVID-19 epidemiology, disease presentation, and management. While children tend to have less severe disease courses compared to adults, children can still develop severe COVID-19 infections, particularly in those with underlying medical conditions such as obesity, chronic lung disease, or prematurity. In addition, children are at risk of severe complications of COVID-19 infection, such as multisystem inflammatory syndrome in children (MIS-C) or long COVID. The case definitions of MIS-C and long COVID have continued to evolve with the increased understanding of these new entities; however, improved methods of diagnosis and determination of the optimal management are still needed. Furthermore, with the continued circulation of SARS-CoV-2 variants, there remains a need for clinicians to remain up-to-date on the latest treatment and prevention options. The purpose of this review is to provide an evidence-based review of what we have learned about COVID-19 in children since the start of the pandemic and how best to counsel children and their families on the best methods of prevention.