1
|
Benvenuto S, Avcin T, Taddio A. Multisystem inflammatory syndrome in children: A review. Acta Paediatr 2024; 113:2011-2023. [PMID: 38714363 DOI: 10.1111/apa.17267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 04/08/2024] [Accepted: 04/25/2024] [Indexed: 05/09/2024]
Abstract
AIM To comprehensively review the literature on multisystem inflammatory syndrome in children (MIS-C). METHODS Narrative review of relevant studies published between April 2020 and January 2024. RESULTS MIS-C is a SARS-CoV-2-related hyperinflammatory syndrome developing 2-6 weeks after COVID-19 in genetically susceptible individuals. Persisting fever, mucocutaneous manifestations, GI and cardiac involvement, together with lymphopenia and elevated inflammatory and cardiac markers are the main clinical features. It is believed to recognise some pathogenetic and clinical overlap with Kawasaki disease. New case definitions have been proposed after an assessment of the diagnostic performance of existing criteria; epidemiological criterion is however progressively losing its usefulness as the pandemic turns into an endemic and in the areas with the highest rates of COVID-19 vaccination. Current guidelines recommend both intravenous immunoglobulin and glucocorticoids in the first-line immunomodulatory treatment, mainly based on comparative retrospective cohorts; the actual role of biologics remains to be adequately established. Strict follow-up is mandatory, especially for those with severe cardiac involvement, as longitudinal studies evaluate the long-term evolution of cardiac damage. CONCLUSION In this paper, we review the epidemiological, pathogenetic, clinical and prognostic features of MIS-C, and outline the main questions which still remain unanswered after more than 3 years of research.
Collapse
Affiliation(s)
| | - Tadej Avcin
- Department of Allergology, Rheumatology and Clinical Immunology, University Children's Hospital, University Medical Center Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Andrea Taddio
- University of Trieste, Trieste, Italy
- Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
| |
Collapse
|
2
|
Tong T, Jin YH, Wang M, Gong FQ. Treatment of multisystem inflammatory syndrome in children. World J Pediatr 2024; 20:325-339. [PMID: 38509432 DOI: 10.1007/s12519-024-00798-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/29/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Multisystem inflammatory syndrome in children (MIS-C), a relatively uncommon but severe pediatric complication, is associated with coronavirus disease 2019 (COVID-19). A variety of treatment approaches, including intravenous immunoglobulins (IVIGs), glucocorticoids (GCs) and biologic agents, such as anakinra and infliximab, have been described for the management of COVID-19-related MIS-C. Anticoagulant therapy is also important. However, a well-developed treatment system has not been established, and many issues remain controversial. Several recently published articles related to the treatment of MIS-C have been released. Hence, in this review, we identified relevant articles published recently and summarized the treatment of MIS-C more comprehensively and systematically. DATA SOURCES We reviewed the literature on the treatment of MIS-C through 20 September 2023. The PubMed/Medline, Web of Science, EMBASE, and Cochrane Library databases were searched with the combination of the terms "multisystem inflammatory syndrome", "MIS-C", "PIMS-TS", "therapy", "treatment", "drug", "IVIG", "GCs", "intravenous immunoglobulin", "corticosteroids", "biological agent", and "aspirin". RESULTS The severity of MIS-C varies, and different treatment schemes should be used according to the specific condition. Ongoing research and data collection are vital to better understand the pathophysiology and optimal management of MIS-C. CONCLUSIONS MIS-C is a disease involving multiple systems and has great heterogeneity. With the accumulation of additional experience, we have garnered fresh insights into its treatment strategies. However, there remains a critical need for greater standardization in treatment protocols, alongside the pressing necessity for more robust and meticulously conducted studies to deepen our understanding of these protocols. Supplementary file1 (MP4 208044 kb).
Collapse
Affiliation(s)
- Tong Tong
- Department of Cardiology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, No. 3333 Binsheng Road, Hangzhou, 310052, China
| | - Yi-Hua Jin
- Department of Cardiology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, No. 3333 Binsheng Road, Hangzhou, 310052, China
| | - Min Wang
- Department of Cardiology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, No. 3333 Binsheng Road, Hangzhou, 310052, China
| | - Fang-Qi Gong
- Department of Cardiology, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, No. 3333 Binsheng Road, Hangzhou, 310052, China.
| |
Collapse
|
3
|
Henderson LA. COVID-19-Related Multi-systemic Inflammatory Syndrome in Children (MIS-C). ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1448:409-425. [PMID: 39117830 DOI: 10.1007/978-3-031-59815-9_28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
Multisystem inflammatory syndrome in children (MIS-C) is a severe complication of SARS-CoV-2 infections in children. This syndrome manifests about a month after the initial viral infection and is characterized by fever, multiorgan dysfunction, and systemic inflammation. This chapter will review the emergence, epidemiology, clinical characteristics, diagnosis, pathophysiology, immunomodulatory treatment, prognosis, outcomes, and prevention of MIS-C. While the pathophysiology of MIS-C remains to be defined, it is a post-infection, hyperinflammatory syndrome of childhood with elevated inflammatory cytokines.
Collapse
Affiliation(s)
- Lauren A Henderson
- Division of Immunology, Boston Children's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
4
|
Tsoukas P, Yeung RSM. Kawasaki Disease-Associated Cytokine Storm Syndrome. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1448:365-383. [PMID: 39117827 DOI: 10.1007/978-3-031-59815-9_25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
Kawasaki disease (KD) is a hyperinflammatory syndrome manifesting as an acute systemic vasculitis characterized by fever, nonsuppurative conjunctival injection, rash, oral mucositis, extremity changes, and cervical lymphadenopathy. KD predominantly affects young children and shares clinical features and immunobiology with other hyperinflammation syndromes including systemic juvenile idiopathic arthritis (sJIA) and multisystem inflammatory syndrome in children (MIS-C). Cytokine storm syndrome (CSS) is an acute complication in ~2% of KD patients; however, the incidence is likely underestimated as many clinical and laboratory features of both diseases overlap. CSS should be entertained when a child with KD is unresponsive to IVIG therapy with recalcitrant fever. Early recognition and prompt institution of immunomodulatory treatment can substantially reduce the mortality and morbidity of CSS in KD. Given the known pathogenetic role of IL-1β in both syndromes, the early use of IL-1 blockers in refractory KD with CSS deserves consideration.
Collapse
Affiliation(s)
- Paul Tsoukas
- Division of Rheumatology, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Rae S M Yeung
- Division of Rheumatology, The Hospital for Sick Children, Toronto, ON, Canada.
- Department of Paediatrics, Institute of Medical Science, University of Toronto, Toronto, ON, Canada.
- Department of Immunology, University of Toronto, Toronto, ON, Canada.
| |
Collapse
|
5
|
Akkoyun EB, Most Z, Katragadda H, Yu A, Nassi L, Oakman N, Ginsburg S, Maamari M. Impact of anakinra use on clinical outcomes in children with moderate or severe multisystem inflammatory syndrome in children: a propensity score matched retrospective cohort study. Pediatr Rheumatol Online J 2023; 21:141. [PMID: 37996856 PMCID: PMC10666339 DOI: 10.1186/s12969-023-00924-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/08/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND The treatment of children with multisystem inflammatory syndrome in children (MIS-C) related to SARS-CoV-2 infection involves immunomodulatory therapies such as IVIG and steroids. Anakinra, an interleukin-1 receptor inhibitor, has also been used, but its effectiveness is not established yet. As optimal regimens for MIS-C remain unknown, we aimed to assess the effect of anakinra in reducing hospital stay in patients with MIS-C. METHODS We included children admitted from May 2020 to May 2021 diagnosed with MIS-C based on CDC criteria. The exposure of interest was anakinra use at any point during admission. The anakinra exposed group and the anakinra unexposed group were propensity score matched based on demographic and clinical severity indicators at initial presentation. Our primary outcome was length of hospital stay. Secondary outcomes were duration of vasoactive support, vasoactive inotropic score (VIS), level of respiratory support, time to fever resolution, reduction of CRP levels, and length of ICU stay. We used Wilcoxon rank sum, t-test, Chi square and Fisher's exact tests. RESULTS Of 138 children diagnosed with MIS-C, 79% had moderate or severe illness and 41% received anakinra. Of those, 31 patients who received anakinra were propensity score matched to 31 who did not. The length of stay in the hospital but not in the ICU was longer in the anakinra group. There were no differences in median duration of vasoactive support, fever resolution, CRP reduction, or VIS. CONCLUSIONS In patients with moderate to severe MIS-C, use of anakinra was associated with longer duration of hospital stay.
Collapse
Affiliation(s)
- Esra B Akkoyun
- Department of Pediatrics, Children's Medical Center, 1935 Medical District Dr. Dallas, Dallas, TX, USA.
- University of Texas Southwestern, Dallas, TX, USA.
| | - Zachary Most
- Department of Pediatrics, Children's Medical Center, 1935 Medical District Dr. Dallas, Dallas, TX, USA
- University of Texas Southwestern, Dallas, TX, USA
| | - Harita Katragadda
- Department of Pediatrics, Children's Medical Center, 1935 Medical District Dr. Dallas, Dallas, TX, USA
- University of Texas Southwestern, Dallas, TX, USA
| | - Andrew Yu
- Department of Pediatrics, Children's Medical Center, 1935 Medical District Dr. Dallas, Dallas, TX, USA
- University of Texas Southwestern, Dallas, TX, USA
| | - Lorien Nassi
- Department of Pediatrics, Children's Medical Center, 1935 Medical District Dr. Dallas, Dallas, TX, USA
- University of Texas Southwestern, Dallas, TX, USA
| | - Nicole Oakman
- Department of Pediatrics, Children's Medical Center, 1935 Medical District Dr. Dallas, Dallas, TX, USA
- University of Texas Southwestern, Dallas, TX, USA
| | - Sarah Ginsburg
- Department of Pediatrics, Children's Medical Center, 1935 Medical District Dr. Dallas, Dallas, TX, USA
- University of Texas Southwestern, Dallas, TX, USA
| | - Mia Maamari
- Department of Pediatrics, Children's Medical Center, 1935 Medical District Dr. Dallas, Dallas, TX, USA
- University of Texas Southwestern, Dallas, TX, USA
| |
Collapse
|
6
|
Chang JC, Young CC, Muscal E, Sexson Tejtel SK, Newhams MM, Kucukak S, Crandall H, Maddux AB, Rowan CM, Halasa NB, Harvey HA, Hobbs CV, Hall MW, Kong M, Aguiar CL, Schuster JE, Fitzgerald JC, Singh AR, Wellnitz K, Nofziger RA, Cvijanovich NZ, Mack EH, Schwarz AJ, Heidemann SM, Newburger JW, Zambrano LD, Campbell AP, Patel MM, Randolph AG, Son MBF. Variation in Early Anakinra Use and Short-Term Outcomes in Multisystem Inflammatory Syndrome in Children. Arthritis Rheumatol 2023; 75:1466-1476. [PMID: 36908050 PMCID: PMC10495537 DOI: 10.1002/art.42495] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 02/03/2023] [Accepted: 03/09/2023] [Indexed: 03/14/2023]
Abstract
OBJECTIVE Evidence regarding effectiveness of interleukin-1 receptor antagonism in multisystem inflammatory syndrome in children (MIS-C) is lacking. We characterized variation in initial treatment with anakinra and evaluated cardiovascular outcomes associated with adding anakinra to standard initial therapy. METHODS We conducted a retrospective cohort study of MIS-C cases in a US surveillance registry from November 2020 to December 2021. Day 0 was the first calendar day of immunomodulatory treatment. Factors associated with initial anakinra use (days 0-1) were identified. We compared cases in patients ages 2-20 years receiving intravenous immunoglobulin (IVIG) and glucocorticoids versus anakinra plus IVIG and/or glucocorticoids on days 0-1, using inverse probability weighting to balance disease severity. Primary outcomes were vasopressor requirement on day 3 and impaired left ventricular ejection fraction on days 3-4. The secondary outcome was 50% reduction in C-reactive protein on day 3. RESULTS Among 1,516 MIS-C cases at 44 sites, 193 (13%) patients received anakinra alone or with other immunomodulators as initial treatment (range 0-74% by site). Site accounted for 59% of residual variance in anakinra use. After balancing disease severity, initial treatment with anakinra plus IVIG and/or glucocorticoids (n = 121) versus IVIG plus glucocorticoids (n = 389) was not associated with significant differences in vasopressor requirement (25.6% versus 20.1%, respectively; risk ratio [RR] 1.27 [95% confidence interval (95% CI) 0.88-1.84]), ventricular dysfunction (33.7% versus 25.7%, respectively; RR 1.31 [95% CI 0.98-1.75]), or C-reactive protein reduction. CONCLUSION We identified substantial variation in initial anakinra use in a real-world population of children with MIS-C, but no average short-term improvement in cardiovascular outcomes associated with early addition of anakinra to IVIG and/or glucocorticoids compared to IVIG and glucocorticoids alone.
Collapse
Affiliation(s)
- Joyce C Chang
- Division of Immunology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Cameron C Young
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Eyal Muscal
- Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Sara K Sexson Tejtel
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas
| | - Margaret M Newhams
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Suden Kucukak
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Hillary Crandall
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah and Primary Children's Hospital, Salt Lake City, Utah
| | - Aline B Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora
| | - Courtney M Rowan
- Division of Pediatric Critical Care Medicine and Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis
| | - Natasha B Halasa
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Helen A Harvey
- Department of Critical Care Medicine, Rady Children's Hospital-San Diego, San Diego, California
| | - Charlotte V Hobbs
- Division of Infectious Disease, Department of Pediatrics, University of Mississippi Medical Center, Jackson
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Michele Kong
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham
| | - Cassyanne L Aguiar
- Department of Pediatric Rheumatology, Children's Hospital of The King's Daughters, Eastern Virginia Medical School, Norfolk
| | - Jennifer E Schuster
- Division of Pediatric Infectious Disease, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri
| | - Julie C Fitzgerald
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Aalok R Singh
- Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Kari Wellnitz
- Division of Pediatric Critical Care, Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City
| | - Ryan A Nofziger
- Division of Critical Care Medicine, Akron Children's Hospital, Akron, Ohio
| | - Natalie Z Cvijanovich
- Division of Critical Care Medicine, UCSF Benioff Children's Hospital Oakland, Oakland, California
| | - Elizabeth H Mack
- Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston
| | - Adam J Schwarz
- Division of Critical Care Medicine, Children's Hospital Orange County, Orange, California
| | - Sabrina M Heidemann
- Division of Pediatric Critical Care Medicine, Children's Hospital of Michigan, Central Michigan University, Detroit
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, and Departments of Pediatrics and Anaesthesia, Harvard Medical School, Boston, Massachusetts
| | - Mary Beth F Son
- Division of Immunology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
7
|
Harahsheh AS, Portman MA, Khoury M, Elias MD, Lee S, Lin J, McCrindle BW. Management of Multisystem Inflammatory Syndrome in Children: Decision-Making Regarding a New Condition in the Absence of Clinical Trial Data. Can J Cardiol 2023; 39:803-814. [PMID: 36455760 PMCID: PMC9705008 DOI: 10.1016/j.cjca.2022.11.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/22/2022] [Accepted: 11/24/2022] [Indexed: 11/30/2022] Open
Abstract
Multisystem inflammatory syndrome in children (MIS-C) is a new illness that evolved during the COVID-19 pandemic with initial reports of severe disease including use of extracorporeal membrane oxygenation and death. Institutions rapidly assembled task forces to develop treatment algorithms. At the national/international levels, collaboratives and associations assembled consensus writing groups to draft guidelines. These guidelines and algorithms were initially on the basis of expert opinion and small case series. Some groups used the Delphi approach, and the resultant guidelines often mimicked those for other conditions that resembled MIS-C, like Kawasaki disease (KD). For instance, intravenous immunoglobulin (IVIG), a known effective treatment for KD, was recommended for MIS-C. Early in the pandemic many favoured IVIG over steroids as first-line therapy. As evidence evolved so did some guidelines, which now endorse the dual use of IVIG with steroids as first-line therapy. In contrast, withholding immunotherapy became an option for some MIS-C patients with mild symptoms. Herein, we review guidelines and discuss the evidence informing early recommendations, how this has evolved, the role and limitations of expert opinion and observational data, and the importance of leveraging existing research infrastructures, such as the intensive care unit collaborative (Overcoming COVID-19 surveillance registry), and the International Kawasaki Disease Registry. Finally, we discuss strategies to rapidly develop, deploy, and adapt clinical trials evaluating the treatment of such rare conditions in children, which might include alternatives to conventional clinical trial design. The emergence of MIS-C during the COVID-19 pandemic has highlighted unmet needs regarding research of a new condition.
Collapse
Affiliation(s)
- Ashraf S Harahsheh
- Division of Cardiology, Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | | | - Michael Khoury
- Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Matthew D Elias
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Simon Lee
- The Heart Center at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Justin Lin
- Labatt Family Heart Centre, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Brian W McCrindle
- Labatt Family Heart Centre, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
8
|
Yap RXL, Leung BPL, Howe HS, Loh ME, Young BE, Fan BE, Lim XR. Immune and coagulation profiles in 3 adults with multisystem inflammatory syndrome. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2023. [DOI: 10.47102/annals-acadmedsg.2022290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
Introduction: There is a paucity of information on the cytokine, complement, endothelial activation, and coagulation profiles of multisystem inflammatory syndrome in adults (MIS-A), a rare but serious complication following recovery from SARS-CoV-2 infection. We aim to examine the immune biomarker and coagulation profiles in association with the clinical presentation and course of MIS-A.
Method: The clinical features of MIS-A patients admitted to our tertiary hospital were documented. Their levels of interleukin (IL)-1β, IL-6, IL-10, IL-17, IL-18, interferon-α (IFN-α), IFN-γ, interferon gamma-induced protein 10 (IP-10), tumour necrosis factor (TNF)-α, monocyte chemoattractant protein (MCP)-1, complement activation product (complement 5a [C5a]), and endothelial biomarker intercellular adhesion molecule-1 (ICAM-1) levels were assayed. The haemostatic profile was assessed with standard coagulation testing and thromboelastography.
Results: Three male patients were diagnosed with MIS-A at our centre from January to June 2022 with a median age of 55 years. All had tested positive for SARS-CoV-2 12–62 days prior to MIS-A presentation, with gastrointestinal and cardiovascular systems as the most commonly involved. Levels of IL-6, IL-10, IL-18, IP-10 and MCP-1 were raised whereas IL-1β, IFN-α, IFN-γ, IL-17 and TNF-α remained normal. Markedly elevated levels of C-reactive protein (CRP), ferritin and ICAM-1 were present in all. C5a was elevated in 2 patients. A hypercoagulable state was demonstrated by raised levels of D-dimer, factor VIII, von Willebrand factor antigen, and ristocetin cofactor with corresponding raised parameters in thromboelastography in the 2 patients who had their coagulation profile assessed.
Conclusion: MIS-A patients demonstrate activation of pro-inflammatory cytokines, endotheliopathy, complement hyperactivation and hypercoagulability.
Keywords: COVID-19, cytokines, hypercoagulability, hyperinflammatory syndrome
Collapse
|
9
|
Pinninti S, Hebson C, Collins J, Trieu C, Boppana S, Buchfellner M, Seripin C, Yarbrough A, Poole C, Ross S, James S, Hutto C, Boppana S. Impact of Severe Acute Respiratory Syndrome Coronavirus 2 Variants on Short- and Mid-term Cardiac Outcomes in Multisystem Inflammatory Syndrome in Children. Open Forum Infect Dis 2023; 10:ofad009. [PMID: 36686629 PMCID: PMC9850272 DOI: 10.1093/ofid/ofad009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 01/09/2023] [Indexed: 01/13/2023] Open
Abstract
Cardiac outcomes of 131 children with multisystem inflammatory syndrome (MIS-C) were examined. The majority of the cohort was male (66.4%) and half were Black (49.6%). Cardiac involvement was evident in 25% of the cohort at diagnosis. Favorable short- and mid-term outcomes were documented on follow-up, irrespective of the severe acute respiratory syndrome coronavirus 2 variants causing the infection.
Collapse
Affiliation(s)
- Swetha Pinninti
- Correspondence: Swetha Pinninti, MD, Division of Pediatric Infectious Diseases, University of Alabama at Birmingham, CHB 114A, 1600 7th Ave S, Birmingham, AL 35233 (); Suresh Boppana, MD, Heersink School of Medicine I, University of Alabama at Birmingham, CHB 114B, 1600 6th Ave S, Birmingham, AL 35233 ()
| | - Camden Hebson
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jacqueline Collins
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Connie Trieu
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - Sushma Boppana
- National Institutes of Health Medical Scientist Training Program, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Markus Buchfellner
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | | | - Claudette Poole
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Shannon Ross
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Scott James
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Cecelia Hutto
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Suresh Boppana
- Correspondence: Swetha Pinninti, MD, Division of Pediatric Infectious Diseases, University of Alabama at Birmingham, CHB 114A, 1600 7th Ave S, Birmingham, AL 35233 (); Suresh Boppana, MD, Heersink School of Medicine I, University of Alabama at Birmingham, CHB 114B, 1600 6th Ave S, Birmingham, AL 35233 ()
| |
Collapse
|
10
|
Estrada-Luna D, Carreón-Torres E, González-Reyes S, Martínez-Salazar MF, Ortiz-Rodríguez MA, Ramírez-Moreno E, Arias-Rico J, Jiménez-Osorio AS. Nutraceuticals for Complementary Treatment of Multisystem Inflammatory Syndrome in Children: A Perspective from Their Use in COVID-19. Life (Basel) 2022; 12:life12101652. [PMID: 36295088 PMCID: PMC9605437 DOI: 10.3390/life12101652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 11/24/2022] Open
Abstract
Multisystem inflammatory syndrome in children (MIS-C) has been widely reported in some children diagnosed with SARS-CoV-2. Clinical signs of MIS-C are manifested at 2 to 4 weeks after SARS-CoV-2 infection, where elevated biomarkers of inflammation and cardiac dysfunction are the hallmark of this syndrome when infection or exposure to SARS-CoV-2 has been confirmed. However, after two years of acknowledgment, MIS-C treatment is still under research to reach safety and effectiveness in the acute phase in children. Therefore, in this review, we discuss the potential use of natural compounds with antioxidant and anti-inflammatory effects to reduce collateral damage caused by hyperinflammation in MIS-C pathology for new research in treatment and interventions.
Collapse
Affiliation(s)
- Diego Estrada-Luna
- Área Académica de Enfermería, Instituto de Ciencias de la Salud, Universidad Autónoma del Estado Hidalgo, Circuito Ex Hacienda La Concepción S/N, Carretera Pachuca-Actopan, San Agustín Tlaxiaca 42160, Mexico
| | - Elizabeth Carreón-Torres
- Department of Molecular Biology, Instituto Nacional de Cardiología Ignacio Chávez, Juan Badiano 1, Sección XVI, Tlalpan, Mexico City 14080, Mexico
| | - Susana González-Reyes
- Facultad de Medicina y Psicología, Universidad Autónoma de Baja California, Tijuana 22390, Mexico
| | - María Fernanda Martínez-Salazar
- Facultad de Ciencias del Deporte, Universidad Autónoma del Estado de Morelos, Av. Universidad No. 1001 Col. Chamilpa, Cuernavaca 62209, Mexico
| | - María Araceli Ortiz-Rodríguez
- Facultad de Nutrición, Universidad Autónoma del Estado de Morelos, Iztaccíhuatl 100 Col. Los Volcanes, Cuernavaca 62350, Mexico
| | - Esther Ramírez-Moreno
- Área Académica de Nutrición, Instituto de Ciencias de la Salud, Universidad Autónoma del Estado Hidalgo, Circuito Ex Hacienda La Concepción S/N, Carretera Pachuca-Actopan, San Agustín Tlaxiaca 42160, Mexico
| | - José Arias-Rico
- Área Académica de Enfermería, Instituto de Ciencias de la Salud, Universidad Autónoma del Estado Hidalgo, Circuito Ex Hacienda La Concepción S/N, Carretera Pachuca-Actopan, San Agustín Tlaxiaca 42160, Mexico
| | - Angélica Saraí Jiménez-Osorio
- Área Académica de Enfermería, Instituto de Ciencias de la Salud, Universidad Autónoma del Estado Hidalgo, Circuito Ex Hacienda La Concepción S/N, Carretera Pachuca-Actopan, San Agustín Tlaxiaca 42160, Mexico
- Correspondence: ; Tel.: +52-771-717-2000 (ext. 4323)
| |
Collapse
|
11
|
Remuzzi G, Schiaffino S, Santoro MG, FitzGerald GA, Melino G, Patrono C. Drugs for the prevention and treatment of COVID-19 and its complications: An update on what we learned in the past 2 years. Front Pharmacol 2022; 13:987816. [PMID: 36304162 PMCID: PMC9595217 DOI: 10.3389/fphar.2022.987816] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 09/12/2022] [Indexed: 12/15/2022] Open
Abstract
The COVID-19 Committee of the Lincei Academy has reviewed the scientific evidence supporting the efficacy and safety of existing and new drugs/biologics for the preventing and treating of COVID-19 and its complications. This position paper reports what we have learned in the field in the past 2 years. The focus was on, but not limited to, drugs and neutralizing monoclonal antibodies, anti-SARS-CoV-2 agents, anti-inflammatory and immunomodulatory drugs, complement inhibitors and anticoagulant agents. We also discuss the risks/benefit of using cell therapies on COVID-19 patients. The report summarizes the available evidence, which supports recommendations from health authorities and panels of experts regarding some drugs and biologics, and highlights drugs that are not recommended, or drugs for which there is insufficient evidence to recommend for or against their use. We also address the issue of the safety of drugs used to treat underlying concomitant conditions in COVID-19 patients. The investigators did an enormous amount of work very quickly to understand better the nature and pathophysiology of COVID-19. This expedited the development and repurposing of safe and effective therapeutic interventions, saving an impressive number of lives in the community as well as in hospitals.
Collapse
Affiliation(s)
- Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | | | - Maria Gabriella Santoro
- Department of Biology, University of Rome Tor Vergata, Rome, Italy
- Institute of Translational Pharmacology, CNR, Rome, Italy
| | - Garret A. FitzGerald
- Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Philadelphia, Philadelphia, PA, United States
| | - Gennaro Melino
- Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Carlo Patrono
- Department of Pharmacology, Catholic University of the Sacred Heart, Rome, Italy
| |
Collapse
|
12
|
Brück N, Schütz C, Kallinich T. Das Pädiatrische Inflammatorische Multisystem Syndrom (PIMS)
in der COVID-19 Pandemie. AKTUEL RHEUMATOL 2022. [DOI: 10.1055/a-1715-5027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
ZusammenfassungNach einer meist mild verlaufenden SARS-CoV-2-Infektion kommt es bei einem
kleinen Teil der Kinder nach einem Zeitraum von ca. 6–8 Wochen zu einer
ausgeprägten multisystemischen Hyperinflammation (Pediatriac
multisystemic inflammatory syndrome (PIMS)). Klinisch präsentieren sich
diese Patienten mit Zeichen eines Kawasaki-Syndroms bzw. eines toxischen
Schocksyndroms. Gerade die kardiale Manifestation mit einer deutlichen
Einschränkung der Herzfunktion erfordert in vielen Fällen eine
intensivmedizinische Behandlung.Die Pathophysiologie ist trotz des beeindruckenden Erkenntnisgewinns der letzten
1 ½ Jahre noch unklar. Möglicherweise spielen
Superantigene eine wesentliche Rolle, die T-Zellen an einer bestimmten
β-Kette des T-Zellrezeptors polyklonal stimulieren.Neben den z.T. intensivmedizinischen supportiven Maßnahmen werden zur
Kontrolle der Inflammation intravenöse Immunglobuline, Steroide und
Biologika eingesetzt.
Collapse
Affiliation(s)
- Normi Brück
- Klinik und Poliklinik für Kinder- und Jugendmedizin,
Universitätsklinikum Carl Gustav Carus an der Technischen
Universität Dresden, Dresden, Deutschland
| | - Catharina Schütz
- Klinik und Poliklinik für Kinder- und Jugendmedizin,
Universitätsklinikum Carl Gustav Carus an der Technischen
Universität Dresden, Dresden, Deutschland
| | - Tilmann Kallinich
- Charité – Universitätsmedizin Berlin, Klinik
für Pädiatrie mit Schwerpunkt Pneumologie, Immunologie und
Intensivmedizin, Berlin, Deutschland
- Deutsches Rheuma-Forschungszentrum Berlin, ein Institut der
Leibniz-Gemeinschaft, Berlin, Deutschland
| |
Collapse
|
13
|
Miyazato Y, Yamamoto K, Yamada G, Kubota S, Ishikane M, Sugiyama M, Ueno M, Matsunaga A, Miyoshi-Akiyama T, Ishizaka Y, Ohmagari N. Multisystem Inflammatory Syndrome in Adult after First Dose of mRNA Vaccine. Emerg Infect Dis 2022; 28:870-872. [PMID: 35148495 PMCID: PMC8962876 DOI: 10.3201/eid2804.212585] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
A 32-year-old man in Japan experienced respiratory failure after receiving the first dose of coronavirus disease (COVID-19) vaccine. He was treated with noninvasive ventilation and corticosteroids. Serologic test results suggested previous COVID-19; therefore, he received a diagnosis of multisystem inflammatory syndrome. COVID-19 vaccination could be a trigger for this condition.
Collapse
|
14
|
Henderson LA, Canna SW, Friedman KG, Gorelik M, Lapidus SK, Bassiri H, Behrens EM, Kernan KF, Schulert GS, Seo P, Son MBF, Tremoulet AH, VanderPluym C, Yeung RSM, Mudano AS, Turner AS, Karp DR, Mehta JJ. American College of Rheumatology Clinical Guidance for Multisystem Inflammatory Syndrome in Children Associated With SARS-CoV-2 and Hyperinflammation in Pediatric COVID-19: Version 3. Arthritis Rheumatol 2022; 74:e1-e20. [PMID: 35118829 PMCID: PMC9011620 DOI: 10.1002/art.42062] [Citation(s) in RCA: 128] [Impact Index Per Article: 64.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 12/22/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To provide guidance on the management of Multisystem Inflammatory Syndrome in Children (MIS-C), a condition characterized by fever, inflammation, and multiorgan dysfunction that manifests late in the course of SARS-CoV-2 infection. Recommendations are also provided for children with hyperinflammation during COVID-19, the acute, infectious phase of SARS-CoV-2 infection. METHODS The Task Force is composed of 9 pediatric rheumatologists and 2 adult rheumatologists, 2 pediatric cardiologists, 2 pediatric infectious disease specialists, and 1 pediatric critical care physician. Preliminary statements addressing clinical questions related to MIS-C and hyperinflammation in COVID-19 were developed based on evidence reports. Consensus was built through a modified Delphi process that involved anonymous voting and webinar discussion. A 9-point scale was used to determine the appropriateness of each statement (median scores of 1-3 for inappropriate, 4-6 for uncertain, and 7-9 for appropriate). Consensus was rated as low, moderate, or high based on dispersion of the votes. Approved guidance statements were those that were classified as appropriate with moderate or high levels of consensus, which were prespecified before voting. RESULTS The guidance was approved in June 2020 and updated in November 2020 and October 2021, and consists of 41 final guidance statements accompanied by flow diagrams depicting the diagnostic pathway for MIS-C and recommendations for initial immunomodulatory treatment of MIS-C. CONCLUSION Our understanding of SARS-CoV-2-related syndromes in the pediatric population continues to evolve. This guidance document reflects currently available evidence coupled with expert opinion, and will be revised as further evidence becomes available.
Collapse
Affiliation(s)
| | - Scott W. Canna
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine
| | - Kevin G. Friedman
- Boston Children's Hospital and Harvard Medical SchoolBostonMassachusetts
| | - Mark Gorelik
- Morgan Stanley Children’s Hospital and Columbia UniversityNew YorkNew York
| | - Sivia K. Lapidus
- Joseph M. Sanzari Children’s Hospital at Hackensack University Medical Center and Hackensack Meridian School of MedicineHackensackNew Jersey
| | - Hamid Bassiri
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine
| | - Edward M. Behrens
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine
| | - Kate F. Kernan
- University of Pittsburgh School of MedicinePittsburghPennsylvania
| | - Grant S. Schulert
- Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of MedicineCincinnatiOhio
| | - Philip Seo
- Johns Hopkins University School of MedicineBaltimoreMaryland
| | - Mary Beth F. Son
- Boston Children's Hospital and Harvard Medical SchoolBostonMassachusetts
| | - Adriana H. Tremoulet
- University of California San Diego and Rady Children’s Hospital San DiegoCalifornia
| | | | - Rae S. M. Yeung
- The Hospital for Sick Children and University of TorontoTorontoOntarioCanada
| | | | | | - David R. Karp
- University of Texas Southwestern Medical CenterDallas
| | - Jay J. Mehta
- Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine
| |
Collapse
|
15
|
Gowin E, Toczyłowski K, Sulik A, Wysocki J, Januszkiewicz-Lewandowska D. The Role of Glucocorticoids in the Treatment of Multisystem Inflammatory Syndrome (MIS-C)—Data from POLISH MIS-C Registry. CHILDREN 2022; 9:children9020178. [PMID: 35204900 PMCID: PMC8870526 DOI: 10.3390/children9020178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/23/2022] [Accepted: 01/26/2022] [Indexed: 12/15/2022]
Abstract
Background: Multisystem inflammatory syndrome (MIS-C) is a condition related to COVID-19. It’s most significant feature is cardiac involvement. Methods: We have analyzed data from 42 hospitals in the Polish MIS-C Registry. To compare the effect of GCS on fever, we formed two groups: the first treated with IVIG and the second treated with IVIG+GCS. Results: There were 111 boys and 56 girls; the mean age was 8.57 years. All the patients were treated with IVIG: 76 patients with IVIG only, and 91 patients with IVIG+GCS. There were no statistically significant differences between the groups regarding age, gender, BMI, or inflammatory markers. Methylprednisolone was the most common drug (80%). Echocardiographic abnormalities on admission were more prevalent in the IVIG+GCS group. Mean time from IVIG infusion to subsidence of fever was 1.1 days, and 1.5 for those in the IVIG+GCS group. Conclusions: GCS are commonly used in the treatment of MIS-C patients in Poland. Various GCS regimens are used, from a single dose to a month-long therapy. Children with lower lymphocyte levels and cardiac abnormalities on an echocardiographic examination performed on admission were more likely to receive GCS+IVIG. The effect of GCS is difficult to access as patients were not randomly assigned to receive the treatment.
Collapse
Affiliation(s)
- Ewelina Gowin
- Health Promotion Department, Poznan University of Medical Sciences, Fredry 10, 61-701 Poznan, Poland;
- Correspondence: ; Tel.: +48-605-723-017
| | - Kacper Toczyłowski
- Department of Pediatric Infectious Diseases, Medical University of Bialystok, Waszyngtona 17, 15-274 Bialystok, Poland; (K.T.); (A.S.)
| | - Artur Sulik
- Department of Pediatric Infectious Diseases, Medical University of Bialystok, Waszyngtona 17, 15-274 Bialystok, Poland; (K.T.); (A.S.)
| | - Jacek Wysocki
- Health Promotion Department, Poznan University of Medical Sciences, Fredry 10, 61-701 Poznan, Poland;
| | - Danuta Januszkiewicz-Lewandowska
- Department of Pediatric Oncology, Hematology and Transplantology, Poznan University of Medical Sciences, Szpitalna 27/33, 60-572 Poznan, Poland;
| |
Collapse
|
16
|
Rajebhosale P, Mohamed M, Swilem M, Abdelmogheth A, Nabawi M, Farahat AA, Alsabbagh W, Lanqawi N, Addas H. Clinical profile and immediate outcome of the multisystem inflammatory syndrome in children: Retrospective observational single center study from the United Arab Emirates. JOURNAL OF PEDIATRIC CRITICAL CARE 2022. [DOI: 10.4103/jpcc.jpcc_22_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
17
|
Yamaguchi Y, Takasawa K, Irabu H, Hiratoko K, Ichigi Y, Hirata K, Tamura Y, Murakoshi M, Yamashita M, Nakatani H, Shimoda M, Ishii T, Udagawa T, Shimizu M, Kanegane H, Morio T. Infliximab treatment for refractory COVID-19-associated multisystem inflammatory syndrome in a Japanese child. J Infect Chemother 2022; 28:814-818. [PMID: 35125343 PMCID: PMC8784439 DOI: 10.1016/j.jiac.2022.01.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 01/11/2022] [Accepted: 01/14/2022] [Indexed: 12/17/2022]
Abstract
Patients with multisystem inflammatory syndrome in children (MIS-C) can develop clinical features resembling Kawasaki disease (KD). A full picture of MIS-C in East Asia which has higher incidence of KD than other regions remains unclear. We report on a 15-year-old Japanese boy with refractory MIS-C who was successfully treated with infliximab. A Japanese boy who was diagnosed with coronavirus disease 2019 (COVID-19) before a month developed MIS-C with fulfilling six principal symptoms of KD. Laboratory data showed extreme hyperferritinemia (11,404 ng/mL), besides lymphopenia and thrombocytopenia. The patient was refractory to initial therapy with intravenous immunoglobulin (IVIG; 2 g/kg), aspirin, and prednisolone. He was therefore administered a second IVIG (2 g/kg) and infliximab (5 mg/kg) on days 7 and 8 from the onset of fever, respectively, which resulted in an improvement of clinical symptoms. Only four Japanese cases with MIS-C were reported and all of them were responsive to IVIG. The hyperferritinemia in this case was distinctive from previously reported MIS-C cases in Japan and other cohorts and may be associated with refractoriness to IVIG therapy. Marked elevation of circulating ferritin levels is known to be induced by tumor necrosis factor-α, which plays a key role in the pathogenesis of both KD and MIS-C. Thus, for MIS-C patients with hyperferritinemia, early intervention with adjunctive infliximab may induce a more rapid resolution of inflammation and improve outcome. Because MIS-C may be heterogeneous with respect to immunopathology, genetic background, clinical phenotypes and response to therapies, optimized treatment strategies according to immunopathogenesis are required.
Collapse
|
18
|
Brisca G, Consolaro A, Caorsi R, Pirlo D, Tuo G, Campanello C, Castagnola E, Moscatelli A, Gattorno M, Ravelli A. Timely Recognition and Early Multi-Step Antinflammatory Therapy May Prevent ICU Admission of Patients With MIS-C: Proposal for a Severity Score. Front Pediatr 2021; 9:783745. [PMID: 34988039 PMCID: PMC8721096 DOI: 10.3389/fped.2021.783745] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 11/30/2021] [Indexed: 12/19/2022] Open
Abstract
In this observational study, we report the clinical, therapeutics and outcome features of 23 patients with multisystem inflammatory syndrome (MIS-C) who have been treated in Gaslini Children Hospital (Genoa, Italy) with a multistep antinflammatory treatment protocol, based on disease severity at admission. Patients were initially assigned to four severity classes on admission and treated accordingly. The therapeutic options ranged from IV immunoglobulin alone to a combination of IVIG plus pulses of methylprednisolone plus anakinra for patients with marked cardiac function impairment or signs of macrophage activation syndrome, with rapid treatment escalation in case of inadequate therapeutic response. With the application of this therapeutic strategy, no patient required admission to Intensive Care Unit (ICU) or invasive mechanical ventilation, and no inotropic drugs administration was required. Early aggressive treatment of MIS-C, with therapeutic interventions modulated based on the severity of clinical manifestations may help to prevent the progression of the inflammatory process and to avoid the need of admission to the ICU. A timely intervention with anti-IL-1 blockers can play a pivotal role in very severe patients that are at risk to have an incomplete response to immunoglobulins and steroids.
Collapse
Affiliation(s)
- Giacomo Brisca
- Terapia Semintensiva, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Alessandro Consolaro
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genoa, Italy.,Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DiNOGMI), Università Degli Studi di Genova, Genoa, Italy
| | - Roberta Caorsi
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Daniela Pirlo
- Terapia Semintensiva, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Giulia Tuo
- UOC Cardiologia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Claudia Campanello
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DiNOGMI), Università Degli Studi di Genova, Genoa, Italy
| | - Elio Castagnola
- UOC Malattie Infettive, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | | | - Marco Gattorno
- Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genoa, Italy.,Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DiNOGMI), Università Degli Studi di Genova, Genoa, Italy
| | - Angelo Ravelli
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DiNOGMI), Università Degli Studi di Genova, Genoa, Italy.,Direzione Scientifica, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| |
Collapse
|