Multisystem Inflammatory Syndrome (MIS-C) Clinical Pathway — Emergency, ICU and Inpatient

ED Evaluation for Possible Multisystem Inflammatory Syndrome in Children (MIS-C)

On April 27th, an alert was issued by the Pediatric Intensive Care Society (PICS) in the UK, reporting a rise in the number of patients presenting with a multisystem inflammatory process, which appeared to share features with toxic shock syndrome, atypical Kawasaki disease, and Kawasaki shock syndrome.

Multiple reports from the US and Europe have since emerged; this syndrome was referred to variably as “Pediatric Multisystem Inflammatory Syndrome (PMIS)” or “Pediatric Inflammatory Multisystem Syndrome Temporally associated with SARS-CoV-2 (PIMS-TS).”

On May 14th , the CDC published a Health Advisory proposing a case definition which they termed “Multisystem Inflammatory Syndrome in Children (MIS-C).

CDC Health Advisory – MIS

MIS-C Information

Case Definition

Note that this definition is for surveillance, and subtle differences exist between criteria prompting evaluation for MIS-C and this definition.

An individual aged < 21 years presenting with fever¹, laboratory evidence of inflammation², and evidence of clinically severe illness requiring hospitalization, with multisystem (≥ 2) organ involvement (cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic or neurological); AND
No alternative plausible diagnoses; AND
Positive for current or recent SARS-CoV-2 infection by RT-PCR, serology, or antigen test; or COVID-19 exposure within the 4 weeks prior to the onset of symptoms

Fever > 38.0°C for ≥ 24 hours, or report of subjective fever lasting ≥ 24 hours
Including, but not limited to, one or more of the following: an elevated C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), fibrinogen, procalcitonin, d-dimer, ferritin, lactic acid dehydrogenase (LDH), or interleukin 6 (IL-6), elevated neutrophils, reduced lymphocytes and low albumin

Note

It is hypothesized that this inflammatory syndrome is an immune mediated vasculitis/vasculopathy following SARS-CoV-2 infection.

The guidance here is based on expert opinion derived from the small number of cases reported thus far.

As this guidance will evolve, consultation for further evaluation and treatment with ID, Rheumatology, Dysregulated Immune Response Team, Cardiology, Hematology, and Critical Care Medicine is important for individualized recommendations for suspected cases. The guidance here will be updated as new data, experience and consensus becomes available, so look for updates.

For patients whose presentation is consistent with Kawasaki Disease, please also refer to the Kawasaki Disease pathway as a resource for diagnosis, evaluation and treatment.

©2020 by Children's Hospital of Philadelphia, all rights reserved.
Use of this site is subject to the Terms of Use.

The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.