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

History and Physical Exam

Focus on identifying fever with multisystem organ involvement including cardiac, renal, respiratory, hematological, gastrointestinal, dermatological, and/or neurological manifestations, as well as alternative diagnoses. Diarrhea and abdominal pain seem to be the most consistent features in reported cases, followed by conjunctivitis, rash and mucous membrane changes. Shock is also present in a majority of reported cases and may have components of cardiogenic, distributive, and hypovolemic shock.

Review recent history of documented/suspected COVID-19 infection or COVID-19 exposure in the past 4-6 weeks prior to the onset of symptoms, as well as other exposures, including travel, pets, and other ill contacts.

Identify other infectious conditions and diagnoses that may explain fever and/or systemic inflammation.

CDC Health Advisory – MIS

Review differential diagnosis to exclude alternative causes for the patient’s signs and symptoms. Refer to Kawasaki Disease Pathway and Sepsis Pathway as clinically indicated.

History and Physical
History	Number of days, height of fever Hydration status, urine output History of any Clinical Features as below Cardiac, renal, respiratory, hematological, gastrointestinal, dermatological, neurological Note Diarrhea and abdominal pain seem to be the most consistent features in the reported cases Followed by conjunctivitis, rash and mucous membrane changes Recent/current antibiotics, anti-pyretics, steroids PMH, allergies Epidemiologic Link to COVID-19 History of COVID-19 disease or compatible syndrome History of close contact with known COVID-19 in past 4 weeks
Physical	General appearance Vital signs, O₂ requirement Concern for Severe Sepsis/Shock ED Sepsis Triage, Features of shock in children Cardiac Concern for acute heart failure, hypotension, tachypnea, tachycardia, poor perfusion, shock Neurologic Headache, irritability, lethargy, altered mental status/confusion, neck stiffness, cranial nerve palsies Dermatologic Rash: polymorphic, maculopapular, petechial, erythroderma NOT vesicular Peripheral edema Gastrointestinal Diarrhea, abdominal pain/tenderness, vomiting, GI bleeding Renal Oliguria Hematologic Signs of easy bleeding/bruising, petechiae Respiratory Cough, difficulty breathing, tachypnea Other Conjunctivitis, which may be bulbar or limbic-involving, without exudate Cervical lymphadenopathy – large, unilateral lymphadenopathy is infrequently reported; diffuse or shotty lymphadenopathy variably observed Oral/pharyngeal mucosal changes, sore throat Extremity Swelling

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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.