Kawasaki syndrome or MIS-C: Children recovering from COVID-19 also face the brunt of the disease

Editor's Note: This story was originally published on 29 June 2020, after early reports of Kawasaki-like symptoms in children in Mumbai. It has republished on 20 July after several reports from hospitals in Chennai, Delhi and other cities of the COVID-related Kawasaki-like syndrome, which experts are calling MIS-C.  

By and large, COVID-19 has not been infecting younger children as they have a stronger immune systems and almost no risk of co-morbidities. However, around April, children in the US started developing inflammatory symptoms that were similar to those of Kawasaki syndrome. There have been several reports of cases among children in France, Italy, Spain and Britain that have shown similar symptoms.

New York Governor Andrew Cuomo said the symptoms included "inflammation of the blood vessels, which in turn could cause heart problems". The syndrome also shares symptoms with toxic shock and Kawasaki disease, which is associated with fever, skin rashes, swelling of the glands, and in severe cases, inflammation of arteries of the heart.

Now, similar concerns have been raised by several hospitals in Delhi, who have reported many children with COVID-19 having symptoms similar to those associated with the rare illness called Kawasaki disease.

Children were thought to be practically immune to COVID-19 infection since they had better immune systems and almost no comorbidities.

A study published in June this year in The Journal of American Medical Association termed this new symptom as “Pediatric Multi-System Inflammatory Syndrome Potentially Associated with COVID-19” (PIMS). The WHO called it Multisystem Inflammatory Syndrome in Children (MIS-C). PIMS, or MIS-C, is a new condition observed in children who have recovered, or are recovering, from COVID-19.

The CDC had put out new guidelines to help doctors identify these new conditions among children. The guidance defines the condition predominantly in children and adults under 21, and manifests in the form of a fever, inflammation, illness severe enough to require hospitalization and impairment of multiple organs such as the heart, kidneys, blood vessels, gut, skin and nerves. Doctors should rule out other plausible diagnoses, as per the guidance, and the children should test positive for a current infection or for antibodies that show they have had a recent infection.

Also read: What is Kawasaki disease and how is it linked to COVID-19 in children?

Patterns in imaging findings

A recent study conducted by the doctors at the Evelina London Children’s Hospital in London, UK has examined the spectrum of imaging findings in children with these new inflammatory conditions.

It began when the hospital saw a rise in children who were admitted with a variety of symptoms that including fever, headaches, abdominal pain, rash, and conjunctivitis. While laboratory results showed that they shared some similarities to those of Kawasaki syndrome or toxic shock syndrome, the symptoms were atypical and more severe.

"Our hospital saw an unprecedented cluster of children presenting with MIS-C, a new hyperinflammatory syndrome in children related to the current COVID-19 pandemic—the recognition of which led to a national alert,” said Shema Hameed the lead author and the consultant pediatric radiologist at the hospital in a statement.

The researchers performed a 'retrospective review' of the 'clinical, laboratory and imaging findings' of the first 35 children, under age 17, who were admitted to the hospital and met the classic definition for MIS-C. The children included 27 boys and eight girls, with an average age of 11 years old.

A retrospective review is a process of determining coverage after treatment has been given. They analyse patient care data to support the coverage determination process.

According to a press statement, the study found that the children that fever was most common in 33 children (94 percent). Gastrointestinal symptoms including abdominal pain, vomiting, and diarrhoea were present in 30 (86 percent) of the children, the rash was seen in 13 children (37 percent) and conjunctivitis in 9 children (26 percent). Twenty-one children (60 percent) were in shock.

Clinical status was severe enough to warrant management in the pediatric intensive care unit in 24 of 35 children (69 percent), of which 7 (20 percent) required mechanical ventilation to compensate for lung function and 20 (57 percent) required inotropic support, to artificially force heart contractions. Two children required further intensive care to treat severe hypoxia-related heart dysfunction. Lab tests also revealed that all of the children had abnormal white blood cell counts.

The study also found a pattern in scans of the childrens' lungs. In children that were part of the study, scans revealed airway inflammation, rapidly-progressing pulmonary edema, coronary artery aneurysms, and extensive abdominal inflammatory changes within the right iliac fossa. The iliac fossa is a large, smooth, concave surface on the internal surface of the ilium bone. The ilium is part of the three fused bones that make up the hip bone.

Pulmonary edema is a condition caused by excess fluid in the lungs and is usually caused by a heart condition.

The findings of this study have been published in the journal Radiology.

Also Read: What is a multi-system inflammatory syndrome in children (MIS-C) and how is it linked to COVID-19?

MIS-C cases in India

Some Delhi hospitals are treating young patients, mostly children, who have been exhibiting symptoms of Kawasaki-like syndrome and there is presumably a link with COVID-19, doctors told PTI.

Pediatric experts at a leading hospital here said in nearly fifty percent of these cases, patients become "more serious" than those suffering from regular Kawasaki disease.

Recently, the Indian Express reported that a 14-year-old girl was admitted to a Mumbai hospital with rashes and high fever, classic symptoms of Kawasaki syndrome. She has been transferred to the ICU on Friday, last week as her conditions had worsened. She has been tested positive for COVID-19 after her father also tested positive. She has been put on a “high dose” of steroids, immunoglobulins, and immunosuppressant drug tocilizumab.

“It is not Kawasaki disease, but similar to it,” said Dr Tanu Singhal, a paediatric infectious disease expert at the Kokilaben hospital, Mumbai as patients who are infected with Kawasaki patients also exhibiting red tongue and eyes. “Children mostly develop the Kawasaki-like symptoms two-three weeks after a Covid-19 infection.”

Singhal also said she has seen two other cases in Mumbai - one at SRCC Hospital and another at a private hospital in Jogeshwari. Both the patients had inflammation, fever and rashes but had tested negative for Covid-19.

An eight-year-old boy from Chennai was the first case, that was reported in India, to be infected with MIS-C. The boy was in a critical condition and was admitted to the ICU in Kanchi Kamakoti CHILDS Trust Hospital, Chennai, reported Hindustan Times. He showed symptoms of toxic shock syndrome and Kawasaki disease according to the pre-print paper published in the journal of Indian Paediatrics on 10 May. He was also treated with "intravenous immunoglobulin and tocilizumab” and recovered within two weeks.

Delhi's Children's Hospital Kalawati Saran has seen six cases of children who tested positive for coronavirus - experiencing fever, respiratory and gastrointestinal issues, rashes which are associated with Kawasaki disease.

Also Read: ‘Straight-Up Fire’ in His Veins: A personal recount of a New York teen who battled the new COVID-19 syndrome