COVID-19 and multisystem inflammatory syndrome in children: Viva

Branching clinical structured oral on multisystem inflammatory syndrome in children: recognition of the toxic school-age child after COVID-19, differentiation from Kawasaki disease and toxic shock, the echocardiogram and cardiac biomarkers, cautious resuscitation, and immunomodulation.

branching clinical structured oral2 min readVerification in progress

Prompt

A previously well 9-year-old girl is brought to the emergency department with four days of persistent fever, abdominal pain, vomiting, and a polymorphous rash. Three weeks ago she had a mild febrile illness. She is toxic and drowsy, with conjunctivitis, red cracked lips, a heart rate of 160, a blood pressure of 84/48, and a capillary refill of 4 seconds. The examiner asks for your structured approach.

Branch 1: Recognising the post-COVID hyperinflammatory emergency

The candidate should immediately recognise that this school-age child with persistent fever, multiorgan involvement (gastrointestinal symptoms, mucocutaneous features, shock), and a SARS-CoV-2 exposure three weeks earlier has multisystem inflammatory syndrome in children until proven otherwise. The key discriminating feature is the temporal relationship: the recent febrile illness two to six weeks earlier is the trigger, and the current presentation is the delayed post-infectious hyperinflammatory phenotype, not acute COVID-19. [1]

The candidate should state that any school-age child with persistent fever and organ dysfunction in the weeks after a COVID-19 illness must be presumed to have multisystem inflammatory syndrome until proven otherwise, and that the first priority is resuscitation of the shock and the early echocardiogram, because cardiac involvement is what makes this condition lethal. The alternative of bacterial sepsis must be covered empirically while the workup proceeds. [1]

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References3Show ledger

[1]Feldstein LR Multisystem Inflammatory Syndrome in U.S. Children and Adolescents. N Engl J Med, 2020.PMID 32598831
[2]Davies P Intensive care admissions of children with paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) in the UK: a multicentre observational study. Lancet Child Adolesc Health, 2020.PMID 32653054
[3]Verdoni L An outbreak of severe Kawasaki-like disease at the Italian epicentre of the SARS-CoV-2 epidemic: an observational cohort study. Lancet, 2020.PMID 32410760