Severe COVID-19 in children: Now termed MIS-C


It was initially thought that children were primarily unaffected by COVID-19 and were asymptomatic carriers if they did have the disease. The rise of multisystem inflammatory syndrome in children (MIS-C) has radically changed this thinking.

In the May 2020 issue of Contemporary Pediatrics, Miranda Hester provided a brief report on a published article in Pediatrics  from March 16, 2020. The article provides the number of children in the Hubei region of China that presented with severe illnesses related to COVID-19 during the initial outbreak. Ms. Hester’s report is entitled: Severe COVID-19 cases are possible in children. Prior to the March 16th publication, the news media queried medical experts in the United States who believed that children were primarily unaffected by COVID-19. The thinking was that children may be asymptomatic carriers. However, large scale testing of children in the United States has not been performed, thus, actual data for children was and is unknown. On April 30, 2020 our New York City Chapter of the National Association of Pediatric Nurse Practitioners held a meeting on COVID-19 in children based on the best available evidence. At that meeting, a member briefly discussed a newly identified presentation of children with symptoms similar to Kawasaki disease. The next day, 4 cases of a Kawasaki-like syndrome were reported in New York City. Nineteen days later, on May 18, 2020, 147 children in New York City, New York, and 15 children in New Jersey have confirmed cases of this newly named disorder, multisystem inflammatory syndrome in children (MIS-C).1 Many other states are now reporting similar cases of MIS-C in children. 

Was the first case of MIS-C unrecognized in China?

Multisystem Inflammatory Syndrome in Children was not reported in any children in the first systematic review published on April 22, 2020, examining 18 published articles on children positive for COVID-19 during the initial outbreak in Wuhan, China.2 However, the authors reported a case of 1 infant presenting with pneumonia, complicated by shock and kidney failure, but successfully treated in the intensive care unit. The infant also had vomiting, diarrhea, fever, and pneumonia, complicated by shock with metabolic acidosis and kidney failure that required intensive care and assisted ventilation. This infant survived. Was this the actual first case worldwide of MIS-C?

Results of the first systematic review

Castagnoli’s et al. systematic review included data from 1065 children with COVID-19 infection in China with 444 cases in children aged younger than 10 years, and 553 children aged between 10 and 19 years. Further, the authors reported that the children presented with symptoms similar to the presentations in adult populations eg, fever, dry cough, fatigue, sore throat, headache, loss of taste and smell, and/or shaking chills. Chest x-ray findings reported bronchial thickening, ground-glass opacities, as well as inflammatory lung lesions. No other cases similar to the critically ill infant were reported. Further, the authors suggested that preliminary data from children who tested positive for COVID-19 and remained asymptomatic, might be a source of viral transmission.

So many questions: No definitive answers

How can we make sense of data on MIS-C as well as asymptomatic cases in children? What are we missing? Which children are most susceptible to MIS-C? Is it preventable? What do we need to know to keep children safe as well as prevent transmission from asymptomatic children to high-risk populations? Which children are the high-risk population for contracting MIS-C? Can this ever-evolving vicious virus be tamed and eliminated? The hope of a vaccine provides a light at the end of the dark tunnel for health care professionals on the front lines. 


1. Russo M. Up to 147 NYC kids sickened by severe new COVID Syndrome; 15 cases confirmed in NJ. NBC New York. Published May 18, 2020. Accessed May 26, 2020.


2. Castagnoli R, Votto M, Licari A, et al. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in children and adolescents: a systematic review. JAMA Pediatr. April 22, 2020. Epub ahead of print. doi: 10.1001/jamapediatrics.2020.1467

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Courtney Nelson, MD
Tina Tan, MD, FAAP, FIDSA, FPIDS, editor in chief, Contemporary Pediatrics, professor of pediatrics, Feinberg School of Medicine, Northwestern University, pediatric infectious diseases attending, Ann & Robert H. Lurie Children's Hospital of Chicago
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