MIS-C, MIS-A cohorts show symptomatic resolution in children, less success in adults
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In a cohort of four children and four adults with multisystem inflammatory syndrome, children generally had superior outcomes after discharge, noted a speaker at the 2021 North American Young Rheumatology Investigator Forum.
“First, I do think we have to define this — of course, the first distinguishing factor between multisystem inflammatory syndrome in adults and children is age, with the age cutoff here being 21 years,” Michael Loncharich, MD, of Walter Reed National Military Medical Center, in Bethesda, Maryland, told attendees at the forum. “Fever is another difference. In adults, fever is not part of the criteria, whereas in children it is — and notably in children subjective fever is permitted for these criteria.”
“In terms of symptomatology, it’s pretty similar for adults and children,” he added. “We expect to see severe illness defined as requiring hospitalization involving at least two organ systems. One difference, again, is in adults we don’t count pulmonary involvement, as in adults it tends to lead to confounding diagnoses. We also expect to see evidence of laboratory inflammation, and of course a link to the SARS-CoV-2 virus. With adults, we’re a little more liberal — we expect the exposure to be within 12 weeks — whereas in children we are more strict — we expect it to be within the past 4 weeks.”
To present the hospitalization outcomes and management of multisystemic inflammatory syndrome in adults (MIS-A) and children (MIS-C), Loncharich and colleagues from Walter Reed analyzed clinical data from four juvenile cases and four adult cases. Data were extracted retrospectively from each patient’s initial COVID-19 diagnosis to their most recent outpatient follow up.
The researchers analyzed each patient’s demographics, comorbidities, MIS presentation, inpatient treatment, outpatient treatment and outcomes at follow up. Outcomes of interest included symptom persistence or resolution, laboratory abnormalities and radiographic findings.
According to Loncharich, 50% of the juvenile patients presented with shock. All the juveniles received intravenous immune globulin (IVIG), methylprednisolone, aspirin and anakinra (Kineret, Sobi). Glucocorticoids were tapered over 8 weeks in three of the children, and over 5 weeks in the remaining case. Meanwhile, aspirin was continued in two patients with coronary artery ectasia and discontinued at hospital discharge in the other two patients without coronary artery involvement. Lastly, anakinra was continued for 4 weeks in three patients, and for 8 weeks in 1 case.
Among the children with MIS-C, three experienced full symptomatic resolution 6 months after discharge with no residual laboratory abnormalities or radiologic changes. The remaining patient demonstrated minimal weakness at this time, although she was able to “return to playing sports at school,” Loncharich said.
Meanwhile, 75% of the adults presented with shock. Half received IVIG, 75% were treated with glucocorticoids tapered over 1 to 8 weeks, and 50% received aspirin continued 1 to 2 months following discharge.
All patients with MIS-A demonstrated residual symptoms. Two patients had persistent chest pain 3 months after discharge, despite normalization of laboratory abnormalities and radiographic changes. In addition, one patient experienced residual weakness and elevated C-reactive protein at 1 month after discharge. The remaining patient demonstrated persistent weakness and dyspnea on exertion at 6-month follow-up.
“In terms of presentation, the adults did have higher elevations of procalcitonin,” Loncharich said. “The pediatric patients had a lower time from the SARS-CoV-2 virus to the development of MIS. In terms of treatment, the pediatric patients received IVIG, anakinra and steroids — none of the adult patients received all of those medications.”
“In terms of outcomes, the children did better,” he added. “Three out of four were completely asymptomatic by 6 months, while two out of the four adults were asymptomatic by 6 months, and one adult — and presumably a second adult soon — has been medically retired from the military due to persistent symptoms.”
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Loncharich M. Multisystem Inflammatory Syndrome in Children and Adults: What Happens after Discharge? Presented at: North American Young Rheumatology Investigator Forum; August 11, 2021, Destin, Florida (hybrid meeting).
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