Abstract

Background

Multisystem inflammatory syndrome in children (MIS-C) has a temporal association with SARS-coronavirus 2 (SARS-CoV-2) infection and can present similarly to Kawasaki disease (KD). After the Centers for Disease Control and Prevention issued a MIS-C case definition in May 2020, we implemented local diagnostic and management strategies to standardize the care for patients with MIS-C encouraging limited laboratory evaluation of non-toxic patients presenting with a febrile illness. We then sought to re-evaluate our diagnostic and management recommendations to ensure appropriate resource utilization for children with MIS-C and KD.

Methods

Patients with MIS-C and KD were identified via convenience sampling of Pediatric Infectious Diseases clinical records at Inova Children’s Hospital from May 1, 2020 to August 28, 2020. Manual chart review was done to extract clinical points of interest and the two cohorts were compared with descriptive statistics. Abdominal symptoms included pain, emesis, and diarrhea. Respiratory symptoms included shortness of breath, tachypnea, cough, and need for mechanical ventilation. Musculoskeletal symptoms included pain and edema. Neurologic symptoms included headache, dizziness, altered mental status, and irritability.

Results

7 patients with KD and 14 patients with MIS-C were identified. No patients with KD had presenting hypotension and 9 patients with MIS-C had presenting hypotension (p < 0.01). Oral changes were seen in 5 patients with KD and 3 patients with MIS-C (p = 0.05). Conjunctival injection, rash, abdominal symptoms, musculoskeletal symptoms, and neurologic symptoms were seen in some patients with KD and MIS-C with no statistically significant occurrence of these symptoms between the two cohorts. The median initial absolute lymphocyte count was 2,860/µL in KD cases whereas it was 1,325/µL in MIS-C cases (p < 0.01). The median platelet count was 367,000/ µL in KD cases versus 193,000 in MIS-C cases (p = 0.03). The median initial C-reactive protein was 11.2 mg/dL in KD cases versus 23.2 mg/dL in MIS-C cases (p < 0.01). There was no statistically significant difference in the white blood cell count, erythrocyte sedimentation rate, alanine transaminase, B-natriuretic peptide, troponin I, or ferritin values between KD and MIS-C patients. Coronary artery dilation or prominence was seen in 4 patients with KD and in 8 patients with MIS-C (p > 0.99). There were no deaths.

Conclusions

Following national recognition of MIS-C we saw approximately 1 MIS-C case per week. Presenting hypotension, an absolute lymphocyte count less than 1400/µL, a platelet count less than 200,000/µL, and a CRP greater than 20 mg/dL best predicted MIS-C versus KD. The initial white blood cell count, alanine transaminase, erythrocyte sedimentation rate, B-natriuretic peptide, troponin I, ferritin, and initial coronary artery dilation did not readily distinguish KD from MIS-C. Thus, our diagnostic management recommending limited laboratory evaluation for non-toxic patients presenting with a febrile rash illness, fever and abdominal symptoms, or fever with conjunctival injection is reasonable.

中文翻译：

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#25：同时评估北弗吉尼亚儿童病例中的川崎病和多系统炎症综合征

摘要

背景

儿童多系统炎症综合征 (MIS-C) 与 SARS-冠状病毒 2 (SARS-CoV-2) 感染有时间关联，并且可能与川崎病 (KD) 相似。在疾病控制和预防中心于 2020 年 5 月发布 MIS-C 病例定义后，我们实施了本地诊断和管理策略，以规范对 MIS-C 患者的护理，鼓励对出现发热性疾病的无毒患者进行有限的实验室评估. 然后，我们试图重新评估我们的诊断和管理建议，以确保对患有 MIS-C 和 KD 的儿童进行适当的资源利用。

方法

MIS-C 和 KD 患者是通过对 2020 年 5 月 1 日至 2020 年 8 月 28 日在 Inova 儿童医院的儿科传染病临床记录的便利抽样来确定的。手动图表审查以提取临床兴趣点并比较两个队列用描述性统计。腹部症状包括疼痛、呕吐和腹泻。呼吸系统症状包括呼吸急促、呼吸急促、咳嗽和需要机械通气。肌肉骨骼症状包括疼痛和水肿。神经系统症状包括头痛、头晕、精神状态改变和易怒。

结果

确定了 7 名 KD 患者和 14 名 MIS-C 患者。没有 KD 患者出现低血压，9 名 MIS-C 患者出现低血压（p < 0.01）。在 5 名 KD 患者和 3 名 MIS-C 患者中观察到口腔变化（p = 0.05）。在一些 KD 和 MIS-C 患者中观察到结膜充血、皮疹、腹部症状、肌肉骨骼症状和神经系统症状，两个队列之间这些症状的发生没有统计学意义。在 KD 病例中，初始绝对淋巴细胞计数中位数为 2,860/μL，而在 MIS-C 病例中为 1,325/μL（p < 0.01）。KD 病例的中位血小板计数为 367,000/μL，而 MIS-C 病例为 193,000（p = 0.03）。KD 病例的初始 C 反应蛋白中位数为 11.2 mg/dL，而 MIS-C 病例为 23.2 mg/dL（p < 0.01）。KD 和 MIS-C 患者的白细胞计数、红细胞沉降率、丙氨酸转氨酶、B-钠尿肽、肌钙蛋白 I 或铁蛋白值无统计学差异。在 4 名 KD 患者和 8 名 MIS-C 患者中观察到冠状动脉扩张或突出（p > 0.99）。没有死亡。

结论

在国家认可 MIS-C 之后，我们每周看到大约 1 个 MIS-C 病例。出现低血压、绝对淋巴细胞计数低于 1400/μL、血小板计数低于 200,000/μL 和 CRP 高于 20 mg/dL 是最能预测 MIS-C 与 KD 的情况。初始白细胞计数、丙氨酸转氨酶、红细胞沉降率、B-钠尿肽、肌钙蛋白 I、铁蛋白和初始冠状动脉扩张不能轻易区分 KD 和 MIS-C。因此，我们的诊断管理建议对出现发热性皮疹疾病、发热和腹部症状或结膜注射发热的无毒患者进行有限的实验室评估是合理的。