When much of the world was still coping with the peak of the COVID-19 pandemic, a worrisome, new pediatric condition potentially linked to the coronavirus started to manifest in some children in Europe in April. When the first suspected cases started to present at New York hospitals, swift action was taken by both City and State officials in early May to warn parents of the symptoms, as reported by Norwood News.

 

In a matter of days, by May 9, three children had died, and New York case numbers had quickly risen. The Empire State now accounts for about half of all cases nationwide, but there are also substantial numbers reported in Washington D.C., and in other states as well. The syndrome has been called different names across the world in the last month but is now more commonly referred to as Multi-Symptom Inflammatory Syndrome for Children (MIS-C).

 

Dr. Edward E Conway Jr. is Chief of Pediatric Critical Care, Vice Chairman at Lewis M. Fraad Department of Pediatrics, and Professor of Pediatrics at Jacobi Medical Center in the Bronx. He has been treating critically ill patients who have contracted MIS-C over the last month and recently gave an interview to Norwood News to explain what it’s been like for doctors dealing with this new syndrome.

 

Origins  

To put things in context, Conway said for the last month or so, pediatricians across the State have basically been inundated with cases of MIS-C. When COVID-19 (as opposed to MIS-C) first struck, he said pediatricians took some solace from the fact that despite the contagion and severity of the virus, kids did not seem to be that affected by it, though it is still unclear why that is.

 

“The young children that had the virus weren’t that sick,” Conway said. “And we weren’t seeing the same morbidity and mortality we were dealing with in our older patients, in young adults in their thirties and forties.” The timing of MIS-C was also curious. Conway said that Italy and England had seen their COVID-19 curves spike several weeks before the U.S., and that in the weeks that followed their respective spikes, they noticed some children had developed this new syndrome, MIS-C.

 

Similarly, cases of MIS-C began to appear in New York State in early May, a few weeks after the COVID-19 peak in April.

 

Diagnosis

Conway said that upon examination of the affected children, doctors tend to associate MIS-C with Kawasaki disease, Toxic Shock Syndrome, Toxic Strep Syndrome or Sepsis, as these are conditions that are already defined, and therapeutic options are available to treat them. “But COVID is so new and devastating,” said Conway. “We know nothing about this virus so we’re either not certain, or don’t know whether this inflammatory syndrome is a direct reaction to the virus, or if it’s the body’s immune reaction several weeks after having had the virus.”

 

He said that while some of the affected children did test positive for COVID-19 when they came into the ICUs, it wasn’t that many. “Many did test positive for the antibody, and that meant that the body had seen the [COVID-19] virus before and had attempted, with these antibodies, to neutralize the virus in the same way the world is trying to make a vaccine to neutralize the virus,” he said. “So that’s sort of the body’s response.”

 

Severity & Data Collection

Conway said that the patients he sees are at the near end of the disease because they’re in the intensive care unit. He said that, like any bell curve, there is probably a mild, moderate, and severe form of MIS-C. “As a critical care doc, the severe form comes to our attention,” he said. “But the good news is, now that we have a definition [for MIS-C], all cases are being reported to New York City Department of Health and to New York State Department of Health so we’re starting to have data collectors.”

 

Conway said by gathering case data, doctors will eventually develop specific checkpoints or markers that will tell them, for example, when they see “X” marker, when analyzing a patient’s condition, they should therefore do “Y”. Conway said there is also a national data repository since other states are now starting to see the syndrome as well, and if doctors can get a much bigger read, and collect data from all around the country, they can, perhaps, find this marker or checkpoint that will help them with treating patients.

 

We asked Conway why he thinks the syndrome only started to appear at this stage of the COVID-19 pandemic, if it is indeed linked to the virus. He said that this was one of the things doctors don’t really yet understand. “That’s why we need to collect all this data, and get a bigger rendering to compare these children,” he said.

 

“Again, why is it now several weeks after the adult peak outbreak?” he said. “Or, is it just that when we hit the adult peak, so many people were infected, and the virus is more ubiquitous, more common, that maybe more people, including children, are exposed to it? There may have been minor cases of this entity early on that we just didn’t know, or we just missed because they didn’t come into the hospital.”

 

Indeed, Conway said that, generally, pediatric case volumes, of all types, have been way down across the five boroughs in all hospitals, in the emergency departments and in the pediatric wards. “Parents have been staying at home, being afraid that their children may be exposed to the virus,” he said.

 

Case Numbers

As of May 27, there were 176 cases across the State, which the health department is currently tracking and investigating, along with the three deaths which occurred in early May. Conway said he is seeing approximately one case a day at Jacobi, sometimes two, that the daily numbers are similar at other pediatric hospitals, and that he’s seeing more boys than girls. “Many diseases in pediatrics seem to be more prone to male than female, and I can’t explain that,” he said.

 

All patients are predominantly school-aged, and are experiencing symptoms similar to Kawasaki disease, and Toxic Shock-like Syndrome possibly due to COVID-19. Of the children displaying such symptoms, 93 percent tested positive for COVID-19 through diagnostic testing, antibody testing or both. A breakdown of the age, race and ethnicity of the affected patients is outlined below.

 

Age of Cases (updated May 27, 2020)

Age	Percent of Cases
<1	7%
1-4	21%
5-9	27%
10-14	27%
15-19	14%
20-21	3%

 

Race and Ethnicity of Cases (updated May 27, 2020)

Race	Percent of Cases
White	22%
Black	31%
Other	17%
Asian	3%
Unknown	27%

 

Ethnicity	Percent of Cases
Not Hispanic	44%
Hispanic/Latino	34%
Unknown	22%

 

Research  

“MIS-C seems to affect the gastrointestinal tract much more frequently or commonly,” Conway said. “In the adult patients, it was the lungs that was the primary organ that was affected.” Conway said doctors can’t explain why that is yet. He also said that in a small number of pediatric patients, doctors are seeing heart inflammation as well.

 

According to Conway, the thing doctors always worry about is Sepsis, which can impact any organ since it’s an inflammatory response by the body. “So, this entity (MIS-C) looks a lot like Sepsis,” he said. Conway said one of the difficulties doctors have encountered in treating patients is that every time they attempt to describe something that MIS-C looks like, there’s always a “but”.

 

“It looks just like this disease X but because there’s something different about this particular virus, it doesn’t really fit into one of our checkpoints,” he said, at least it doesn’t yet. “You look up disease X, and it has always got one or two things that are different than MIS-C.” Conway said this is why some people call the syndrome Kawasaki-like, because it’s similar to Kawasaki or it’s Sepsis-like. “It’s similar to a lot of other things that we see,” he said. “Many diseases can look similar, and we need to analyze the data to see if there are any that are unique to MIS-C”.

 

Conway added that although it’s been around for 30 plus years, doctors still don’t know what causes Kawasaki disease, which is similar to MIS-C. Despite this, doctors are able to treat Kawasaki (and MIS-C), especially if detected early. In a May 6 State health department MIS-C advisory, it was mentioned that, in some cases, the impacted patients either tested positive for COVID-19, or tested positive for the antibodies, but in other cases, they didn’t have any trace of either the virus or the antibodies.

 

“Yeah, there are still several children that are like that,” said Conway, explaining it was possible that among the kids who no longer had COVID-19, they either didn’t have an immune response, or it was too early to see their immune response. “Here again, life is a bell curve and cases may range from mild to severe,” he said.

 

Symptoms & Treatment

Conway was anxious to reassure parents that, despite the growing case numbers and despite the potential severity of the condition, many of the impacted patients have mild symptoms, and may not even need hospitalization, highlighting again that, as a Pediatric ICU physician, he only sees the sickest patients.

 

“Some may be mild and may be being discharged home,” he said. The purpose of issuing the initial guidelines and definitions of the syndrome so quickly in early May was to educate parents about MIS-C and tell parents when they should see a doctor, since early intervention is critical. “So, using the guidelines that are out there, the definitions, if a child has a fever for more than several days, if they have gastrointestinal complaints like decreased appetite, symptoms such as fever, vomiting or diarrhea, unusual, fleeting rashes that come and go, or inflammation of the eyes, we’ve been telling them, they need to call their pediatrician,” Conway said.

 

Their pediatrician will then examine the child. “You need to do the laying on of hands,” he said. “If they look ill in any way, or their vital signs are abnormal, they would be referred to an emergency department where they will be further evaluated, and more blood tests may be necessary.” Conway said the good news is that if doctors see the children early, and they’re symptomatic in any way, they have different treatment algorithms that they can employ.

 

Questions from Parents

 With many parents worried about the unknown, we asked Conway if the patients who have contracted MIS-C had any underlying health conditions. “So actually, that’s one of the amazing things,” he said. “With a large number of these patients and talking to colleagues and other centers that have seen more, there doesn’t seem to be an underlying reason,” he said.

 

“They’re young, healthy children. There has been no identified comorbidity in the pediatric patients, as opposed to the adults [who contracted COVID-19], many of whom had obesity, morbid obesity, hypertension, diabetes, renal failure, adult diseases.”

 

One parent asked us to ask if MIS-C was contagious. “So, we think that once you’ve made antibodies to the virus [COVID-19], it’s not very likely that you would still be contagious,” Conway said.

 

He was also asked if there was, perhaps, any genetic reason why the impacted children contracted the condition. “Centers are currently looking at the genetics of this disease,” he said. “We suspect that there is probably an underlying genetic predisposition because the number of children with this syndrome is so small.”

 

Another concern was the long-term effects of the syndrome. Conway said that MIS-C is too new to predict this.

 

One parent read that the syndrome inflames the heart, and wondered if a child has allergies or asthma, and therefore “inflames” quite easily, would that child be more at risk of contracting MIS-C, like people with respiratory defects are more at risk of getting COVID-19. Conway said the heart may be involved, as can many other organs. “Some of the cardiac blood tests we follow are elevated in this syndrome but may also be elevated in many other inflammatory states,” he said.

 

“We just don’t know. These kids are all getting follow up with pediatric cardiologists. Allergies and asthma have not been seen in the majority of these kids, to date.” Conway added that, again, there are therapeutic options available to treat MIS-C.

 

He said all of the patients he has seen at his hospital have been treated, have been discharged, and are doing well. “All are being followed closely,” he said, adding that a large number of hospitals are also setting up COVID follow-up reporting clinics that will include laboratory and possible cardiac follow-up, if needed.

 

[We’ll] “just follow these labs every week, because we don’t know what this disease is going to look like in two weeks from now, or six weeks from now, six months from now, so we’re going to follow these children very closely,” he said, adding that parents may want to log on to the CDC for updates too.

  

Reassurance

Even though the disease is new, Conway’s main message was one of measured reassurance. “So, one thing that I want the public to take away from this, is that this is a very small number of children that are affected,” he said. “If we think of the population of children in New York City – I don’t know several million – and you think that we’re talking about, you know, 173, the number is very small, and the majority of those children do well.”

 

The core takeaway is clear. “If your child appears unwell, call your pediatrician,” he said. “Hospitals have taken exhaustive steps to ensure that they are safe areas for your children to be seen.”

 

According to federal data, as of Nov. 1, 2021, there have been 5,526 cases of MIS-C, including 48 deaths, reported in the United States.