Are Steroids Always Necessary in Multisystem Inflammatory Syndrome in Children (MIS-C)?
DOI:
https://doi.org/10.12974/2311-8687.2024.12.09Keywords:
Immunomodulation, Immunoglobulins, Fever, COVID-19, Critical careAbstract
Multisystem Inflammatory Syndrome in Children (MIS-C) treatment is still under debate and involves Intravenous Immunoglobulins (IVIG) and/or steroids. We retrospectively analysed data from the patients admitted to Our Institution during the year 2020 to investigate whether prompt IVIG treatment conditions cardiac dysfunction and need for support and if addition of steroids in different doses correlates with outcomes.
Days of fever, time between fever appearance and IVIG treatment, left ventricular ejection fraction (LVEF%) at admission and Cardiac Function Recovery Time (time between worst LVEF and resume of LVEF >55%) were used as outcomes.
38 patients were admitted with MIS-C. All except one received IVIG; 24 received also different Methylprednisolone dosages. Time to IVIG treatment, adjusted for age and sex, correlated with global duration of fever (Coefficient: 1.2; 95% CI:0.73-1.68) and with Vasoactive Inotropic Score (VIS) (Coefficient: 0.09; 95% CI 0.02-0.15), with pericardial effusion (Coefficient: 2.37; 95% CI: 0.45-4.2). Global duration of fever was associated with time to IVIG (Coefficient: 0.8; 95% CI :0.49-1.13) and positive Covid-19 swab (Coefficient: 1.71; 95% CI 0.21-3.22). Cardiac Function Recovery Time did not show differences with different steroid dose regimens. High-dose steroids did not show any benefit in our cohort.
References
Swann OV, Holden KA, Turtle L, Pollock L, Fairfield CJ, Drake TM, et al. Clinical characteristics of children and young people admitted to hospital with covid-19 in United Kingdom: prospective multicentre observational cohort study. BMJ. 27 agosto 2020; m3249. https://doi.org/10.1136/bmj.m3249
Belhadjer Z, Méot M, Bajolle F, Khraiche D, Legendre A, Abakka S, et al. Acute Heart Failure in Multisystem Inflammatory Syndrome in Children in the Context of Global SARS-CoV-2 Pandemic. Circulation. 4 agosto 2020; 142(5): 429-36. https://doi.org/10.1161/CIRCULATIONAHA.120.048360
Radia T, Williams N, Agrawal P, Harman K, Weale J, Cook J, et al. Multi-system inflammatory syndrome in children & adolescents (MIS-C): A systematic review of clinical features and presentation. Paediatric Respiratory Reviews. giugno 2021; 38: 51-7. https://doi.org/10.1016/j.prrv.2020.08.001
Abrams JY, Godfred-Cato SE, Oster ME, Chow EJ, Koumans EH, Bryant B, et al. Multisystem Inflammatory Syndrome in Children Associated with Severe Acute Respiratory Syndrome Coronavirus 2: A Systematic Review. The Journal of Pediatrics. novembre 2020; 226: 45-54.e1. https://doi.org/10.1016/j.jpeds.2020.08.003
Ahmed M, Advani S, Moreira A, Zoretic S, Martinez J, Chorath K, et al. Multisystem inflammatory syndrome in children: A systematic review. EClinicalMedicine. settembre 2020; 26: 100527. https://doi.org/10.1016/j.eclinm.2020.100527
Harwood R, Allin B, Jones CE, Whittaker E, Ramnarayan P, Ramanan AV, et al. A national consensus management pathway for paediatric inflammatory multisystem syndrome temporally associated with COVID-19 (PIMS-TS): results of a national Delphi process. The Lancet Child & Adolescent Health. febbraio 2021; 5(2): 133-41. https://doi.org/10.1016/S2352-4642(20)30304-7
Jonat B, Gorelik M, Boneparth A, Geneslaw AS, Zachariah P, Shah A, et al. Multisystem Inflammatory Syndrome in Children Associated With Coronavirus Disease 2019 in a Children's Hospital in New York City: Patient Characteristics and an Institutional Protocol for Evaluation, Management, and Follow-Up. Pediatric Critical Care Medicine. marzo 2021; 22(3): e178-91. https://doi.org/10.1097/PCC.0000000000002598
Närhi F, Moonesinghe SR, Shenkin SD, Drake TM, Mulholland RH, Donegan C, et al. Implementation of corticosteroids in treatment of COVID-19 in the ISARIC WHO Clinical Characterisation Protocol UK: prospective, cohort study. The Lancet Digital Health. aprile 2022; 4(4): e220-34.
McCrindle BW, Rowley AH, Newburger JW, Burns JC, Bolger AF, Gewitz M, et al. Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Scientific Statement for Health Professionals From the American Heart Association. Circulation [Internet]. 25 aprile 2017 [citato 5 giugno 2024]; 135(17). Disponibile su: https: //www.ahajournals.org/doi/10.1161/CIR.0000000000000484. https://doi.org/10.1161/CIR.0000000000000484
Banday AZ, Arul A, Vignesh P, Singh MP, Goyal K, Singh S. Kawasaki disease and influenza-new lessons from old associations. Clin Rheumatol. luglio 2021; 40(7): 2991-9. https://doi.org/10.1007/s10067-020-05534-1
Riphagen S, Bird R. Ventilatory management of critically ill children in the emergency setting, during transport and retrieval. Ungern‐Sternberg B, curatore. Pediatric Anesthesia. febbraio 2022; 32(2): 330-9. https://doi.org/10.1111/pan.14358
Olivotto S, Basso E, Lavatelli R, Previtali R, Parenti L, Fiori L, et al. Acute encephalitis in pediatric multisystem inflammatory syndrome associated with COVID-19. European Journal of Paediatric Neurology. settembre 2021; 34: 84-90. https://doi.org/10.1016/j.ejpn.2021.07.010
Bova SM, Serafini L, Capetti P, Dallapiccola AR, Doneda C, Gadda A, et al. Neurological Involvement in Multisystem Inflammatory Syndrome in Children: Clinical, Electroencephalographic and Magnetic Resonance Imaging Peculiarities and Therapeutic Implications. An Italian Single-Center Experience. Front Pediatr. 12 agosto 2022; 10: 932208. https://doi.org/10.3389/fped.2022.932208
Channon-Wells S, Vito O, McArdle AJ, Seaby EG, Patel H, Shah P, et al. Immunoglobulin, glucocorticoid, or combination therapy for multisystem inflammatory syndrome in children: a propensity-weighted cohort study. The Lancet Rheumatology. aprile 2023; 5(4): e184-99. https://doi.org/10.1016/S2665-9913(23)00035-8
Son MBF, Murray N, Friedman K, Young CC, Newhams MM, Feldstein LR, et al. Multisystem Inflammatory Syndrome in Children - Initial Therapy and Outcomes. N Engl J Med. luglio 2021; 385(1): 23-34. https://doi.org/10.1056/NEJMc2111096
Belhadjer Z, Auriau J, Méot M, Oualha M, Renolleau S, Houyel L, et al. Addition of Corticosteroids to Immunoglobulins Is Associated With Recovery of Cardiac Function in Multi-Inflammatory Syndrome in Children. Circulation. 8 dicembre 2020; 142(23): 2282-4. https://doi.org/10.1161/CIRCULATIONAHA.120.050147
Ouldali N, Toubiana J, Antona D, Javouhey E, Madhi F, Lorrot M, et al. Association of Intravenous Immunoglobulins Plus Methylprednisolone vs Immunoglobulins Alone With Course of Fever in Multisystem Inflammatory Syndrome in Children. JAMA. 2 marzo 2021; 325(9): 855. https://doi.org/10.1001/jama.2021.0694
Narum S, Westergren T, Klemp M. Corticosteroids and risk of gastrointestinal bleeding: a systematic review and meta-analysis. BMJ Open. maggio 2014; 4(5): e004587. https://doi.org/10.1136/bmjopen-2013-004587
on behalf of the Rheumatology Study Group of the Italian Society of Pediatrics, Cattalini M, Taddio A, Bracaglia C, Cimaz R, Paolera SD, et al. Childhood multisystem inflammatory syndrome associated with COVID-19 (MIS-C): a diagnostic and treatment guidance from the Rheumatology Study Group of the Italian Society of Pediatrics. Ital J Pediatr. dicembre 2021; 47(1): 24. https://doi.org/10.1186/s13052-021-00980-2
Musolino AM, Boccuzzi E, Buonsenso D, Supino MC, Mesturino MA, Pitaro E, et al. The Role of Lung Ultrasound in Diagnosing COVID-19-Related Multisystemic Inflammatory Disease: A Preliminary Experience. JCM. 1 gennaio 2022; 11(1): 234. https://doi.org/10.3390/jcm11010234
Camporesi A, Gemma M, Buonsenso D, Ferrario S, Mandelli A, Pessina M, et al. Lung Ultrasound Patterns in Multisystem Inflammatory Syndrome in Children (MIS-C)-Characteristics and Prognostic Value. Children. 21 giugno 2022; 9(7): 931. https://doi.org/10.3390/children9070931
Gawlik AM, Berdej-Szczot E, Chmiel I, Lorek M, Antosz A, Firek-Pędras M, et al. A tendency to worse course of multisystem inflammatory syndrome in children with obesity: MultiOrgan Inflammatory Syndromes COVID-19 related study. Front Endocrinol. 26 settembre 2022; 13: 934373. https://doi.org/10.3389/fendo.2022.934373
Calcaterra V, Bosoni P, Dilillo D, Mannarino S, Fiori L, Fabiano V, et al. Impaired Glucose-Insulin Metabolism in Multisystem Inflammatory Syndrome Related to SARS-CoV-2 in Children. Children. 13 maggio 2021; 8(5): 384. https://doi.org/10.3390/children8050384
Garbin M, Raso I, Piersanti A, Gianolio L, De Silvestri A, Calcaterra V, et al. Advanced Echocardiographic Analysis in Medium-Term Follow-Up of Children with Previous Multisystem Inflammatory Syndrome. Children. 18 giugno 2022; 9(6): 917. https://doi.org/10.3390/children9060917
DeBiasi RL. Immunotherapy for MIS-C - IVIG, Glucocorticoids, and Biologics. N Engl J Med. luglio 2021; 385(1): 74-5. https://doi.org/10.1056/NEJMe2108276
