COVID-19 and MIS-C in Paediatrics
1. COVID-19 in Children
Definition
COVID-19 is an infectious disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) that affects the respiratory system and other organs. In children, the disease is usually mild but may occasionally lead to severe complications including Multisystem Inflammatory Syndrome in Children (MIS-C).
Etiology
Caused by SARS-CoV-2, an RNA coronavirus belonging to the Coronaviridae family.
Pathophysiology
- Virus enters host cells via ACE2 receptors present in respiratory epithelium, heart, intestine, kidney.
- Viral replication causes:
* Local inflammation
* Cytokine release
- Immune response produces:
* Antibodies
* T-cell activation
- In some children, exaggerated immune response occurs weeks later → MIS-C.
Children generally have milder disease due to:
- Lower ACE2 receptor expression
- Strong innate immune response
- Frequent exposure to other viruses leading to cross-immunity.
Modes of Transmission
- Respiratory droplets
- Aerosol transmission
- Direct contact with contaminated surfaces
- Close contact with infected individuals
Incubation period: 2–14 days (average 5 days)
Risk Factors for Severe Disease
- Obesity
- Chronic lung disease
- Congenital heart disease
- Immunodeficiency
- Neurological disorders
- Infants <1 year
- Diabetes mellitus
Clinical Features
Asymptomatic Infection
Very common in children.
Mild Disease
- Fever
- Cough
- Sore throat
- Rhinorrhea
- Fatigue
- Headache
- Myalgia
- Anosmia
- Ageusia
Gastrointestinal Symptoms
- Vomiting
- Diarrhea
- Abdominal pain
Moderate Disease
- Pneumonia
- Persistent fever
- Mild respiratory distress
Severe Disease
- Severe pneumonia
- Acute respiratory distress syndrome
- Shock
- Multi-organ involvement
Complications
- Pneumonia
- ARDS
- Myocarditis
- Thrombosis
- Neurological complications
- MIS-C
- Long COVID
Investigations
Diagnostic Test
- RT-PCR for SARS-CoV-2 (gold standard)
Rapid Tests
- Antigen test
Blood Tests
- CBC
- CRP
- ESR
- Ferritin
- D-dimer
- LDH
Imaging
- Chest X-ray
- HRCT chest in severe cases
Other Tests
- Liver function tests
- Renal function tests
- Cardiac markers (Troponin, BNP)
Differential Diagnosis
- Influenza
- RSV infection
- Adenovirus infection
- Bacterial pneumonia
- Sepsis
- Kawasaki disease
Management
1. Asymptomatic or Mild Disease
Supportive care only.
Non-pharmacologic Measures
- Isolation
- Adequate hydration
- Nutrition
- Antipyretics
- Monitoring symptoms
2. Moderate Disease
Hospital admission may be required.
Oxygen Therapy
- Nasal prongs
- Face mask
3. Severe Disease
Oxygen Support
- High flow nasal oxygen
- Non-invasive ventilation
- Mechanical ventilation if required
Pharmacological Treatment
Paracetamol
Indication: Fever relief
Mechanism: COX inhibition → reduced prostaglandin synthesis
Dose
- Children: 10–15 mg/kg every 4–6 hours
Adverse Effects
- Liver toxicity (high doses)
Contraindications
- Severe liver disease
Monitoring
- Liver function if prolonged use
Remdesivir
Indication: Moderate to severe COVID-19 requiring oxygen.
Mechanism
- Inhibits viral RNA-dependent RNA polymerase → blocks viral replication.
Dose
- ≥3.5 kg children
- Day 1: 5 mg/kg IV
- Day 2–5: 2.5 mg/kg IV daily
Adverse Effects
- Elevated liver enzymes
- Nausea
Contraindications
- Severe liver dysfunction
Monitoring
- Liver function tests
Dexamethasone
Indication: Severe COVID-19 with oxygen requirement.
Mechanism
- Corticosteroid → suppresses inflammatory cytokine response.
Dose
- 0.15 mg/kg/day (max 6 mg/day) for 5–10 days
Adverse Effects
- Hyperglycemia
- Secondary infection
Contraindications
- Uncontrolled systemic infections
Monitoring
- Blood glucose
- Signs of infection
Prevention
Vaccination
COVID vaccines significantly reduce severe disease.
Examples:
- Covaxin
- Covishield
- Pfizer‑BioNTech COVID‑19 Vaccine
Other Preventive Measures
- Hand hygiene
- Mask use
- Respiratory etiquette
- Isolation of infected individuals
2. MIS-C (Multisystem Inflammatory Syndrome in Children)
Definition
MIS-C is a post-infectious hyperinflammatory syndrome occurring 2–6 weeks after SARS-CoV-2 infection, characterized by fever, systemic inflammation, and multi-organ involvement.
Pathophysiology
- Delayed immune dysregulation after COVID infection
- Massive cytokine release
- Immune-mediated endothelial injury
- Multiorgan inflammation
- Similarities with Kawasaki disease and toxic shock syndrome.
Diagnostic Criteria (WHO / CDC)
- Age <21 years
- Fever ≥3 days
- Elevated inflammatory markers
- Multisystem involvement (≥2 organs)
- Evidence of SARS-CoV-2 infection or exposure
- No alternative diagnosis
Clinical Features
General
- Persistent fever
- Extreme fatigue
Gastrointestinal
- Severe abdominal pain
- Vomiting
- Diarrhea
Cardiovascular
- Myocarditis
- Hypotension
- Shock
- Coronary artery dilation
Mucocutaneous
- Rash
- Conjunctivitis
- Red lips
- Strawberry tongue
Neurological
- Headache
- Confusion
- Seizures
Investigations
Blood Tests
- CBC → lymphopenia
- CRP (very high)
- ESR
- Ferritin
- D-dimer
- IL-6
- Procalcitonin
Cardiac Tests
- Troponin
- BNP
Imaging
- Echocardiography
- Chest X-ray
- Abdominal ultrasound
SARS-CoV-2 Testing
- RT-PCR
- Antibody test
Differential Diagnosis
- Kawasaki disease
- Toxic shock syndrome
- Septic shock
- Macrophage activation syndrome
- Severe COVID-19
Management of MIS-C
All children should be hospitalized.
Supportive Care
- Oxygen therapy
- Fluid resuscitation
- Vasopressors for shock
- ICU management if severe
Immunomodulatory Therapy
Intravenous Immunoglobulin (IVIG)
Indication: First-line treatment.
Mechanism
- Modulates immune response
- Neutralizes inflammatory cytokines
Dose
- 2 g/kg single infusion
Adverse Effects
- Headache
- Fever
- Aseptic meningitis
- Rare thrombosis
Monitoring
- Vital signs during infusion
Methylprednisolone
Indication
- Moderate to severe MIS-C
- IVIG non-response
Mechanism
- Potent anti-inflammatory corticosteroid.
Dose
- 1–2 mg/kg/day IV
Severe cases:
- Pulse therapy 10–30 mg/kg/day for 3 days
Adverse Effects
- Hyperglycemia
- Hypertension
- Infection risk
Aspirin
Indication
- Prevent thrombosis and coronary complications.
Mechanism
- COX inhibition → antiplatelet effect.
Dose
- 3–5 mg/kg/day
Adverse Effects
- Gastric irritation
- Bleeding
Contraindications
- Active bleeding
- Severe liver disease
Anticoagulation
Low Molecular Weight Heparin
Example: Enoxaparin
Dose
- 1 mg/kg every 12 hours
Indication
- High D-dimer
- Ventricular dysfunction
- Thrombosis risk
Complications of MIS-C
- Cardiogenic shock
- Coronary artery aneurysm
- Myocardial dysfunction
- Arrhythmias
- Thromboembolism
- Multi-organ failure
Prognosis
- Most children recover with treatment.
- Mortality rate: <2%
- Cardiac follow-up required for 6–12 months.
Follow-Up
- Repeat echocardiography
- Cardiology evaluation
- Monitor inflammatory markers
- Gradual return to physical activity
If you want, I can also give:
• 50 MCQs on COVID-19 and MIS-C in paediatrics
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