Multisystem Inflammatory Syndrome in Children (MIS-C)

Multisystem Inflammatory Syndrome in Children (MIS-C) is a sequela of the COVID-19 infection. To put it simply, children who have MIS-C are previously infected with the COVID-19 virus. They have a post-infectious immune response that results in significant levels of inflammation in organ systems, resulting in certain signs and symptoms. Consequently, Kids or adolescents suffering from this condition suffer very serious multi-systemic inflammatory symptoms requiring hospitalisation. 

The presentation is usually about two to four weeks after an acute COVID-19 infection. MIS-C is a rare condition but parents and clinicians should be aware of the signs and symptoms given the severity of the illness. Most children do recover, while some, unfortunately, can die from it. Meanwhile, others who have inflammation involving the heart may suffer from lasting damage. In order to identify children with MIS-C, it is important to ask about the history of COVID-19 infection or exposure when evaluating children with serious systemic symptoms.

WHO Criteria :

All of the following : 

  • Child 0-19 years old age
  • Evidence of COVID-19 or contact with COVID-19 
    (Diagnosed by antigen testing, serology or RT-PCR)
  • Fever more than 3 days
  • Elevated markers of inflammation
    (Eg CRP, ESR, procalcitonin) 
  • No other obvious microbial cause of inflammation
    (Including bacterial sepsis, staphylococcal or streptococcal shock syndromes)

Plus Any 2 of the following : 

  • Skin findings such as rash or bilateral non-purulent conjunctivitis or mucocutaneous inflammation
    (Oral, hands, or feet)
  • Hemodynamic instability: hypotension or shock
  • Features of cardiac dysfunction
    (From ECHO findings or elevated proBNP, Troponins
  • Evidence of Coagulopathy
    (Elevated PT, PTT, d-Dimers)
  • Gastrointestinal dysfunction
    (Eg diarrhoea, vomiting, or abdominal pain)

CDC Definition :

  • An individual aged <21 years presenting with fever*, laboratory evidence of inflammation**, and evidence of clinically severe illness requiring hospitalization, with multisystem (>2) organ involvement (cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic or neurological); AND
  • No alternative plausible diagnoses; AND
  • Positive for current or recent SARS-CoV-2 infection by RT-PCR, serology, or antigen test; or exposure to a suspected or confirmed COVID-19 case within the 4 weeks prior to the onset of symptoms.

*Fever >38.0°C for ≥24 hours, or report of subjective fever lasting ≥24 hours.

**Inflammation, including but not limited to, one or more of the following: an elevated C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), fibrinogen, procalcitonin, d-dimer, ferritin, lactic acid dehydrogenase (LDH), or interleukin 6 (IL-6), elevated neutrophils, reduced lymphocytes and low albumin.


Once diagnosed with MIS-C, the patient must be hospitalised. Treatments are primarily supportive care while managing the inflammation, as there are still no studies comparing the clinical efficacy of various treatment options. For now, there are two main medications directed at treating MIS-C, which are the IV Steroids and IVIG, while ongoing sepsis will be treated with broad-spectrum antibiotics

And because MIS-C patients are at risk of becoming hypercoagulable resulting in conditions like venous thromboembolism, anti-coagulation including low dose aspirin may be necessary. However, individualised medications as such are taken into consideration based on each patient’s condition. MIS-C patients with evidence of cardiac dysfunction or low blood pressure, on the other hand, may need other medications like vasopressors.

Who can get it?

It is most common in children of 5 to 13 years of age, but younger children and older children can get it. Young adults can get it too. And in adults, it’s called MIS-A (Multisystem Inflammatory Syndrome in Adults)

Are MIS-C and Kawasaki Disease the same?

No. Although both conditions have a very similar presentation. Kawasaki Disease is a medium vessel vasculitis presented with symptoms such as fever, conjunctivitis, mucous membrane changes and swollen hands and feet. Meanwhile, MIS-C can present in many different ways depending on which areas of the body have the associated inflammatory response. MIS-C have been reported to be associated with myocardial dysfunction and shock as well. In addition, children or adolescents with MIS-C typically complain of gi symptoms (eg abdominal pain, diarrhoea or vomiting) which are uncommon in children with Kawasaki Disease. Finally, Kawasaki diseases are usually diagnosed in younger age group children (less than 5 years old) whereas MIS-C tends to be in school-age children (including adolescents). Above all, a positive history of exposure to COVID-19 distinguishes MIS-C with Kawasaki Disease.

What are the laboratory abnormalities?

  • Raised CRP
  • Raised ESR

Other common lab findings include: 

  • High procalcitonin
  • High ferritin
  • Lymphopenia
  • Thrombocytopenia
  • Hyponatremia
  • Raised creatinine
  • Raised ALT
  • Low albumin
  • High D-dimer
  • Raised troponin
  • High BNP and pro-BNP

What parents need to know about MIS-C

In short, contact your physician or go to the nearest Emergency Room if your child is showing symptoms of:

Ongoing Fever PLUS the one of the following ;

  • Stomach pain
  • Diarrhoea
  • Vomiting
  • Skin rash
  • Bloodshot eyes
  • Dizziness or lightheadedness

Note that MIS-C signs and symptoms vary from child to child and not all have the same presentation. 

When else to Seek Emergency Care

If your child is showing any of these signs, seek emergency care immediately:

  • Trouble breathing
  • Persistent pain or pressure in the chest
  • Confusion
  • Inability to wake or stay awake
  • Pale, grey or blue-coloured skin, lips, or nail beds


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