MULTISYSTEM INFLAMMATORY SYNDROME: Is COVID-19 opening a Pandora’s box?June 9, 2021
After Mucormycosis, can Multisystem Inflammatory Syndrome (MIS-C) play havoc in India in the wake of the COVID-19 pandemic?
The condition has already been reported in more than 2,000 children who have recovered from COVID-19 or were born to COVID affected women in India, and is likely to see an increase going forward.
MIS refers to a condition where the patient develops fever, along with inflammation in multiple organs such as the heart, lungs and the brain. Fever, difficulty in breathing, stomach pain and a bluish discolouration of skin and nails are telltale signs of this disease, according to medical experts. The age of the children contracting this disease ranges from 6 months to 15 years. The maximum cases, however, are being reported between the ages of 5 and 15.
Medical experts and clinicians from several hospitals from across the country, including National Capital Region and Gujarat, confirmed that the cases of MIS-C are increasing among children who have recovered from coronavirus infection.
As of Jun 1, Delhi alone recorded 109 cases of MIS-C syndrome in children recovered from COVID-19, while another 68 other cases were reported in Gurugram and Faridabad. At least 10 cases of MIS-C have been reported from Ahmedabad Civil Hospital in the past few days, while two children have lost their lives to the disease. More than 100 cases of MIS-C have been reported from Rajkot.
The Rising Graph
According to data by Indian Academy of Paediatrics Intensive Care Chapter, during the second wave of COVID-19, more than 2,000 cases of MIS-C have been reported in the country.
“Acute infection of COVID-19 in children leads to two kinds of changes — a child may get pneumonia or there could be an antibody-mediated inflammation called MIS-C. Only prompt recognition can help catch the problem in time,” says
Dr Dhiren Gupta, chairperson-elect of Indian Academy of Paediatrics Intensive Care Chapter and paediatrician at Sir Ganga Ram Hospital, New Delhi.
In one instance, a newborn whose mother had recovered from the virus before delivery was detected with the disease within 12 hours of birth, according to sources at a private hospital in Memnagar, Ahmedabad. The baby’s mother had been infected by COVID-19 about a month and a half ago. Doctors at the hospital are checking the women’s medical history to analyse the COVID-19 linkage.
One of these cases, reported in the last week of April from Akanksha Hospital and Research Institute (AHRI) in Anand, Gujarat, involved a newborn baby, born at 38 weeks gestation. The baby was admitted to the neonatal unit of the hospital within an hour of his birth with an extremely diseased condition indicated by a weak cry, shock, and low heart pumping rate, which pointed towards multisystem inflammatory syndrome in children (MIS-C).
Doctors from AHRI confirmed that the condition appeared to be linked with COVID-19 after they found a high concentration of antibodies in the child, though an RT-PCR and antibody tests on the baby was negative for the SARS CoV-2 infection. An RT-PCR test on the mother also found her negative for the virus.
What is MIS?
Multisystem inflammatory syndrome (MIS) in children (MIS-C) and adults (MIS-A) are febrile syndromes with elevated inflammatory markers that usually start to show two to six weeks after a severe acute respiratory manifestation due to COVID-19 infection and is a serious condition that appears to be linked to COVID-19.
In children who develop multisystem inflammatory syndrome, the organs and tissues such as the heart, lungs, blood vessels, kidneys, digestive system, brain, skin or eyes become severely inflamed.
“This syndrome can affect different body parts, including lungs, the nervous system and the heart. But, it is curable and can have very less impact if diagnosed early,” says Dr Gunjan Kela, HoD (Dept. of Paediatrics) at Sri Aurobindo Institute of Medical Sciences (SAIMS).
According to clinicians attending MIS cases at various hospitals, most of the children start showing symptoms of the disease two to six weeks after recovering from COVID-19. Children who recover from COVID-19 typically have a sudden increase of antibodies that affects the kidney, lungs and liver and this plays a role in them getting infected by MIS-C.
“MIS-C is considered a post-COVID complication among children. It could affect children from one to 18 years of age. While it usually does not affect children with high immunity, those suffering from obesity are more prone to MIS-C,” says Dr Rakesh Joshi, a child specialist and Additional Superintendent of Ahmedabad Civil Hospital.
Children infected by MIS-C mostly show symptoms like fever, red rashes, weakness, vomiting, stomach ache and breathing problems. If any of the problems are seen, the child would immediately require treatment.
“At present, doctors and researchers are studying this disease at the Civil Hospital. Children who have been infected by MIS-C are under observation. So far, it has been found that such children have fever for three days and also have diarrhoea, which leads to weakness,” Dr Joshi told journalists.
Very common in newborns
Medical experts, including senior pediatricians, confirm that MIS-C has become common among children, including newborns, during the current wave of the pandemic.
“The current double-mutant strain of COVID-19 has thrown up several cases where newborns were found to be affected by MIS-C. Of them, several also test positive for COVID-19 antibodies,” says Dr Sheila Aiyer, Head, Department of Paediatrics, SSG Hospital, Vadodara in Gujarat.
Dr Aiyer, who treated at least 14 newborns with COVID-19 antibodies for the syndrome at SSG Hospital, says: “We do not check antibodies in all newborns unless they are showing MIS-C. However we are seeing it very frequently now, though it was rare in the first wave.”
Child specialists are now discussing the possibility of a higher prevalence, especially since the numbers they are seeing after the second wave are not at all insignificant.
For instance, 13 out of 14 newborns admitted at the SSG Hospital in Vadodara with MIS-C symptoms had high levels of COVID-19 antibodies in them.
“A couple of the newborns admitted with the MIS symptom did not survive. It could be due to overlaps with other neonatal comorbid conditions, like diabetics, anaemia, developmental challenges, and seizures. But now, we are trying to put the first four cases of newborns with antibodies at SSG as case studies,” says Dr Aiyer.
According to her, if the concentration of antibodies in a newborn is higher than that in the mother, it indicates that the baby has self-produced the antibodies. “If the antibodies are passed on by the mother, the concentration of the baby’s antibodies will be lower than that of the mother. But we have had a couple of cases where we have seen the newborn with higher concentration, which means that the babies have produced their own antibodies,” Dr Aiyer said.
“Newborns can get infected by COVID-19 in three ways — by contact with an infected caretaker after birth, a vertical transmission within the womb by the infected mother. It can also be airborne. [In cases] where the RT-PCR test is negative, but antibodies are present, the mother may have been infected during the pregnancy and produced antibodies, which was passed onto the foetus through the placenta,” said Dr Biraj Thakkar, a neonatologist at AHRI.
According to Dr Thakkar, while COVID-19 antibodies protect adults from the virus, they can impair the immune system in newborns and the baby may have to be put on ventilator support and administered steroids.
Asymptomatic parent and affected newborns
In the AHRI case, the family was unaware that the mother had contracted COVID-19 during her pregnancy and recovered.
The medical team at AHRI could later confirm that the mother could probably have recovered without showing symptoms and the family was not aware of the same. But the presence of high-level antibodies in the baby meant that it was passed by the mother through the placenta. This is now known to be harmful to babies in the case of COVID-19.
“Even the baby’s lungs were affected and we had put him on a high-frequency ventilator and administered steroids. A D-dimer test on the newborn revealed a level of 21,000 when normally infected babies test up to the value of 3,000,” said Dr Thakkar to reporters who spoke to him after confirming the first case of MIS-C at the hospital.
After 22 days of hospitalisation — nine days on ventilator support and around 12 days on oxygen support, the baby was discharged from NICU on May 13, Dr Thakkar informed. He said the effects of COVID-19 antibodies on newborns are “more visible” in the current wave because more expectant mothers seem to have been infected in the second half of 2020 as compared to the initial days of the pandemic.
—with inputs from Agencies