What is MIS-C—and Should Parents in Georgia Be Worried?

A rare but serious condition linked to COVID-19 can affect kids. Learn the warning signs and how to protect your family.

child lying in hospital bed

Medically reviewed in August 2020

Updated on August 14, 2020

Scientists have learned that older age is a risk factor for severe cases of COVID-19, but this doesn’t mean that kids are immune to the disease.

In fact, nearly 100,000 children in the United States tested positive for SARS-CoV-2, the coronavirus that causes COVID-19, in the last two weeks of July, according to a report from the American Academy of Pediatrics and the Children’s Hospital Association.

The Centers for Disease Control and Prevention (CDC) also reported an outbreak among children and staffers within days of their arrival at a summer camp in Georgia in late June. Of the 344 people for whom test results were available, 260 tested positive. There have been about 19,000 children under age 17 diagnosed with COVID-19 in Georgia as of August 13, according to the state’s Department of Public Health.

Fortunately, for reasons that aren’t yet clear, kids are more likely to develop mild infections that may go undetected. But even though serious complications among children are uncommon, some infected kids do develop more severe infections.

One particularly worrisome COVID-19-related complication affecting young people is a newly identified condition called multisystem inflammatory syndrome in children, or MIS-C.

Reported cases on the rise
In May, former U.S. Food and Drug Administration commissioner Scott Gottlieb, MD, warned about a link between coronavirus infection and this dangerous new inflammatory disorder in children. By the end of June, doctors from several countries reported about 1,000 cases of MIS-C.

In the U.S., a July 2020 study published in the New England Journal of Medicine (NEJM) investigated 186 cases of MIS-C associated with COVID-19 in 26 different states. Researchers found that many of the young people affected were otherwise healthy children and teens. Of these cases, four were fatal. A separate July 2020 study in NEJM included 95 confirmed cases in New York State. Of these cases, two were fatal. There have been at least 11 cases of MIS-C in Georgia as of August 6, according to the CDC.

“Up until this, a lot of people, myself included, were kind of reassured by the fact that children didn’t seem to be as severely affected” by COVID-19 compared to adults, says Cara Haberman, MD, a pediatric hospital medicine specialist at Wake Forest Baptist Health in Winston-Salem, North Carolina. “We didn’t get off as easy as we thought—there is this pretty scary and severe illness. It’s rare, but it exists, and we have to worry about it.”

What is MIS-C and what are the warning signs?
Like its name implies, multisystem inflammatory syndrome in children is a condition associated with inflammation in at least two different parts of the body—the heart, lungs, kidneys, brain, skin, eyes or organs of the digestive system.

MIS-C typically begins with fever—often 3 to 5 days of a persistently high temperature, Dr. Haberman explains.

In addition, children with early MIS-C often show gastrointestinal warning signs, including belly pain, vomiting and diarrhea. Rash is common. Children may also develop sleepiness, confusion or headaches. Red eyes and swollen lymph nodes are other possible symptoms. Some of these signs of MIS-C could be confused with more benign childhood illnesses.

So, how can parents distinguish between routine childhood fevers or bellyaches and much more serious issues?

“That’s what’s been really hard,” Haberman admits. “You see kids with fever and vomiting all the time. How would you know to worry?”

Call your doctor right away if your child has a fever of 100.4 degrees or higher that lasts more than 24 hours, plus one or more of the following:

  • Unexplained weakness or tiredness
  • Red rash
  • Belly pain
  • Neck pain
  • Vomiting and diarrhea
  • Mucous membrane changes and red cracked lips
  • Red eyes
  • Swelling of hands or feet
  • Headache

“Any time parents are concerned about high fevers or any of these sorts of symptoms, they should bring it up to their physician as soon as they can and make sure that they mention if there’s been an exposure to COVID, or a potential exposure,” says Kacy Ramirez, MD, a pediatric infectious-diseases specialist at Wake Forest Baptist Health.

Keep in mind the following warning signs of a medical emergency that require immediate attention:

  • Trouble breathing
  • Bluish lips or face
  • Confusion
  • Drowsiness or trouble waking
  • Severe belly pain
  • Chest pain or pressure

If your child develops one or more of these serious symptoms, call 911 or go to the emergency room right away.

How MIS-C is diagnosed
In order to diagnose MIS-C, doctors need to rule out other possible causes. Children must also test positive for current infection with SARS-CoV-2, have antibodies to the coronavirus (which would indicate that they were infected in the past and recovered) or have a history of exposure to an infected person within 4 weeks of when their symptoms started.

In most cases, children with MIS-C have antibodies for the disease and are not currently infected.

It can be confusing, Haberman says, because some children develop MIS-C symptoms without having originally had obvious signs of COVID-19 in the first place. They may have mild or no COVID-19 symptoms but then develop this overreaction of the immune system 2 to 4 weeks later, she explains.

In the United States, Hispanic and Black children are disproportionately affected by MIS-C, accounting for a combined 70 percent of cases as of August 6. This could be due to the fact that COVID-19 is more common in these communities.

Wake Forest pediatricians developed an algorithm to help colleagues decide when a child with fever should undergo outpatient testing to check for MIS-C. Laboratory tests can pick up telltale inflammatory markers and cell patterns. Among the possible signs of MIS-C:

  • Elevated C-reactive protein (CRP): Levels of this substance produced by the liver may be higher than normal when there is inflammation in the body.
  • Elevated erythrocyte sedimentation rate (ESR): This blood test measures how quickly red blood cells settle at the bottom of a test tube. A faster-than-normal rate may signal inflammation in the body.
  • Low levels of lymphocytes (a type of white blood cell) and/or platelets (cells that circulate in the blood, which are involved in clotting).

“We check them and then we trend them for a day or two, make sure that they’re headed in the right direction. As long as they are, that’s really reassuring,” Haberman notes.

Definitive diagnosis depends on the whole picture—the child’s symptoms and signs, history, bloodwork and possibly tests, such as electrocardiograms, echocardiograms, X-rays or CT scans.

So does COVID-19 cause MIS-C?
Probably, but we’re not certain. Doctors do not yet know exactly what causes MIS-C.  It can take time to establish that a particular pathogen causes a disease, and researchers are being careful not to state categorically yet that infection with the SARS-CoV-2 virus causes MIS-C.

That said, there is strong evidence linking the two. Many children with MIS-C have a history of recent COVID-19 or of a likely exposure, and most carry the telltale antibodies that mark a recent infection with the coronavirus. Most, however, do not show current evidence of infection.

“What we understand about it is that it’s probably a spectrum of COVID-related disease with severe inflammation,” says Dr. Ramirez. “It’s probably an inflammatory response to the virus.”

Ruling out other issues
Some adults infected with SARS-CoV-2 experience a potentially deadly inflammatory response known as a cytokine storm. But this typically strikes in the second week of illness—not a month later, as is more often the case with MIS-C.

“Adults don’t seem to have this lag period where they are asymptomatic in between. Why this is the case is still very unclear,” Haberman says.

MIS-C can also resemble other inflammatory syndromes, including Kawasaki disease (KD). Both MIS-C and KD can, for instance, result in heart problems, lesions of the skin and mucous membranes and central nervous system disturbances.

Still, there are important differences. KD typically strikes toddlers, whereas the most recent CDC data indicates that children with MIS-C are, on average, 8 years old.

Levels of inflammatory markers like CRP were also higher in a group of British children with MIS-C compared to children diagnosed with KD, and their blood counts differed in important ways, recent research found.

Patterns of cardiac injury are different as well. MIS-C patients reportedly experience cardiovascular shock much more often than KD patients. But enough patients have features of both that the two inflammatory diseases may shed light on each other, Haberman points out.

“Finding out some more answers about MIS-C may answer some questions about Kawasaki disease and what types of viruses are associated with that illness,” she explains.

How MIS-C is treated
Most children diagnosed with MIS-C are sick enough to be hospitalized, according to Ramirez.

Because the disease can strike so many organ systems, treatment typically requires a team of medical professionals. British researchers reporting an early cluster of cases in May advised the involvement of a range of specialists with expertise in intensive care, cardiology, infectious diseases, immunology and rheumatology.

In addition to supportive measures, such as intravenous fluids, treatment typically includes intravenous immunoglobulin (a drug that contains antibodies), steroids, antibiotics and anti-inflammatory drugs ordinarily used to treat autoimmune disease. This regimen can also successfully treat kids with KD.

Although most children with MIS-C get better, the ideal treatment is still unknown, Ramirez says. We also know very little so far about the long-term consequences of MIS-C.

Protecting your child
Protection against MIS-C can be summed up in two words: Avoid COVID-19.

“Parents should just do their best to limit exposure of their family and their children to the coronavirus,” Ramirez recommends.

And remember, MIS-C is rare. For the kids who are affected, the sooner they receive treatment, the better. Most children are able to recover if they are diagnosed and treated early on.

Bottom line, Ramirez says: “It’s something to be concerned about. But it is still a rare condition.”

“Does it change that mental calculation you make about how at risk are kids? I think it does,” Haberman adds. “Does it change anybody’s decision to go or not to go to school? I don’t know. I think that’s a really tough decision for everybody.”

Article sources open article sources

Davies, N.G., Klepac, P., Liu, Y. et al. “Age-dependent effects in the transmission and control of COVID-19 epidemics.” Nature Medicine. 26, 1205–1211 (2020).
American Academy of Pediatrics. “Children and COVID-19: State Data Report.” July 30, 2020.
Centers for Disease Control and Prevention. “SARS-CoV-2 Transmission and Infection Among Attendees of an Overnight Camp — Georgia, June 2020.” August 7, 2020.
Georgia Department of Public Health. “Georgia Department of Public Health Daily Status Report.” Accessed August 14, 2020.
Michael Levin, F.Med.Sci., Ph.D. “Childhood Multisystem Inflammatory Syndrome — A New Challenge in the Pandemic.” New England Journal of Medicine. 2020; 383:393-395.
Leora R. Feldstein, Ph.D., Erica B. Rose, Ph.D., Steven M. Horwitz, M.D. et al. Multisystem Inflammatory Syndrome in U.S. Children and Adolescents. New England Journal of Medicine. 2020; 383:334-346.
Elizabeth M. Dufort, M.D., Emilia H. Koumans, M.D., M.P.H., Eric J. Chow, M.D., M.P.H. et al. “Multisystem Inflammatory Syndrome in Children in New York State.” New England Journal of Medicine. 2020; 383:347-358.
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Centers for Disease Control and Prevention. “Coronavirus Disease 2019 (COVID-19): Frequently Asked Questions.” August 4, 2020.
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