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Multisystem Inflammatory Syndrome in Children - Initial Therapy and Outcomes.

Mary Beth F Son1, Nancy Murray1, Kevin Friedman1

  • 1From the Division of Immunology (M.B.F.S.), and the Departments of Cardiology (K.F., J.W.N.) and Anesthesiology, Critical Care, and Pain Medicine (C.C.Y., M.M.N., A.G.R.), Boston Children's Hospital, the Division of Pediatric Critical Care Medicine, MassGeneral Hospital for Children (P.H.Y.), and the Departments of Anesthesia (A.G.R.) and Pediatrics (M.B.F.S., K.F., P.H.Y., J.W.N., A.G.R.), Harvard Medical School - all in Boston; the COVID-19 Response Team, Centers for Disease Control and Prevention (N.M., L.R.F., C.E.R., M.M.P.), and the Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta (K.M.T.) - both in Atlanta; the Commissioned Corps of the U.S. Public Health Service, Rockville (L.R.F., M.M.P.), and the Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore (B.J.R.) - both in Maryland; the Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston (L.L.L.); the Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Medical Center of Dallas, Dallas (M.M.); the Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla (A.R.S.), the Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, New York (V.L.S.), and the Division of Pediatric Critical Care, Department of Pediatrics, State University of New York Downstate Health Sciences University (S.D.), and Pediatric Critical Care, New York City Health and Hospitals, Kings County Hospital (M.A.K.), Brooklyn - all in New York; the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Central Michigan University, Detroit (S.M. Heidemann); the Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.C.F.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham (M.K.); the Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven (J.S.G.), and the Division of Critical Care, Connecticut Children's, Hartford (C.L.C.) - both in Connecticut; the Division of Pediatric Critical Care, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis (J.R.H.); the Department of Pediatrics, Department of Microbiology, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson (C.V.H.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (J.E.S.); the Department of Pediatrics, Joseph M. Sanzari Children's Hospital at Hackensack University Medical Center, Hackensack (K.N.C.), and the Department of Pediatrics, Division of Pediatric Critical Care, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson Medical School, Rutger's University, New Brunswick (S.M. Horwitz) - both in New Jersey; the Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH (M.W.H.); the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle (L.S.S.); the Department of Pediatrics, University of North Carolina Children's Hospital, Chapel Hill (S.P.S.); the Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock (K.I.); the Department of Pediatrics, Division of Cardiology, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans, New Orleans (T.T.B.); the Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora (A.B.M.); the Division of Pediatric Critical Care, Miller Children's and Women's Hospital of Long Beach, Long Beach (C.J.B.), and the Division of Critical Care Medicine, University of California San Francisco Benioff Children's Hospital Oakland, Oakland (N.Z.C.) - both in California; the Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis (C.M.R.); the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami (G.E.M.); the Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston (E.H.M.); the Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY (V.L.M.); the Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville (N.B.H.); and the Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago (B.M.C.).

The New England Journal of Medicine
|June 16, 2021
PubMed
Summary

Combining intravenous immune globulin (IVIG) with glucocorticoids for multisystem inflammatory syndrome in children (MIS-C) reduced cardiovascular dysfunction compared to IVIG alone. This combination therapy offers a promising approach for treating MIS-C patients.

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Area of Science:

  • Pediatric immunology
  • Infectious diseases
  • Cardiology

Background:

  • Multisystem inflammatory syndrome in children (MIS-C) is a serious condition requiring effective immunomodulatory treatments.
  • Real-world data is crucial for guiding therapeutic decisions in MIS-C management.
  • Assessing the effectiveness of different immunomodulatory medication combinations is essential.

Purpose of the Study:

  • To evaluate the real-world effectiveness of initial immunomodulatory therapy for MIS-C.
  • To compare the outcomes of intravenous immune globulin (IVIG) plus glucocorticoids versus IVIG alone.
  • To identify optimal treatment strategies for reducing cardiovascular complications in MIS-C.

Main Methods:

  • Analysis of surveillance data from 58 U.S. hospitals (March-October 2020).
  • Inclusion of pediatric patients under 21 with MIS-C.
  • Propensity-score matching and inverse probability weighting to compare IVIG plus glucocorticoids vs. IVIG alone, adjusting for baseline severity and demographics.

Main Results:

  • Initial treatment with IVIG plus glucocorticoids was associated with a significantly lower risk of cardiovascular dysfunction (17% vs. 31%) compared to IVIG alone.
  • Reduced risks of left ventricular dysfunction and shock requiring vasopressors were observed with the combination therapy.
  • The combination therapy also led to lower use of adjunctive treatments, without affecting fever risk.

Conclusions:

  • Initial treatment with IVIG plus glucocorticoids is associated with improved cardiovascular outcomes in children with MIS-C.
  • This combination therapy demonstrates superior effectiveness compared to IVIG alone in preventing or mitigating cardiovascular dysfunction.
  • Findings support the use of IVIG plus glucocorticoids as a preferred initial treatment for MIS-C.