Though New York state has reported approximately 100 cases, and Connecticut around eight of a multi-system inflammatory disease in children that may be a COVID-19 complication, parents should be aware, but not overly alarmed at this point, said Newtown pediatricians Dr Laura Nowacki and Dr Richard Auerbach, and Physician-in-Chief Dr Juan Salazar of Connecticut Children's Center recently.

Dr Nowacki's office has seen one case that she suspects of being Kawasaki Disease or Kawasaki-like illness this spring, before they were able to test. Kawasaki Disease, which can cause heart and blood vessel damage when untreated, has been diagnosed and successfully treated in children for many years.

On May 11, Yale New Haven Children’s Hospital reported three patients diagnosed with Pediatric Multi-System Inflammatory Syndrome. “Unfortunately, this disease carries features of toxic shock syndrome and elements of Kawasaki Disease and strikes school-aged children. While these cases are exceptionally rare, given our proximity to New York where there have been a significant number reported, we have been watching their experience closely,” said Clifford Bogue, physician-in-chief of YNHCH, at ynhh.org. “We are working diligently with local and state health officials to address this issue and strongly recommend that children who may be suffering from symptoms seek early referrals to pediatric infectious disease specialists, rheumatologists or cardiologists.”

The Connecticut Mirror reported on May 14 that “Yale New Haven Health officials said Wednesday they are treating two new cases of the mysterious illness, in addition to the three reported there earlier this week.

One of the young patients has now been released from Yale New Haven Hospital while the others ‘are doing quite well,’ said Dr. Thomas Balcezak, chief clinical officer of the Yale New Haven health system.” Balcezak also told CTMirror.org that four of five children had tested positive for COVID-19 and that the fifth child is also suspected to be positive.

In an advisory posted at emergency.cdc.gov, the CDC provided background information on cases of the syndrome, and “recommends healthcare providers report any patient who meets the case definition to local, state, and territorial health departments to enhance knowledge of risk factors, pathogenesis, clinical course, and treatment of this syndrome.” The CDC also notes that “It is currently unknown if multisystem inflammatory syndrome is specific to children or if it also occurs in adults. There is limited information currently available about risk factors, pathogenesis, clinical course, and treatment for MIS-C.”

“We think it is the individuals immune system response to the virus,” Dr Nowacki said, noting again that the disease is rare and treatable, particularly if adults are alert to early symptoms. A high fever over the course of several days should be a red flag, she said. Other symptoms, as listed by the CDC, include rash, swelling of hands and feet, irritation and redness of the whites of the eyes, swollen lymph glands in the neck, and irritation and inflammation of the mouth, lips, and throat. YNHH also includes vomiting and diarrhea as symptoms.

“We’re asking tons of questions,” Dr Nowacki said, when parents call with reports of high fevers, as “[Kawasaki] is a multi-organ systems” issue.

A Challenge To Differentiate

Dr Auerbach, of Auerbach Pediatrics in Newtown, said that while his office has a patient diagnosed with presumptive Kawasaki Disease once every year or two, "Despite concerns of MIS-C (Multisystem Inflammatory Syndrome in Children) associated with COVID-19, and some suspected low-grade cases, we have not had any definitive COVID-19 cases, either with or without this inflammatory syndrome.

"Since the main feature of MIS-C is fever, and since almost any system can be involved, it is almost impossible to differentiate MIS-C from other non-COVID viral syndromes or inflammatory conditions," Dr Auerbach wrtoe in an e-mail to The Newtown Bee.

"[MIS-C] is a relatively rare phenomenon," he concurred with Drs Nowacki and Salazar, "given the prevalence of COVID-19," and added, "Kawasaki's a more well-defined condition with specific management and treatment protocols, a better understood natural history." This is despite its unclear etiology, he said, and the rare condition that may follow.

"Since there is no treatment, other than supportive measures for COVID," Dr Auerbach said, "most - if not all - practices are not evaluating these children in the office. If they require more significant intervention or are in respiratory distress, then they are generally referred to the Emergency Department [ED]."

Symptoms that would warrant a trip to the ED, this pediatrician stated, would include respiratory distress, severe intractable abdominal pain, unusual neurologic symptoms, or symptoms suggestive of severe inflammation.

He noted that with recognition of the symptoms and support, most children do well.

His practice is making sure that other patients have no exposure to possibly sick children by providing a separate back entrance for any children who may present with concerning symptoms that require a more hands-on assessment than is possible through the office's Telehealth platform, Dr Auerbach said.

‘A Constellation Of Findings’

Dr Juan Salazar, physician-in-chief for Connecticut Children’s Center, and chairman of the Pediatrics Department for the UConn School of Medicine, agreed with Dr Nowacki’s assessment that it is not necessary for parents to be overly concerned at this time. The inflammatory disease, now known as MIS-C (Multisystem Inflammatory Syndrome in Children), is still a very rare disease, he stressed, and seems to follow infection with the coronavirus that causes COVID-19.

Children’s has had three cases of MIS-C, with “two discharged and doing fine,” Dr Salazar said.

“What we’re seeing now is in the pediatric age group, up to adolescence,” he said, adding that probably 99 percent of the time, children who test positive for COVID-19 will not get MIS-C.

New York has seen more cases, he noted, simply because there is a greater population of children in that state than in others.

This childhood illness is not contagious, Dr Salazar said, though the virus that appears to precede it certainly is. “We do not yet know” the consequences of contracting MIS-C, he said. Children suspected of having MIS-C are treated in the hospital as potentially infected cases of the virus. Treatment is adapted from that of Kawasaki Disease, with intravenous infusion of human gamma globulin and a high dose of steroids, which are anti-inflammatory. “It has been very effective,” Dr Salazar noted.

He reiterated how rare MIS-C actually is, emphasizing that parents need to be aware but not panic.

“Clearly, if a kid has documented COVID-19, and develops a fever, rash, red eyes, cracked lips, or lymph node swelling in the neck, if they are not acting well,” that is the time to contact a pediatrician, said Dr Salazar. One symptom alone does not indicate this newly concerning childhood illness, he said.

“It is a constellation of findings. And always, always with a fever,” he added. That means a temperature of 101 F. for one to three days that is not attributed to anything else. It is the combination of the fever with other symptoms that should be concerning.

Parents need to take precautions to prevent infection with novel coronavirus, Dr Salazar said. “[MIS-C] is secondary to the initial infection.” Observe physical distancing, even after May 20 when the state begins to reopen.

“Be cautious in public places, and for children over the age of 3, wearing a mask in public is very important,” Dr Salazar said.

Anyone with concerns can call the Connecticut Children’s Center hotline at 1-833-226-2363, where experienced pediatric nurses will “help walk you through it,” he said. “If you are concerned, we can help through referrals, or a telehealth visit.” More information can be found at connecticutchildrens.org.

“Teaching kids safety practices is important,” during this pandemic, agreed Dr Nowacki. Her practice, Newtown Center for Pediatrics, offers numerous tips for staying healthy on Facebook. Hand washing properly and social distancing remain important, and she encouraged parents modeling the wearing of face masks to reduce the possibility of little children being frightened of seeing people in masks when they are out and about.

What is important, said this pediatrician, is continued prevention, education, and getting the facts.