Clinical Characteristics of Multisystem Inflammatory Syndrome in Children With Severe and Critical Symptoms in the Pediatric Intensive Care Unit
Generally, children infected with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS COV-2) have mild symptoms or are asymptomatic. However, some children have severe and critical symptoms affecting several organ systems, including the gastrointestinal, cardiovascular, respiratory, and neurological systems. These severe and critical symptoms are associated with multisystem inflammatory syndrome in children (MISC). This study aimed to describe the clinical features, ventilation modalities usage, and outcome conditions of these children. This was a retrospective study of children with COVID-19 and MISC who were treated in the COVID-19 isolation pediatric intensive care unit (PICU) of Saiful Anwar General Hospital over one year. The data were obtained from medical records and were analyzed descriptively. A total of 491 pediatric patients with suspected COVID-19 were included; 51 had a confirmed COVID-19 diagnosis; 9/491 (1.8%) were patients with MISC who were treated in the PICU; and 7/9 (78%.0) of MISC patients in the PICU used mechanical ventilators. The frequency of MISC patients with gastrointestinal problems was 7/9 (78%) patients, respiratory problems was 9/9 (100%), and myocardial injury (increased troponin) was 5/9 (56%) patients. All MISC patients admitted to the PICU experienced shock with vasoactive drugs including dobutamine, epinephrine, norepinephrine and vasopressin. All MISC patients with severe and critical symptoms had comorbidities. Invasive mechanical ventilation was provided for 7 patients, and 2 patients received non-invasive ventilation. The mean of PEEP used in the invasive ventilation was 7-9 cmH2O. The length of the ventilator usage was 2-21 days, with 2 patients passing away, both with a comorbidity and multiorgan system injuries. It can be concluded that pediatric patients with confirmed COVID-19 may also have MISC with severe and critical symptoms. Early recognition of pediatric patients with MISC is necessary to reduce morbidity and mortality.
Keywords: COVID-19, multisystem inflammatory syndrome, children
 Hu B, Guo H, Zhou P, Shi ZL. Characteristics of SARS-CoV-2 and COVID-19. Nature Reviews Microbiology. 2021;19(3):141–154.
 Jurado Hernández JL, Álvarez Orozco IF. COVID-19 in children: Respiratory involvement and some differences with the adults. Frontiers in Pediatrics. 2021;9.
 World Health Organization. WHO coronavirus (COVID-19) dashboard. WHO; 2021. Available from: https://covid19.who.int
 Satuan Tugas Penanganan COVID-19. Peta Sebaran Covid-19. 2021. Available from: https://covid19.go.id/peta-sebaran-covid19.
 Ali AS, Al-Hakami AM, Shati AA, Asseri AA, Al-Qahatani SM. Salient conclusive remarks on epidemiology and clinical manifestations of pediatric COVID-19: Narrative Review. Frontiers in Pediatrics. 2020;8.
 Meena J, Yadav J, Saini L, Yadav A, Kumar J. Clinical features and outcome of SARSCoV-2 infection in children: A systematic review and meta-analysis. Indian Pediatrics. 2020;57(9):820–826.
 Hoste L, van Paemel R, Haerynck F. Multisystem inflammatory syndrome in children related to COVID-19: A systematic review. European Journal of Pediatrics. 2021;180(7):2019–2034.
 Whittaker E, Bamford A, Kenny J, et al. Clinical characteristics of 58 children with a pediatric inflammatory multisystem syndrome temporally associated with SARSCoV-2. JAMA. 2020;324(3):259.
 Pereira MFB, Litvinov N, Farhat SCL, et al. Severe clinical spectrum with high mortality in pediatric patients with COVID-19 and multisystem inflammatory syndrome. Clinics (Sao Paulo, Brazil). 2020;75:e2209.
 Souza TH, Nadal JA, Nogueira RJN, Pereira RM, Brandão MB. Clinical manifestations of children with COVID19: A systematic review. Pediatric Pulmonology. 2020;55(8):1892–1899.
 Lu X, Zhang L, Du H, et al. SARS-CoV-2 infection in children. New England Journal of Medicine. 2020;382(17):1663–1665.
 Götzinger F, Santiago-García B, Noguera-Julián A, et al. COVID-19 in children and adolescents in Europe: A multinational, multicentre cohort study. The Lancet Child & Adolescent Health. 2020;4(9):653–661.
 Riphagen S, Gomez X, Gonzalez-Martinez C, Wilkinson N, Theocharis P. Hyperinflammatory shock in children during COVID-19 pandemic. The Lancet. 2020;395(10237):1607–1608.
 Kadafi K. The difficulty of establishing the diagnosis of pediatric COVID-19 in Indonesia. Pediatrics Sciences Journal. 2020.
 World Health Organization. Multisystem inflammatory syndrome in children and adolescents with COVID-19. WHO; 2020. Available from: https://www.who.int/newsroom/commentaries/detail/multisystem-inflammatory-syndrome-in-children andadolescents-with-covid-19
 Verdoni L, Mazza A, Gervasoni A, et al. An outbreak of severe Kawasaki-like disease at the Italian epicentre of the SARS-CoV-2 epidemic: An observational cohort study. The Lancet. 2020;395(10239):1771–1778.
 Miller J, Cantor A, Zachariah P, Ahn D, Martinez M, Margolis KG. Gastrointestinal symptoms as a major presentation component of a novel multisystem inflammatory syndrome in children that is related to coronavirus disease 2019: A single center experience of 44 cases. Gastroenterology. 2020;159(4):1571–1574.e2.
 Suresh Kumar A, Awasthi P, Thakur A, et al. Intensive care needs and short-term outcome of multisystem inflammatory syndrome in children (MIS-C): Experience from north India. Journal of Tropical Pediatrics. 2021;67(3).
 Winant AJ, Blumfield E, Liszewski MC, Kurian J, Foust AM, Lee EY. Thoracic imaging findings of multisystem inflammatory syndrome in children associated with COVID-19: What radiologists need to know now. Radiology: Cardiothoracic Imaging. 2020;2(4):e200346.
 Kneyber M. Practice recommendations for the management of children with suspected or proven COVID-19 infections from the Paediatric Mechanical Ventilation Consensus Conference (PEMVECC) and the section Respiratory Failure from the European Society for Paediatric and Neonatal Intensive Care (ESPNIC). Paediatric Mechanical Ventilation Consensus Conference. 2020. Available from: https://www.espnic.eu/practice-recommendations-for-managing-children-withproven-or-suspected-covid 19/
 Rimensberger PC, Kneyber MCJ, Deep A, et al. Caring for critically ill children with suspected or proven coronavirus disease 2019 infection: recommendations by the scientific sections’ collaborative of the European Society of Pediatric and Neonatal. Intensive Care. Pediatric Critical Care Medicine. 2021;22(1):56–67.
 Prata-Barbosa A, Lima-Setta F, Santos GR dos, et al. Pediatric patients with COVID-19 admitted to intensive care units in Brazil: A prospective multicenter study. Jornal de Pediatria. 2020;96(5):582–592.
 Fisler G, Izard SM, Shah S, Lewis D, Kainth MK, Hagmann SHF, et al. Characteristics and risk factors associated with critical illness in pediatric COVID-19. Annals of Intensive Care. 2020;10(1):171.
 Carvalho WB de, Rodriguez IS, Motta EHG da, Delgado AF. Ventilatory support recommendations in children with Sars-CoV-2. Revista da Associação Médica Brasileira. 2020;66(4):528–533.
 Critically-ill pediatric patients with COVID-19. An update. Archivos Argentinos de Pediatria. 2020;118(5).
 Kadafi K, Latief A, Pudjiadi A. Determining pediatric fluid responsiveness by stroke. volume variation analysis using ICON® electrical cardiometry and ultrasonic cardiac output monitor: A cross-sectional study. International Journal of Critical Illness and Injury Science. 2020;10(3):123.
 Hennon TR, Penque MD, Abdul-Aziz R, Alibrahim OS, McGreevy MB, Prout AJ, et al. COVID-19 associated multisystem inflammatory syndrome in children (MISC) guidelines; A western New York approach. Progress in Pediatric Cardiology. 2020;57:101232.
 Belhadjer Z, Méot M, Bajolle F, Khraiche D, Legendre A, Abakka S, et al. Acute heart. failure in multisystem inflammatory syndrome in children in the context of global SARS-CoV-2 pandemic. Circulation. 2020;142(5):429–436.