At the time of this report, there were approximately 138,000 COVID-19 cases and 237 associated deaths reported in Qatar. Since the initiation of COVID-19 screening at Sidra Medicine (April 16 to Nov. 21, 2020), a total of 28,653 COVID-19 tests were performed of which 7,812 were on individuals < 18 years old. During this period, a total of 167 children were positive for COVID-19 by RT-qPCR, and 7 of these patients fulfilled the WHO criteria for MIS-C and were managed in our hospital. The mean age at diagnosis was 5.6±2.7, and the majority of the cases were male (71.4%) (Table 1). All patients were previously healthy. Five out of 7 cases were initially admitted to the pediatric intensive care unit (PICU), primarily for vascular support.
Table 1
Patient characteristics and clinical presentation
| Case-1 | Case-2 | Case-3 | Case-4 | Case-5 | Case-6 | Case-7 | Summary |
Demographics |
Age | 6 | 6 | 3 | 7 | 7 | 9 | 1 | Mean, 5.6±2.7 |
Gender | Male | Male | Male | Male | Female | Female | Male | Male, 71.4% |
Clinical presentation |
Fever | Yes | Yes | Yes | Yes | Yes | Yes | Yes | 100% |
Rash | No | Yes | Yes | Yes | Yes | Yes | Yes | 85.7% |
Tachycardia | Yes | No | Yes | Yes | No | Yes | Yes | 71.4% |
Tachypnea | No | Yes | No | No | Yes | No | No | 28.6% |
Hypotension | Yes | Yes | No | Yes | No | No | No | 42.9% |
Abdominal pain | Yes | No | Yes | *Yes | Yes | Yes | No | 71.4% |
Diarrhea | No | No | Yes | No | No | Yes | Yes | 42.9% |
Vomiting | Yes | Yes | Yes | Yes | Yes | Yes | Yes | 100% |
Decreased oral intake | Yes | Yes | Yes | No | No | No | Yes | 57.1% |
Cough | Yes | No | No | No | No | No | No | 14.3% |
Sore throat | No | Yes | No | No | No | No | No | 14.3% |
Conjunctivitis | No | Yes | No | Yes | No | Yes | Yes | 57.1% |
*Patient underwent laparoscopic appendectomy |
Fever and rash were the most common presenting symptoms among the MIS-C cases in our hospital with 100% and 85.7% of the patients experiencing these symptoms, respectively (Table 1). Additionally, gastrointestinal symptoms were common among these patients with 100%, 71.4% and 42.9% patients presenting with vomiting, abdominal pain and loose stools, respectively. Upper respiratory tract infection (URTI) symptoms were less prevalent in our study group, with cough and sore throat experienced by one patient each, and conjunctivitis in 3 other patients. Two of the cases were suspected to have urinary tract infection (UTI) based on initial urine microscopy, however none had urinary tract symptoms at the time of presentation or had a positive urine culture after presentation.
Two of the cases had previous positive RT-qPCR results for SARS-CoV-2 (Table 2). At presentation, only case had positive nasopharyngeal swab (NPS) for SARS-CoV-2. Two of the remaining 4 cases were initially negative by RT-qPCR in NPS but were later found to have positive COVID-19 serology. Additional RT-qPCR testing for these patients using nasopharyngeal wash (NPW) specimens confirmed the presence of SARS-CoV-2 RNA. Of the 6 children who were tested for antibodies to SARS-CoV-2, all were positive.
Table 2
| Case-1 | Case-2 | Case-3 | Case-4 | Case-5 | Case-6 | Case-7 | Summary |
COVID-19 |
RT-qPCR | NPS-Neg NPW-Pos | NPS-Neg NPW-Pos | NPS-Pos | NPS-Neg | *NPS-Pos | *NPS-Pos | NPS-Neg | 71.4% cases positive in at least one specimen |
Serology | Positive | Positive | Positive | Positive | Not done | Positive | Positive | 6/6, 100% positive |
Hematology |
WBC (109/L) | 27.3 | 19.4 | 16 | 9.7 | 16.9 | 6.9 | 24.1 | 71.4% above range (Ref: 4–14) |
Neutrophil (109/L) | 24.4 | 16.5 | 5.3 | 9.5 | 13.9 | 4.6 | 16.1 | 71.4% above range (Ref: 0.8–7.2) |
Lymphocyte (109/L) | 0.9 | 0.8 | 1.2 | 0.2 | 2.1 | 0.6 | 6.5 | 71.4% below range (Ref: 1.3-8) |
Platelets (103/mL) | 140 | 80 | 570 | 105 | 116 | 105 | 900 | 71.4% below range (Ref: 150–400) |
Inflammatory markers |
CRP (mg/L) | 262.2 | 228.3 | 162 | 304.5 | 93 | 82.8 | 143 | 100% above range (Ref: 0-7.5) |
Ferritin (ng/mL) | 324 | 581 | 377 | 334 | 326 | 341 | 621 | 100% above range (Ref: 10–56) |
PCT (ng/mL) | 21.6 | 7.22 | 9.4 | > 50 | 2.15 | Not done | 0.59 | 6/6, 100% above range (Ref: <0.1) |
IL-6 (pg/mL) | 35 | 4 | Not done | Not done | 2665 | Not done | 100 | 3/4 above range (Ref: 0-16.4) |
Coagulation |
PT (sec) | 16.8 | 15.1 | 18.3 | 17 | 17.5 | 15.9 | 12 | 83% above range (Ref: 11.7–15.1) |
D-dimer (mg/L) | 7440 | 2266 | 7500 | > 7500 | 3538 | 2381 | 3060 | 100% above range (Ref: ≤500) |
Fibrinogen (mg/dL) | 4 | 3.9 | 3.4 | 4.4 | 3.7 | 3.6 | 4.3 | 28.6% above range (Ref: 1.6-4) |
Cardiac |
Troponin (ng/L) | 40 | 14 | 68 | 309 | 161 | 34 | 4 | 100% above range (Ref: 0-0.4) |
NT-proBNP (ng/L) | 5253 | 7006 | 2314 | 2874 | 592 | 506 | 1444 | 100% above range (Ref: <125) |
NPS, nasopharyngeal swab; NPW, nasopharyngeal wash; WBC, white blood cell; CRP, C-reactive protein; PCT, procalcitonin; PT, prothrombin time; NT-proBNP, N-terminal B‐type natriuretic peptide |
*Previous positive |
All patients had extensive laboratory workup done upon admission or at the time when MISC was suspected (Table 2). Although total white blood cell (WBC) counts were variable among our study population with a range between 6.9 to 27.3 (109/L), 5 of 7 cases were lymphopenic for their age. Additionally, 5 cases had a low platelet count for their age, although none had severe thrombocytopenia. All of our MIS-C cases showed a hyperinflammatory status with remarkably high C-reactive protein (CRP), procalcitonin (PCT) and ferritin levels, and deranged coagulation profile. IL-6 was high in 3 of 4 cases who were tested during their hospital stay.
Chest radiography was performed on 6 of 7 patients (Table 3). The most commonly described abnormalities were bilateral perihilar infiltrates and peribronchial thickening. Bilateral interstitial opacities and pulmonary edema were described in just one patient. Abdominal ultrasound (US) was performed on 6 of 7 patients. The most significant finding was that of an aortic aneurysm in one patient. The remaining patients had a variety of non-specific findings including increased echogenicity of the liver, gall bladder wall edema and thickening, bulky and echogenic kidneys, enlarged mesenteric lymph nodes, pleural effusions and ascites.
Table 3
| Case-1 | Case-2 | Case-3 | Case-4 | Case-5 | Case-6 | Case-7 | Summary |
Hospital length of stay (days) | 12 | 10 | 6 | 20 | 7 | 8 | 27 | Mean, 12.9±7.8 |
ICU stay (days) | 12 | 10 | None | 11 | 4 | 3 | None | 71.4% |
Shock | Yes | Yes | None | Yes | None | Yes | None | 57.1% |
Abnormal echocardiogram | Yes | No | No | No | Yes | No | Yes | 42.9% |
Abnormal EKG | Low voltage in limb leads | Not done | Not done | Initial ECG RBBB | No | No | Deep Q wave in inferior leads | 42.9% |
LAD/RCA z-score ≥ 2.5 | No | No | No | No | No | No | *Yes | 14.3% |
Pericardial Effusion | Minimal | No | No | No | No | No | No | 14.3% |
Ejection Fraction | 51% | 65% | 68% | 65% | 54% | 69% | 70% | 28.6% below range (Ref: <55%) |
Mitral valve regurgitation | Mild | No | Trivial | No | Mild | No | No | 42.9% |
Abnormal CXR | Yes | Yes | Yes | Yes | Yes | Not done | Yes | 6/6, 100% abnormal |
Pleural effusion | Small bilateral | No | No | No | Small right sided | No | No | 28.6% |
Mechanical ventilation | None | None | None | Yes | None | None | None | 14.3% |
Abnormal US abdomen | Yes | Yes | Yes | No | Yes | Not done | Yes | 5/6, 83.3% abnormal |
CXR, Chest X-ray; US, ultrasound |
*LAD large aneurysm 9.5 mm (Z score + 31.44), RCA small aneurysm 3.1 mm (Z score + 4.16), LMCA medium aneurysm 5.2 mm Z score + 7.75 |
Echocardiograms were performed on all patients at diagnosis with at least 4 weeks of follow-up, and after 8 weeks or earlier for patients with abnormal findings (Table 3). Cardiovascular involvement was seen in 3 of 7 patients in our study group (42.9%). Two patients had transient ventricular dysfunction with ejection fraction (EF) < 55%. Five patients (71.4%) received vasoactive support. All patients had elevated levels of N-terminal B‐type natriuretic peptide (NT-proBNP) and troponin (Table 2). None of our cases had arrhythmias even in the acute stage. Coronary-artery aneurysms identified on the basis of a z score of 2.5 or higher in the left anterior descending (LAD) or right coronary artery (RCA) was seen in one patient (Table 3; Case-7) who developed a giant aneurysm in the left anterior descending (LAD) coronary artery (initially 4.9 mm, z-score > 10). This patient also had a dilated left main coronary artery measuring 3.9 mm (z-score + 3.7) and a dilated right coronary artery measuring 2.6 mm (z-score + 2.7). The patient was placed on anticoagulation and dual antiplatelet therapy in addition to two doses of intravenous immunoglobulin (IVIG) and interleukin-1 (IL-1) inhibitor (anakinra). His LAD aneurysm enlarged to 9.5 mm z-score + 31.4 and was still present on the latest follow-up after 8 weeks from diagnosis.
The mean hospital stay of our MIS-C patients was 12.9 days, with 5 initially requiring intensive care management for ionotropic support (Table 3). Only one case (Case-4; Table 3) presented with acute respiratory distress syndrome (ARDS) and required mechanical ventilation. This patient also had prolonged fever and required 2 doses of IVIG, pulse steroids, and anakinra after no response to the initial measures. Broad spectrum antibiotics were initiated in all of the cases after consultation with the infectious disease team (Table 4). Aspirin was given to all patients during their hospital stay and on discharge for coronary thrombosis prophylaxis. All of our patients recovered and were discharged from the hospital in good clinical condition.
Table 4
| Case-1 | Case-2 | Case-3 | Case-4 | Case-5 | Case-6 | Case-7 | Summary |
IVIG | Yes | Yes | Yes | Yes | Yes | Yes | Yes | 100% |
Corticosteroids | Yes | Yes | No | Yes | Yes | Yes | Yes | 85.7% |
Antibiotics | Augmentin, meropenem, vancomycin and ceftriaxone | Ceftriaxone and clindamycin | Ceftriaxone | Ceftriaxone and meropenem | Piperacillin/ tazobactam and meropenem | Ceftriaxone | Ceftriaxone | 100% |
Anticoagulants | Enoxaparin | Enoxaparin | No | Enoxaparin | Enoxaparin | Enoxaparin | Enoxaparin | 85.7% |
Epinephrine/ norepinephrine | Yes | Yes | No | No | No | Yes | No | 42.9% |
Aspirin | Yes | Yes | Yes | Yes | Yes | Yes | Yes | 100% |
Interleukin-1ra inhibitor | No | No | No | Yes | No | No | Yes | 28.6% |
IVIG, intravenous immunoglobulin |