Distinct clinical and immunological features of SARS-CoV-2-induced multisystem inflammatory syndrome in children

J Clin Invest. 2020 Nov 2;130(11):5942-5950. doi: 10.1172/JCI141113.


BACKGROUNDPediatric SARS-CoV-2 infection can be complicated by a dangerous hyperinflammatory condition termed multisystem inflammatory syndrome in children (MIS-C). The clinical and immunologic spectrum of MIS-C and its relationship to other inflammatory conditions of childhood have not been studied in detail.METHODSWe retrospectively studied confirmed cases of MIS-C at our institution from March to June 2020. The clinical characteristics, laboratory studies, and treatment response were collected. Data were compared with historic cohorts of Kawasaki disease (KD) and macrophage activation syndrome (MAS).RESULTSTwenty-eight patients fulfilled the case definition of MIS-C. Median age at presentation was 9 years (range: 1 month to 17 years); 50% of patients had preexisting conditions. All patients had laboratory confirmation of SARS-CoV-2 infection. Seventeen patients (61%) required intensive care, including 7 patients (25%) who required inotrope support. Seven patients (25%) met criteria for complete or incomplete KD, and coronary abnormalities were found in 6 cases. Lymphopenia, thrombocytopenia, and elevation in inflammatory markers, D-dimer, B-type natriuretic peptide, IL-6, and IL-10 levels were common but not ubiquitous. Cytopenias distinguished MIS-C from KD and the degree of hyperferritinemia and pattern of cytokine production differed between MIS-C and MAS. Immunomodulatory therapy given to patients with MIS-C included intravenous immune globulin (IVIG) (71%), corticosteroids (61%), and anakinra (18%). Clinical and laboratory improvement were observed in all cases, including 6 cases that did not require immunomodulatory therapy. No mortality was recorded in this cohort.CONCLUSIONMIS-C encompasses a broad phenotypic spectrum with clinical and laboratory features distinct from KD and MAS.FUNDINGThis work was supported by the National Institutes of Health, National Institute of Arthritis and Musculoskeletal and Skin Diseases; the National Institute of Allergy and Infectious Diseases; Rheumatology Research Foundation Investigator Awards and Medical Education Award; Boston Children's Hospital Faculty Career Development Awards; the McCance Family Foundation; and the Samara Jan Turkel Center.

Keywords: COVID-19; Clinical practice; Immunology.

Publication types

  • Comparative Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Adolescent
  • Adrenal Cortex Hormones / administration & dosage*
  • Betacoronavirus / metabolism*
  • Biomarkers / blood
  • COVID-19
  • Child
  • Child, Preschool
  • Female
  • Fibrin Fibrinogen Degradation Products / metabolism
  • Humans
  • Immunoglobulins, Intravenous / administration & dosage*
  • Immunomodulation*
  • Infant
  • Interleukin 1 Receptor Antagonist Protein / administration & dosage*
  • Interleukin-10 / blood
  • Interleukin-6 / blood
  • Macrophage Activation Syndrome / blood
  • Macrophage Activation Syndrome / diagnosis
  • Macrophage Activation Syndrome / drug therapy
  • Macrophage Activation Syndrome / immunology
  • Male
  • Mucocutaneous Lymph Node Syndrome / blood
  • Mucocutaneous Lymph Node Syndrome / diagnosis
  • Mucocutaneous Lymph Node Syndrome / drug therapy
  • Mucocutaneous Lymph Node Syndrome / immunology
  • Natriuretic Peptide, Brain / blood
  • Retrospective Studies
  • SARS-CoV-2
  • Systemic Inflammatory Response Syndrome* / blood
  • Systemic Inflammatory Response Syndrome* / diagnosis
  • Systemic Inflammatory Response Syndrome* / drug therapy
  • Systemic Inflammatory Response Syndrome* / immunology


  • Adrenal Cortex Hormones
  • Biomarkers
  • Fibrin Fibrinogen Degradation Products
  • IL10 protein, human
  • IL6 protein, human
  • Immunoglobulins, Intravenous
  • Interleukin 1 Receptor Antagonist Protein
  • Interleukin-6
  • fibrin fragment D
  • Natriuretic Peptide, Brain
  • Interleukin-10

Supplementary concepts

  • pediatric multisystem inflammatory disease, COVID-19 related