Shock and Myocardial Injury in Children With Multisystem Inflammatory Syndrome Associated With SARS-CoV-2 Infection: What We Know. Case Series and Review of the Literature

J Intensive Care Med. 2021 Apr;36(4):392-403. doi: 10.1177/0885066620969350. Epub 2020 Nov 5.


Background: Multisystem inflammatory syndrome associated with SARS-CoV-2 infection can lead to myocardial injury and shock in children, likely the result of a severe inflammatory state, and can mimic Kawasaki disease.

Objective: To describe the characteristics of shock and myocardial injury in children with confirmed or suspeted COVID-19 during the SARS-CoV-2 pandemic in Spain, including clinical presentation, laboratory and imaging findings, treatment, disease course, and outcome. An extensive literature review is provided.

Methods: Retrospective case series including all children (age 1 month-18 years) admitted to a pediatric intensive care unit in Madrid, Spain, between March 15 and April 30, 2020 with suspected or confirmed SARS-CoV-2 infection and shock.

Results: Twelve previously healthy patients with shock, age 5 to 14 years, were included. All required volume resuscitation and 75% required vasoactive/inotropic support. Distributive shock was present on admission in 67% (n = 8), and 4 patients (33%) showed features of cardiogenic shock. Myocardial injury was diagnosed in 67% (n = 8) and ventricular dysfunction in 33% (n = 4). The most common symptoms on presentation were fever (100%), anorexia (100%), diarrhea (75%), and vomiting (75%). Five patients showed signs of Kawasaki disease but none met the criteria for the classic form. Laboratory findings revealed lymphopenia (83%), thrombocytopenia (83%), and increased inflammatory markers (100%). Respiratory status was not significantly impacted. Chest X-ray showed bilateral alveolar infiltrates in 7 (58%) and bilateral pneumonia in 3 (25%). COVID-19 was confirmed in 11 cases (92%). All received empirical therapy against COVID-19, thromboprophylaxis and immunomodulation. Median stay in the PICU and inpatient ward was 4.5 and 10 days, respectively. No patients died.

Conclusion: Multisystem inflammatory syndrome in children with COVID-19 can mimic Kawasaki disease and lead to a combination of distributive and cardiogenic shock, probably secondary to a hyperinflammatory state that remains to be precisely defined. Treatment strategies include hemodynamic support, empirical therapies against COVID-19, thromboprophylaxis, and immunomodulation.

Keywords: COVID-19; children; inflammation; multisystem inflammatory syndrome; myocardial injury; pediatric intensive care; shock.

Publication types

  • Review

MeSH terms

  • Adolescent
  • COVID-19 / complications*
  • Child
  • Child, Preschool
  • Female
  • Heart Injuries / virology*
  • Humans
  • Infant
  • Infant, Newborn
  • Intensive Care Units, Pediatric
  • Male
  • Mucocutaneous Lymph Node Syndrome / virology
  • Retrospective Studies
  • SARS-CoV-2*
  • Shock / virology*
  • Spain
  • Systemic Inflammatory Response Syndrome / complications*
  • Ventricular Dysfunction / virology

Supplementary concepts

  • pediatric multisystem inflammatory disease, COVID-19 related